Every finding on record at Gower Convalescent Center, Inc

Based on observation, interview, and record review, the facility failed to store, prepare, and distribute food in accordance with professional standards for food safety when the facility staff thawed sausage in the refrigerator on a wire rack shelf above a box of sausage rolls and ground beef, when [NAME] B did not wash hands between glove changes while preparing and serving food, and additionally when [NAME] C sat two frozen chicken strips on a package of hamburger buns that still contained hamburger buns while waiting for the air fryer to heat up. This had the potential to affect all resident's. The facility census was 67.Review of the facilities Storage-Refrigerated Foods policy, not dated, showed: Place meat, poultry and seafood items on the lowest shelf to minimize leakage onto other stored foods. Review of the facilities Glove-ology flyer, not dated, showed:-Washing hands thoroughly before and after wearing or changing gloves was the most important thing to reduce surface bacteria, sweat, dirt and grim build-up on skin and under nails;-Glove use in itself did not guarantee food safety;-Always wash hands before and after using disposable gloves.Observation of the kitchen on 05/20/26 at 8:00 A.M. showed ground sausage in a steam table pan stored above a box of sausage rolls and ground beef in the walk in refrigerator.Observation on 05/20/26 at 11:15 A.M. showed [NAME] C used a gloved hand to take two frozen chicken strips out of the freezer and placed them on a package of hamburger buns that still contained hamburger buns while waiting for the air fryer to warm up.Observation on 05/20/26 at 12:35 P.M. showed [NAME] B prepared a plate of food then took of his/her gloves, put on a new pair of gloves without washing his/her hands, touched his/her stomach with the gloved hands, then prepared another plate of food without changing gloves or washing hands.During an Interview on 05/20/26 at 11:17 A.M. [NAME] A said Frozen chicken strips should not be placed on a package of hamburger buns.During an Interview on 05/20/26 at 11:20 A.M. [NAME] C said He/she probably should not have sat the frozen chicken strips on the package of hamburger buns.During an Interview on 05/20/26 at 12:54 P.M. [NAME] B said he/she was not sure if hands should be washed between each glove change while handling food.During an Interview on 05/20/26 at 12:56 P.M. [NAME] A said hands were supposed to be washed each time gloves were changed.During an Interview on 05/20/26 at 12:58 P.M. [NAME] C said hands were supposed to be washed each time gloves were changed.During an Interview on 05/21/26 at 8:17 A.M. [NAME] A said as long as the thawing ground sausage was in a steam table pan it was okay to store above the bottom shelf since nothing would be able to drip on what was stored below the sausage.During an Interview on 05/21/26 at 12:07 P.M. the Administrator said:-Hands should be washed when changing gloves while working in the kitchen;-It was cross contamination to place frozen chicken strips on a bag of hamburger buns that still contained hamburgers;-Raw meat should not defrost on a shelf above other food.

Based on interview and record review, the facility failed to inform residents and/or their responsible parties, in advance of the risks and benefits of proposed care. When the facility failed to obtain written consent before beginning psychotropic medications (medications that affect the mind, emotions, and behavior) for three Residents (Resident #8, Resident #9, and Resident #19) of the 17 sampled residents. The facility census was 67.The facility did not provide a Psychotropic Medications policy. 1. Review of Resident #8's Quarterly Minimum Data Set (MDS), a federally mandated assessment completed by facility staff, dated 04/24/26, showed:- Moderate cognitive impairment;- Independent with activities of daily living (ADL's);- Diagnoses: Alzheimer's disease, anxiety disorder, and bipolar disorder (mental health condition characterized by extreme, cyclical shifts in mood, energy, and activity levels). Review of the resident's Comprehensive care plan, dated 04/20/26, showed:- The Resident was at risk for adverse consequences related to receiving antidepressant medication Sertraline, anticonvulsant medication Gabapentin for pain, Lorazepam for anxiety as needed and Melatonin for sleep;- The Resident was to have consistent approach amongst caregivers. Review of the Physician's Order Sheet, dated 05/21/26, showed:- Order for lorazepam 0.5mg (milligram) by mouth as needed (an anti-anxiety medication) began on 03/12/26;- Order for sertraline 50mg by mouth at bedtime (an antidepressant medication) began on 3/12/26. Review of the resident's medical record on 05/21/26 showed the facility did not have any record of a consent form for the resident regarding the use of psychotropic medications and the risks and benefits. 2. Review of Resident #9's Quarterly MDS, dated [DATE], showed:- Cognitively intact;- Minimal staff assistance with ADL's;- Diagnoses included: Emphysema (long term lung condition that causes shortness of breath), heart failure, and high blood pressure. Review of the resident's comprehensive care plan, dated 05/07/26, showed:- The Resident was at risk for adverse consequences related to receiving antidepressant medication Sertraline, anticonvulsant medication Gabapentin for pain, Lorazepam for anxiety as needed and Melatonin for sleep;- The Resident was to have consistent approach amongst caregivers. Review of the Physician's Order Sheet, dated 05/21/26, showed:- Order for lorazepam 0.5mg (milligram) by mouth as needed (an anti-anxiety medication) began on 09/24/25;- Order for buspirone 15mg by mouth three times a day (an anti-anxiety medication) began on 7/12/23;- Order for venlafaxine 150mg by mouth daily (an antidepressant medication) began on 01/04/24;- Order for lithium 300mg by mouth every other day (a mood stabilizer medication) began on 01/01/24;- Order for mirtazapine 45mg by mouth at bedtime (an antidepressant medication) began on 01/28/26;- Order for quetiapine 100mg by mouth at bedtime and 50mg by mouth daily (an antipsychotic medication) began on 01/03/25. Review of the resident's medical record on 05/21/26 showed the facility did not have any record of a consent form for the resident regarding the use of psychotropic medications and the risks and benefits. During an interview on 5/20/26 at 2:42 P.M., the Director of Nursing (DON) said she had called the person responsible for getting the consents signed and was told they have not all been completed and signed. She said they informed consents should have been signed and dated. During an interview on 05/21/26 at 11:48 A.M., the DON said psychotropic consents should be obtained for new psychotropic medications and should be done with any increase or decrease as well. 3. Review of Resident #19's Quarterly MDS, dated [DATE] showed:-Cognitive skills intact;-Two falls with no injury;-Diagnoses included high blood pressure, anxiety and hip fracture;-In the last seven days, the resident received seven anti-anxiety medications, seven antidepressant medications, and seven anticoagulants; -No antipsychotic medications were received. Review of the resident's drug regimen review, dated 04/09/26 showed:-The pharmacist recommended to decrease Alprazolam (used to treat anxiety) o.5 milligrams (mg.) twice daily to 0.35 mg in the morning and continue the 0.5 mg. dose at bedtime; -On 05/06/26 the physician declined due to the resident had been on this regimen for years and the resident's spouse was in the process of dying. Review of the resident's care plan, dated 05/07/26 showed:-The resident was at risk for adverse consequences related to receiving an antidepressant (Citalopram) for depression, Trazodone to help the resident sleep and an antianxiety medication, (Alprazolam). 5/6/26 a gradual dose reductions (GDR) were declined for Alprazolam and Citalopram; -Approaches included: assess resident's functional status prior to initiation of drug's use to serve as a baseline. Attempt gradual dose reduction yearly (after the first year) unless clinically contraindicated;-Attempt to give the lowest dose possible;-Monitor the resident's behavior and response to medication, review for continued need at least quarterly and Pharmacy consultant review. Review of the resident's POS dated May 2026 showed an order with a start date of 12/01/2025 give Alprazolam 0.5 mg. twice daily for anxiety. Review of the resident's undated Psychotropic Medication Informed Consent showed:-Medication drug class, Benzodiazepine;-Medication, Alprazolam 0.5 mg. given twice daily to decrease anxiety symptoms; -Reason for use of the medication, documented diagnosis of generalized anxiety;-Per note on 01/30/26, the resident was being seen by Behavioral Health Solution and order were per the physician; -Non-pharma-logical interventions included: Encourage resident to socialize with peers;-Enjoys one on one interactions, not large groups and likes to watch television; -The informed consent was not signed by the resident or responsible party or by a staff member and was not dated. During an interview on 05/20/26 at 2:42 P.M., the DON said she had called the person responsible for getting the consents signed and was told they have not all been completed and signed. She said they informed consents should have been signed and dated. During an interview on 05/21/26 at 7:53 A.M., the MDS/Care Plan Coordinator said ff a new order was received for psychotropic medication, he/she filled out the risks and benefits with the resident and/or the family. He/She would either get a verbal consent from the family or if the resident was alert and oriented, explain it to the resident and get a signature. It should also be care planned. He/She thought the Charge Nurse (CN) would get the consents signed.

Based on interview and record review, the facility failed to implement policies and procedures to ensure resident trust accounts (RTF) were credited with interest monthly for three residents (Resident #33, #49, and #55) and failed to obtain written authorization for the disbursement of funds from the RTF for two residents (Resident #49 and #55). The facility census was 67.Request for facility policy on the Management of the RTF not provided.1. Review of Resident #33's Annual Minimum Data Set (MDS), a federally mandated assessment, dated 04/01/26, showed: - He/she had severe cognitive impairment;- Diagnoses: non-traumatic brain dysfunction, Alzheimer's disease and anxiety disorder.Review of the Resident's January - March 2026 Quarterly RTF statement, showed:- He/She had a balance of $433.22 on 01/01/26 and a balance of $563.22 on 03/31/26;- Resident did not receive any credits for interest for the quarter;- On 03/31/26 had a charge for $20.00 for a haircut without a signed receipt from the resident or guardian authorizing this service.2. Review of Resident #49's Annual MDS, dated [DATE], showed: - He/She was cognitively intact;- Diagnoses: hypertension, anxiety disorder, and depression.Review of the Resident's January - March 2026 Quarterly RTF statement, showed:- He/She had a balance of $2,247.32 on 01/01/26 and a balance of $1,802.32 on 03/31/26;- He/She did not receive any credits for interest for the quarter;- He/She had a withdrawal of $700.00 for clothing on 02/03/26 with no signed receipt on file with the Business Office Manager (BOM).3. Review of Resident #55's Quarterly MDS, dated [DATE], showed: - He/She was moderately cognitively impaired;- Diagnoses: Alzheimer's Disease.Review of the Resident's January - March 2026 Quarterly RTF statement, showed:- He/She had a balance of $511.89 on 1/1/26 and a balance of $621.89 on 03/31/26;- He/She did not receive any credits for interest for the quarter.During an interview on 05/21/26 at 9:25 A.M., the BOM said:- The bank pays out interest every six months and we credit it to the active residents at the end of June and the end of December. She did not know that residents should be credited with interest into their account on a monthly basis.- If a resident discharges before the end of the month credit in June or December they will not receive any interest that has accrued during that period which could amount to five months of interest. - She did not have any signed receipts for work conducted in the salon for residents and did not have a signed receipt for the clothing disbursement to Resident #49. That transaction was done based on a verbal request from the resident and the resident's family member. During an interview on 05/21/26 at 2:35 P.M., the Administrator said:- She was not sure how often residents should be credited with interest from funds in the RTF.- There should be signed receipts or authorizations for resident transactions that involve the RTF account.

Based on record review and interview, the facility failed to maintain a system to ensure the resident trust fund (RTF) account was managed in accordance with proper accounting principles by not maintaining a monthly written reconciliation of all monies held in the resident trust fund account. The facility managed funds for 9 residents. The facility census was 67.Request for facility policy on the Management of the RTF not provided.1. Review of the monthly bank statements from April 2025 through March 2026 did not contain a written record of a reconciliation of the RTF account with the bank statements. During an interview on 05/21/26 at 9:25 A.M., the Business Office Manager (BOM) said:- She reconciles the RTF account monthly but does not record the reconciliation or have paperwork showing the account funds reconcile with the bank statements.During an interview on 05/21/26 at 2:35 P.M., the Administrator said:- There should be a written record of the monthly reconciliation of the RTF account done by the BOM.

Based on observation, interview and record review, the facility failed to provide proper respiratory care when staff failed to document the date when oxygen tubing was replaced for four residents (Resident #9, #11, #31, and #44), failed to ensure clean concentrator filters for one resident (Resident #11), and failed to provide proper storage for tubing (Residents #44) resulting in possible exposure to bacteria during oxygen usage and possible adverse effects. This affected four of 17 sampled residents. The facility census was 67. Review of facility Policy for Administration of Medications and Cleaning a Nebulizer Machine, dated as revised on 07/27/2021, showed:- After each treatment - discard any leftover medication;- Rinse the nebulizer medication cup and mouthpiece or mask with warm running water and place on a paper towel to air dry;- When dry, connect to the tubing and run nebulizer machine for 10 to 20 seconds;- Place dry equipment and tubing in a plastic container;- Weekly - replaced used tubing, mask, or mouthpiece with new tubing, mask, or mouthpiece. No facility policy provided for oxygen administration or oxygen supplies. 1. Review of Resident #9's Quarterly Minimum Data Set (MDS), a federally mandated assessment completed by facility staff, dated 05/19/26, showed:- Cognitively intact;- Required minimal staff assistance with activities of daily living (ADL's);- Diagnoses: Emphysema (long term lung condition that causes shortness of breath), heart failure, and high blood pressure. Review of the resident's Comprehensive care plan, dated 05/07/26, showed:- The Resident required oxygen at two liters per minute via nasal cannula continuously due to shortness of breath with activity, emphysema (long term lung condition that causes shortness of breath), and chronic bilateral pleural effusions (an accumulation of excess fluid in the pleural spaces (the thin cavities between the lungs and the chest wall) on both sides of the chest). Review of the resident's physician orders, dated 01/30/26, showed:- Administer oxygen at two liters via nasal canula and adjust to keep blood oxygen levels above 90%;- Change all oxygen tubing, humidifier bottles, and nebulizer tubing and plastic bags once weekly on Wednesday and ensure all items are dated and excess tubing is stored in the new plastic storage bags;- The day shift CMT to clean oxygen humidifier bottle and change the distilled water each day;- The evening CMT to check oxygen humidifier bottle and fill with distilled water as needed;- The night nurse to check oxygen humidifier bottle to ensure it is not empty and fill with distilled water as needed. Observation of the resident's room, on 05/18/2026 at 10:10 A.M., showed:- Oxygen on and operating at two liters per minute via nasal cannula;- No storage bag for the oxygen tubing on the concentrator;- There had been no date written on the oxygen tubing and no date written on the humidifier bottle;- Nebulizer mask and tubing sat on the trash can. Observation of the resident's room, on 05/19/2026 at 8:00 A.M., showed:- The oxygen tubing remained undated with no storage bag;- The nebulizer tubing undated, with no storage bag, sitting open on nebulizer. Observation of the resident's room, on 05/20/2026 at 8:30 A.M., showed:- The oxygen humidifier bottle and tubing had been changed and dated 5/18;- The oxygen tubing had a blue cover down the length of the tubing, but no storage bag present;- The nebulizer tubing was dated 5/18, and the tubing was twisted under the wheel of the bedside table and the nebulizer mask had been hanging from the nebulizer machine tubing nub. During an interview on 05/21/26 at 8:30 A.M., the resident said he/she would expect the nursing staff to maintain his/her oxygen supplies properly. 2. Review of Resident #31's Quarterly MDS, dated [DATE], showed:- Cognitively intact;- Required moderate assistance from staff for toileting, showering, and dressing;- Diagnoses: chronic respiratory failure and anxiety. Review of he resident's Comprehensive care plan, dated 03/06/26, showed:- Required one person assistance with bathing, transfers, and dressing;- Required supplemental oxygen for COPD diagnosis;- The nursing staff were required to administer oxygen as ordered and change tubing weekly per protocol. Review of the resident's physician orders, dated 05/21/26, showed:- Oxygen at two liters via nasal canula and adjust to keep blood oxygen levels above 90%;- Change nebulizer tubing and plastic bag weekly on Wednesday and date both items;- Replace nebulizer tubing every Wednesday evening. Observation of the resident's room, on 05/18/2026 at 9:00 A.M., showed:- Oxygen on at two liters per minute via nasal cannula;- No bag for storing the oxygen tubing and the tubing and humidifier bottle had been undated;- The nebulizer mask and tubing sat on the nebulizer machine undated and with no storage bag;- The portable oxygen tank tubing undated. Observation of the resident's room, on 05/21/26 at 8:10 A.M., showed:- Oxygen on at two liters per minute via nasal cannula;- The oxygen tubing and humidifier dated;- The portable oxygen tank tubing dated but were not stored in a bag;- The nebulizer mask and tubing dated but were on the nebulizer and not in a storage bag. During an interview on 05/21/26 at 8:10 A.M., the resident said he/she would expect the nursing staff to maintain his/her oxygen supplies properly. During an interview on 05/20/2026 at 3:20 P.M., Licensed Practical Nurse (LPN) A said:- Oxygen and nebulizer tubing should be dated when changed by the Certified Medication Technicians (CMT), usually weekly. They change them when doing the breathing treatments;- The tubing and nebulizer mask should be kept in a plastic bag after being rinsed off and dried on paper towels;- The humidifier bottle gets rinsed daily, rinsed in baby soap weekly, and changed monthly. They should be dated when changed;- The oxygen concentrator filters should be cleaned. During an interview on 05/20/2026 at 3:28 P.M., CMT B said:- The oxygen tubing and nebulizer mask and tubing should be dated when changed by the CMT's;- The humidifier bottle should be dated when changed monthly, and rinsed daily, baby soap rinsed weekly;- Maintenance is always working on the filters, they are the ones who clean them on the concentrators and air conditioners. During an interview on 05/21/2026 at 8:00 A.M., CMT C said:- The oxygen tubing and nebulizer tubing should be changed weekly by the med techs on this side in the afternoon and on the other side usually in the morning on Wednesdays;- The oxygen and nebulizer tubing should be dated when its changed;- The facility used the blue sleeve to protect the oxygen tubing from touching the floor on the residents who wear it all the time;- The nebulizer tubing and mask should be stored in a bag when not being used, unless it's being cleaned and laid out to dry on paper towels. Then it goes in the bag;- Storage bags should be used for oxygen tubing used on the portable tanks. During an interview on 05/21/26 at 7:57 A.M., the Director of Nursing (DON) said the nebulizer mask should be stored in a bag after it has been cleaned and is dry and should be dated as well. 3. Review of Resident #11's Quarterly MDS, dated [DATE], showed: -The resident was not cognitively intact; -The resident required oxygen therapy; -Diagnoses of acute pulmonary edema (build up of fluid in the lungs), heart failure (a condition where the heart is too weak to effectively pump blood), wheezing (a high pitched whistling sound that occurs when breathing). Review of Resident #11's care plan, dated 04/20/2026, showed: -The resident required supplemental oxygen as needed to keep oxygen saturation (a measurement of the cells in blood that carry oxygen) above 90%; -Staff were to change the oxygen tubing weekly. Observation on 05/18/2026 at 4:10 P.M. showed: -An oxygen concentrator sitting in the resident's room with the oxygen tubing coiled up sitting on top of the concentrator; -No date on the oxygen tubing indicating when the oxygen tubing was changed; -The oxygen concentrator filter had a layer of dust built up on it. Observation on 05/19/2026 at 2:17 P.M. showed: -Oxygen tubing covered with a CPAP hose cover, the part of the oxygen tubing that went into the resident's nose was not covered and the oxygen tubing was still coiled up and sitting on top of the oxygen concentrator; -The oxygen concentrator filter had a layer of dust built up on it. During an Interview on 05/21/2026 at 9:17 A.M. the Infection Control Nurse said: -The CPAP hose cover acted as a barrier so the oxygen tubing would not touch the floor while in use; -He/she believed that the oxygen filters were cleaned monthly but was not sure; -The resident's oxygen tubing should have been kept in a bag to keep it clean since the resident only used the oxygen as needed. During an Interview on 05/21/2026 at 9:25 A.M. the MDS Coordinator said: -Oxygen tubing was changed weekly and the filters on the oxygen concentrators were cleaned at the same time the tubing was changed; -He/she was not sure if the oxygen tubing should have been kept in a bag to keep it clean or if it was okay for the oxygen tubing to be coiled up and sat on the top of the oxygen concentrator. During an Interview on 05/21/2026 at 11:49 A.M. the Director of Nursing (DON) said: -Oxygen tubing should be changed weekly on Wednesday's and labeled with the date it was changed; -The oxygen filters were cleaned either monthly or weekly; -She was not sure if there was any documentation in the resident's medical record when oxygen tubing was changed and oxygen concentrator filters were cleaned. 4. Review of Resident #44's Quarterly MDS, dated [DATE] showed: Cognitive skills severely impaired. Dependent on the assistance of staff for toilet use, lower extremity dressing, personal hygiene, and transfers. Required substantial to maximum assistance with showers and upper extremity dressing. Always incontinent of urine. Frequently incontinent of bowel. Diagnoses included high blood pressure, diabetes mellitus, anxiety and depression. Review of the resident's care plan revised 3/31/26 showed it did not address the use of oxygen. Review of the resident's POS, dated May 2026 showed asStart date: 10/20/25 - Oxygen - titrate to keep oxygen saturation (amount of oxygen in the blood) greater than 90%. Review of the resident's Treatment Administration Record (TAR), dated May 2026, showed: Oxygen - titrate to keep oxygen saturation greater than 90%. No oxygen saturation was documented. Observation on 5/18/26 at 2:28 P.M. showed the oxygen tubing was not dated and the humidified water bottle was not dated. The oxygen tubing was draped over the oxygen concentrator and was not in a protective bag. Observation on 5/19/26 at 1:54 P.M., showed the oxygen tubing was not dated and the humified water bottle was not dated. The oxygen tubing remained draped over the oxygen concentrator and was not in a protective bag. During an interview on 5/21/26 at 7:53 A.M., the MDS/Care Plan Coordinator said: The resident used the oxygen as needed. The oxygen tubing should be changed weekly and dated when changed, even if the oxygen was only used as needed. There should be an order for the oxygen tubing and the humified water bottles to be changed. The oxygen saturation should be documented. The oxygen tubing and the humidified water bottle should be dated. During an interview on 5/21/26 at 8:33 A.M., CNA A said the resident used the oxygen at night and as needed, but does not use it continuously. During an interview on 5/21/26 at 8:56 A.M., Certified Medication Technician (CMT) A said: The resident used the oxygen in the mornings when his/her oxygen saturation was low. He/She would let the Charge Nurse (CN) know what the oxygen saturation was. The oxygen and nebulizer tubing should be changed weekly and dated with the staff's initials. The humidified water bottle should be changed monthly and dated. During an interview on 5/21/26 at 11:48 A.M., the Administrator and the DON said: The oxygen tubing should be changed weekly and dated. The CMTs change them weekly on Wednesdays. The humidified water bottles are not dated and should be changed monthly. The nurses should document the oxygen saturation on the TARs.

Based on observations, interviews and record review, the facility failed to ensure one of the 17 sampled residents, (Resident #10) received care which would allow the resident to achieve his/her highest practicable well-being. The facility census was 67. Review of the facility's Resident Rights Policy revised 8/25 showed:-As a resident, you have the right to a dignified existence, self-determination, and communication with access to people and services inside and outside the facility. -The facility must treat you with respect and dignity and care for you in a manner and in an environment that promotes maintenance or enhancement of your quality of life, while recognizing your individuality. -The right to reside and receive services in the facility with reasonable accommodation of your needs and preferences except when to do so would endanger your health or safety or the health or safety of other residents.-You have the right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and support for daily living safely. The facility must provide a safe, clean, comfortable, and homelike environment. -Housekeeping and maintenance services necessary to maintain a sanitary, orderly and comfortable interior. 1.Review of Resident #10's Comprehensive Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 03/03/26 showed:- Cognitive skills intact;- Upper and lower extremity impaired on one side;- Dependent on the assistance of staff for toilet use, showers, lower extremity dressing; - Required substantial to maximum assistance with upper extremity dressing, personal hygiene and transfers;- Occasionally incontinent of urine;- Always continent of bowel;- No falls;- Diagnoses included high blood pressure, diabetes mellitus, stroke, hemiplegia (paralysis affecting one side of the body) and hemiparesis (muscular weakness on one side of the body). Review of the resident's care plan, revised 04/0/26 showed:- Since his/her stroke in November 2025, the left side of the resident's body is flaccid. The ability to walk, dress, toilet, and maintain personal hygiene has deteriorated. He/She had a recent fall which caused a fractured pelvis and a brain bleed. Approaches included placing a pillow on his/her lap to keep the left arm positioned. Follow Occupational Therapy/Physical Therapy/Speech Therapy (OT/PT/ST) recommendations. He/She had a blue splint to wear on the left hand every night. Place the sling on the left arm before transferring due to hemiplegia. Preferred to use the bedside commode or the bedpan. Provide one or two staff assistance for transfers, dressing, toileting, bathing and bed mobility. - The resident experienced occasional bladder incontinence related to left hemiplegia and limited mobility, which usually occurred at night. Approaches included adapting the environment to maximize independence: grab bars, bedside commode, bedpan. Provide one or two staff assistance for toileting. Observation and interview on 05/18/26 at 2:03 P.M., showed:- The resident sat in a wheelchair in his/her room. - He/She had been in the current room for about three weeks, and he/she was unable to use the bathroom in his/her room because they had been working on it. They were supposed to put a grab bar on the wall by the toilet and were not sure what else. - There was a bedpan in a plastic bag on the floor. It had various tools on one side of the bathroom. Did not have a bedside commode in the bathroom. - If he/she had to go to the bathroom, the staff took him/her to the 100 or the 200 halls to use the bathroom. It was especially hard when the resident had diarrhea. - He/She would prefer to use the bathroom in his/her room. At night he/she used the bedpan. - No one has told the resident when the bathroom would be fixed. During an interview on 05/19/26 at 2:50 P.M., the Director of Nursing (DON) said she was not sure when the resident was moved rooms. She was not aware the grab bar had not been installed in the resident's bathroom. Normally, they make sure the room is completely ready before the resident is moved. They had recently just remodeled the resident's room. She thought the resident had moved to the room on 05/11/26. During an interview on 5/19/26 at 2:53 P.M., the Maintenance Director said:-He/She was verbally notified on Friday, 05/15/26 about the resident needing a grab bar in the bathroom. -It has not been installed yet because he/she had to order one and it had been ordered. -At 3:35 P.M., he/she placed a toilet safety rail over the toilet for the resident to use. -At 3:39 P.M., he/she brought a copy of the order for the grab bar. He/She said it had not been ordered yet; it was still in his/her cart to be ordered online. During an observation and interview on 05/19/26 at 3:40 P.M., the resident said:-He/She did not know if the toilet safety rail would work or not because it did not seem very stable.-He/She did not like having to leave his/her room to get the 100 or 200 halls to go to the bathroom, especially when he/she had diarrhea. It made him/her feel terrible and very embarrassed. -He/She had had an accident waiting for the staff to take him/her to the bathroom and it was so embarrassing. He/She hated not being able to clean him/herself up after going to the bathroom, but having diarrhea on top of it, was just so embarrassing! During an interview on 05/20/26 at 10:29 A.M., the Maintenance Director said:-He/She was aware the resident had been moved to a different room but was not aware of when the transfer took place.-If he/she had been aware, the maintenance staff would have checked the room to ensure it was ready and everything was set up for the resident. During an interview on 05/21/26 at 7:53 A.M., the MDS/Care Plan Coordinator said:-The resident had a stroke and had fallen with fractures prior to being admitted to the facility. -He/She thought the resident had moved to a different room in the last week. -He/She was not aware there was not a grab bar in the resident's bathroom for the resident to use. The resident should be able to use the bathroom in his/her room. During an interview on 05/21/26 at 8:33 A.M., Certified Nurse Aide (CNA) A said:-To get the resident up and out of bed would take two staff, otherwise the resident is a one person assist. It takes two staff to toilet the resident. -He/She did not know until this week the resident was unable to use the bathroom in his/her room. They take the resident to the bathroom on 100 or 200 halls. The resident does well with the gait belt (a special belt placed around the resident's waist to provide a handle to hold onto during a transfer) and using the grab bar to stand and pivot onto the toilet. -The bathroom in the resident's room is tight for space, and the toilet is not working, at least that's what the resident said. -He/She did not know if there was a grab bar on the wall in the resident's room or not. During an interview on 05/21/26 at 8:56 A.M., Certified Medication Technician (CMT) A said:-The resident is not able to use his/her left side. The therapist thought the resident would have an easier time getting in and out of bed if the resident was in room [ROOM NUMBER] due to the resident's left side not working. -He/She thought the staff took the resident into the big bathrooms on the 100 and 200 halls because the resident's bathroom didn't have enough space. During an interview on 05/21/26 at 9:12 A.M., CNA B said:-The resident is a two person assist, especially when toileting because of how he/she pivots. The resident is not able to move his/her left side at all. -He/She thought the resident moved last week or the week before that. -The resident is unable to use the bathroom in his/her room because it does not have a grab bar for the resident to use. He/She was aware the resident was not able to use his/her bathroom in his/her room.-He/She thought they filled out a maintenance request for the grab bar last Thursday.-They take the resident to the big bathrooms on the 100 or 200 halls to use the toilet. -During an interview on 05/21/26 at 9:26 A.M., the Maintenance Director said:-The request for the grab bars was filled out on 05/19/26. As far as he/she is aware, the resident's toilet is working in the resident's bathroom. During an interview on 05/21/26 at 11:45 A.M., the Speech Therapist (ST) said:-He/She was not aware of any grab bars in the resident's bathroom. -He/She thought the staff took the resident to the bigger bathrooms on the 100 or 200 halls because the resident was a two person assist.-The resident can hold onto the grab bar with his/her right hand but did not think the resident had enough strength to hold onto it with his/her left hand. During an interview on 05/21/26 at 11:48 A.M., the DON and the Administrator said:-The aides take the resident to the big bathroom on the 100 or 200 halls. -The resident's room should have been set up before the resident moved into it. They were not aware that the room was not ready. It was not made clear to the DON or the Administrator. -They had just remodeled room [ROOM NUMBER]. If they had known it was not ready, they would not have moved the resident. -She had observed the staff taking the resident to the bigger bathrooms but was not aware that the resident was uncomfortable with it.

Based on observation, interview, and record review, the facility failed to protect Resident #1's right to be free from abuse when Resident #2 grabbed Resident #1 by the hair and jerked his/her head around. Facility census was 78. Review of the facility policy titled, Abuse and Neglect, dated 9/29/2017, showed: -The residents of the facility have the right to be free from physical abuse. Residents of the facility must not be subjected to abuse or neglect by anyone. It is the responsibility of our employees, facility consultants, attending physicians, family members, visitors, etc., to promptly report any incident or suspected incident of neglect or resident abuse, including injuries of unknown source, and theft or misappropriation of resident property to the facility management team. Our facility will not condone resident abuse by anyone. - If a resident is observed/accused of abusing another resident, our facility will implement the following actions: -Remove the aggressor from the situation of the aggressor is still in the area in which the incident occurred. -Temporarily separate the resident from other residents as a therapeutic intervention to help lower the agitation. -Determine the environment or possible triggers leading up to the incident. -Initiate a discussion with the resident if possible to determine the cause of the agitation. -Determine if the resident's emotional needs such as boredom, depression, or loneliness are being met. - Notify the family or responsible party. -Notify the resident's Physician. -Document the behavior and interventions. -Use the Consulting Psychiatric Services when appropriate and available. -Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. -Physical abuse includes hitting, slapping, pinching, and kicking. 1. Review of Resident #1's quarterly Minimum Data Set (MDS, a federally mandated assessment completed by staff) dated 1/22/2025, showed: -The resident's diagnoses included: Dementia (a group of thinking and social symptoms that interferes with daily functioning), senile degeneration of the brain (a general term for a group of neurological disorders that cause a decline in cognitive function), Bells Palsy (a condition that causes sudden weakness in the muscles on one side of the face), anxiety disorder (a mental health disorder characterized by severe, ongoing anxiety that interferes with daily activities), major depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life); - He/She has moderate difficulty hearing, clear speech, usually understands others and usually makes self understood; -He/She scored one on the Brief Interview for Mental Status (BIMS, a structured evaluation aimed at evaluating aspects of cognition in elderly patients). This score indicated severely impaired cognitive abilities; -He/She has displayed no behaviors. Review of Resident #1's comprehensive care plan, dated 2/26/2025, showed: -He/She had dementia and senile degeneration of the brain. -He/She is slow to process information and have word finding problems. -He/She has anxiety and does not remember he/she lives at the facility. -Keep the resident away from Resident #2. 2. Review of Resident #2's annual MDS, dated [DATE], showed: -Diagnoses included: Alzheimer's Disease (a progressive disease that destroys memory and other important mental functions), severe dementia, generalized anxiety disorder major depressive aphasia (a language disorder that affects a person's ability to communicate); -He/She has adequate hearing, clear speech, understands others and makes self understood; -He/She scored 3 on the BIMS. This score indicates severely impaired cognitive abilities; -He/She has displayed no behaviors. Review of the resident's comprehensive care plan, dated 2/25/2025, showed: -The resident has physical and verbal behavioral symptoms directed toward others at times (calling names, cussing, hitting, kicking, pushing, scratching, grabbing). -Allow distance in seating (arms length) other residents around resident. -Avoid over-stimulation. Keep away from Resident #1. -Seat Resident #2 where constant/near constant observation is possible. -When he/she becomes physically abusive, keep distance between him/her and others (staff, other residents, visitors). Review of Resident #2's progress notes showed: -2/24/2025 at 6:33 P.M.: Resident #2 was brought back from the dining room, he/she had been telling another resident he/she needs to go to the hospital, yelling take him/her to the hospital. Resident #2 was in the area by the nursing station and he/she was wanting the resident next to him/her, Resident #1, to not be crazy over the baby doll. Resident #1 came up behind Resident #2, grabbed Resident #1's ponytail, and shaking Resident #1's head all around and would not let go. Staff assisted Resident #2 to his/her room and assisted to bed. Staff notified the resident's families and physician of the incident; -2/24/2025 at 6:55 P.M.: Resident #2 has been placed on 15 minute checks related to behaviors; -2/24/2025 at 7:05 P.M.: Resident #2 will be separated and supervised while around other residents. During an interview on 3/31/25 at 10:34 A.M., CNA A stated: -He/she was working the evening of 2/24/25. Resident #2 had just come back from dinner and was sitting at the nurses station, near Resident #1. -CNA A was cleaning a wheelchair and facing away from the residents. CNA A heard Resident #1 scream. CNA A turned around and saw Resident #2 had a hold of Resident #1's hair and pulling his/hear head around. -CNA A went toward the residents and the charge nurse also got up from behind the desk to separate the residents. CNA A helped Resident #2 to let go of Resident #1's hair and assisted Resident #2 to his/her room. During an interview on 3/31/25 at 4:01 P.M., Licensed Practical Nurse (LPN) A said: -He/She was working of 2/24/25. Between 6:30 and 7:00 P.M., both residents were sitting by the nurses station. LPN A heard Resident #1 yell and looked up at the residents. Resident #2 had come up behind Resident #1, had grabbed Resident #1's hair and was pulling his/her head around. LPN A and CNA A assisted in separating the residents, and Resident #2 was assisted to his/her room. Resident #1 was assessed and there were no injuries noted; -Earlier in the evening, Resident #2 became upset at dinner, yelling at another resident that they needed to get away from the table and staff brought Resident #2 back to the nurses station; -Resident #2 does have to be monitored for behaviors, as he/she yells at other residents and can be mean. Review of the facility investigation, dated 2/26/2025, showed: -On the evening of 2/24/2025, staff at the nurses station heard a scream. Upon investigation, found Resident #2 holding onto Resident #1's ponytail and shaking his/her head around; -Certified Nurses Assistant (CNA) A said that around 6:15 P.M. - 6:30 P.M., he/she was washing a wheelchair when he/she heard a loud scream come from Resident #1. When CNA A looked over, Resident #2 had a very tight grip on Resident #1's hair. The charge nurse stepped in and removed Resident #2's hand from Resident #1's hair. No one else witnessed the incident. During an interview on 3/17/2025 at 1:07 P.M., the Director of Nursing said staff responded appropriately to the incident. During an interview on 3/17/2025 at 1:07 P.M., the Administrator said staff responded appropriately to the incident. During a follow up interview on 3/31/25 at 9:50 A.M., the Administrator and Director of Nursing said: -As defined by the facility policy, abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain or mental anguish. Physical abuse includes hitting, slapping, pinching and kicking. It also includes controlling behavior through corporal punishment; -The Director of Nursing stated that the incident was reported to the state agency because it is her understanding that resident to resident altercations be reported; -The Administrator stated that the facility reported the resident to resident altercation to the state agency because the facility should report any and all resident to resident altercations. During an interview on 3/31/25 at 11:56 A.M., the Physician said: -He/She was notified by the facility of the incident; -He/She is unsure who gave the order for Resident #2 be placed on 15 minute checks for observation. He/She did not give that order; -Resident #2's actions toward Resident #1 are abuse. MO250135

Based on observation, interview and record review, the facility failed to store, prepare and serve food in accordance with professional standards of food service safety when staff failed to date the receipt of incoming products in the dry storeroom, label and date used products in the freezer and refrigerator, label, date and dispose of leftovers in the refrigerator, monitor refrigerator and freezer temperatures on a daily basis, and follow sanitation requirements for cleanliness, handwashing and hairnets in the kitchen and dining room. This affected all residents by putting them at risk for a food borne illness. The facility census was 78. Review of facility policy Hair Restraints for Dining Service, revised [DATE], showed: - Hair restraints shall be worn by all Dining Services staff when in food production, dishwashing areas or when serving food from the steam table. Hair restraints must be worn in the kitchen at all times; - Hair restraints, hats, and/or beard guards shall be used to prevent hair from contacting exposed food, any facial hair that is longer than the eyebrow shall require coverage with a beard guard in the production and dishwashing areas; Review of facility policy Food Storage, revised [DATE], showed: - All food will be stored on shelves. No food will be stored directly on any floor surface; - Perishable foods will be stored either in the walk-in cooler/refrigerator or the freezer. Cooler will maintain a temperature of ,d+[DATE] degrees F, freezer will be maintained at 0 degrees F; - All food stock will be rotated and consumed in the sequence obtained, First in - First out; - All opened or prepared foods will be stored in air tight/ sealable containers; - All containers will be labeled and dated; - Quality Control: the temperature of both the cooler and freezer will be checked twice daily, a log will be maintained to record the temperatures, the Dietary Manager (DM) will verify that these checks are done; - Food storage areas will be checked on a weekly basis to ensure that foods are being dated when opened and foods are being discarded in a timely manner. All food dates will be checked prior to each use; - Food Storage Times: Cooked meat or poultry (3 days), luncheon meat opened (4 days), Juices & Fruit Drinks (7 days) 1. Continuous observation in the kitchen on [DATE] showed: - 8:45 A.M. hand washing station did not have paper towels to dry hands off; Food Prep Area: - (5) Bags of cereal opened with no dates or labels; - Plastic cups stored face up; - Floor need middle area near stove has old food debris and stains; - Top of dishwasher has dirt buildup; - (6) Broken tiles throughout kitchen area, trip hazard and sanitation issue; - Sauerkraut in colander/strainer has loose metal strainer wires exposed and the metal sealing around the utensil is coming off which can house bacteria, metal introduction into food, and safety issue; - Weekly cleaning schedule posted but is blank for ,d+[DATE] and ,d+[DATE] and shows not completed; - 11:30 A.M. [NAME] (B) does not have beard covered with hair net; - Kitchen area very cluttered and unorganized with (3) carts blocking a door; - Kitchen prep area has very little working surfaces due to utensils and dishware not stored and taking up space; - Broken ice chest with various random items stored in it lying on top of a clean dish cart; - The temperature log for the refrigerator and freezer are not up to date; Dry Storeroom: - Bag of rice opened and undated; - Bag of graham cracker crumbs, opened and undated; - Box of sprinkles, opened and undated; - 1000 island dressing containers (3) no receipt dates; - Dented can of nacho cheese used to hold door open to storeroom; - Single servings of applesauce loose with no dates; - No dates on Oreo cookie case boxes, honey bun case boxes, or Ritz bits cracker case boxes, unable to determine if first in first out is followed by this receipt and storage system; - (3) large plastic containers of heavy-duty mayo no dates; Freezer - Opened, resealed fish parts no label or date; - Red raspberry sherbet opened, no date; - Loose bags of peas (5), green beans (10), brussel sprouts (5), unopened, no dates; - Frozen french fries, resealed no dates; - Large frozen turkey in corner of freezer lying on the floor; - Bowl of single serving sherbet on the ground, no label or covered; - Single serving package of pudding on the ground; - Box of pork chops uncovered and exposed in box to air; - Frozen meat raw on the ground; - (2) single serving sherbet on ground under rack; - No thermometer to read in the freezer to record temperature; Refrigerator - Virginia ham package 32oz undated; - [NAME] onion (raw and rotten) hanging off shelf grid; - Leftover expired corn beef dated ,d+[DATE] (12 days old); - Leftover expired oven roasted turkey breast dated ,d+[DATE] (5 days old); - (3) cannisters of cottage cheese no dates unopened; - Leftover expired thick and easy nectar opened ,d+[DATE] (13 days old); - Spilled oil under three storage racks; Continuous observation in the ,d+[DATE] hall dining room on [DATE] showed: - 12:04 P.M. Staff member in dining room wipes mouth with the back side of their gloved hand, continues serving; - 12:07 P.M. Dietary staff passing trays to residents wearing gloves and not changing them between each tray of food passed out. Staff member touches back of he chair, a wheelchair and then enters kitchen to pour drinks and opens and closed the refrigerator without hand washing; - Dishwasher (A) in kitchen has a beard cover that is positioned under the beard and not covering the exposed hair; - Staff member in kitchen has a beard cover but it does not cover moustache or sideburns; - Dietary staff resting their gloved hands-on serving surfaces between residents; - 12:09 P.M. Staff are not changing gloves or sanitizing between serving resident meals; - 12:10 P.M. CNA (I) assisting resident in drinking bends over resident's food cups and staff member's beard is touching resident's straw that is in one of their food cups; - 12:22 P.M. Dining Assistant (B) comes out of kitchen and serves resident, goes back to the serving counter still wearing gloves and does not wash hands upon entry to kitchen. CNA (I) comes out of kitchen and serves resident, re-enters kitchen, does not wash hands, still wearing same gloves; - 12:23 P.M. CNA (I) waiting for next tray and still hasn't washed hands, goes back into the kitchen and gets a new plate and serves resident and returns to kitchen, no hand washing; - 12:33 P.M. CNA (I) continues to enter and exit kitchen serving meals and not washing hands or changing gloves; Continuous observation in the ,d+[DATE] hall dining room on [DATE] showed: - 12:10 P.M. CMT (B) without gloves on or washing their hands touched a resident's silverware to help them to eat; - 12:21 P.M. Ice water pre-staged in dining room are in glasses which are not covered and open to the air and dust; Continuous observation in the ,d+[DATE] hall dining room on [DATE] showed: - 11:56 A.M. Dining Assistant (A) pushed food cart from kitchen to dining room with gloved hands, handled dirty electrical cord at bottom of cart and plugged it into socket. Started serving drinks to residents without washing hands or changing gloves; - Dining Assistant (A) served residents fresh fruit cups at a table and left to serve another table. Residents from the first table said they didn't want the cups so the Dining Assistant (A) removed the two fruit cups and put them back into the stock of fruit cups that were handled out to the rest of the residents; Continuous observation in the kitchen on [DATE] at 9:10 A.M. showed: - Dented can still holding open door to storeroom; - Monday morning cleaning log now signed off, ,d+[DATE], ,d+[DATE], & ,d+[DATE] cleaning log is blank as completed; - (4) carts around dishwashing station causing a cluttered environment with trip hazards; - Tubing from the sanitizer next to the stove is unconnected and lying on the floor in the walking path, trip hazard; - Front and side of stove has dried food stains on the surfaces and appears not cleaned for some time; Storeroom [ROOM NUMBER] - Bread on trays with no receipt dates; - (5) 5lb containers of peanut butter, no dates; - Dirty dust mop stored next to bottled water and bread; - Plastic ware utensils stored on shelf open and not covered; Refrigerator - Opened and resealed turkey meat no dates; - Carton of whipping cream unsealed with no date; - Snack box of cheese sticks, fresh fruit and Ensure boxes with no dates on the non-fruit items; Continuous observation during lunch preparation in the kitchen on [DATE] showed: - 10:20 A.M. no paper towels at the hand washing station; - Bread stored on top of menu books against the wall; - DM enters kitchen from hallway without hand washing and picks up dessert containers of food and stores them; - Dining Assistant (B) washes hands at washing station but turns off faucet with bare hand contaminating his/her hands in the process because there were no paper towels; - Dining Assistant (C) changed gloves but did not wash hands; - 10:45 A.M. [NAME] (A) pulls up pants with gloved hands then touches frozen/defrosting meat in sink, puts on new pair of gloves without washing hands; - [NAME] (A) working with raw meat while wearing gloves, removes gloves and grabs tin foil to cover meat without washing hands, outside of tin foil is now contaminated; During an interview conducted on [DATE] at 10:05 A.M., the DM said: - They expect that daily cleaning is done and deep cleaning is conducted every 3 months by wiping down walls and shelves and getting behind equipment; - The cooks, aides and the DM are doing the daily cleaning and expectations are that equipment, countertops and floors are cleaned including the steam table and sweeping and moping the floors; - If the cleaning log is not signed off the DM doesn't know if the daily cleaning has been completed; - The policy on dented cans is to not use them but they don't put any marking on them and there's nothing to stop someone from grabbing the dented can holding the door open and using it when the DM is not around; - It is expected that no food items will be stored on the ground and all incoming material is put away in two hours; - It is expected that received dates are put on all items incoming into the storeroom; - Opened boxes of cans and food also get a date when the case carton is opened; - All refrigerator and freezer temperatures are monitored by the administrator and maintenance through a computer system and they no longer record temperatures daily or check to see if the food temperatures are being maintained visually; During an interview on [DATE] at 1:45 P.M., Dietician said: - Would expect kitchen surfaces and floor to be cleaned daily; - Would expect the pathways through the kitchen to be free of clutter and trip hazards; - Would expect refrigerators, freezers and storerooms to not have food containers or items on the floor; - Would expect packages to have open dates placed on the outside of each package; - Would expect daily temperature checks for the freezer and refrigerator to be monitored and recorded daily one to two times; - Would expect leftovers to be kept 3 days only before disposing of and in accordance with published policies; - Would expect all packaged food items to be labeled as to their contents; - Cups should be stored upside down; During an interview on [DATE] at 2:40 P.M., Maintenance Supervisor said: - The Administrator implemented a new temperature application that monitors the refrigerator and freezer. The monitoring program is not officially online and there is no policy, but he has a phone application he can open to see the temperatures and it should send an alarm to him if the temperatures are out of specification. The system hasn't been tested as far as he knows and he doesn't check the temperatures daily or record what they are during the day; During an interview on [DATE] at 11:21 A.M., Dishwasher (A) said: - Hairnet requirements are to cover all the hair on your head including beard and mustache; - He/she has had training in hygiene, proper handling of utensils, and drink handling; - Their job covers doing the dishes, passing out halls trays and sometimes serve meals in the dining room but no food preparation; - Observation during the interview showed that Dishwasher (A) was wearing a beard net in the kitchen but did not cover up his/her moustache; During an interview on [DATE] at 1:30 P.M., Administrator said: - Staff members should wash their hands and/or don gloves prior to touching a resident's silverware to assist them in eating; - Pre-staged drinks should not be left uncovered and sitting in the dining room; - If staffs gloves become dirty, torn, or contaminated at meal service staff members need to wash their hands after taking off the gloves and put on fresh gloves; - It is expected that kitchen personnel with wear hair coverings and beard nets to cover all hair longer than their eyebrows; - Staff should wash their hands upon entering the kitchen each time; - She expects paper towels to be available at the hand washing station in the kitchen; - She expects cooking utensils to be in good repair and report to the administrator if they are not; - She expects that staff members annotate on boxes when items are received into the kitchen but if they are removed from the cartons no dates are required; - She expects leftovers to have storage dates and labels; - She expects opened containers in storage to be resealed tightly with open dates and food labels affixed; - She would not expect food items to be stored on the ground; - Cans with visible dents should be sent back or disposed of immediately; - There is a temperature monitoring application in place that is not completely finished. There are sensors in the freezer and the refrigerator to notify staff when it's out of specification. It's is not completely documented in the QAQI process and no one is recording temperatures and there have been no checks to verify the temperatures are accurate between the program and the actual temperature sensors. She would not expect to have thermometers in the freezer or refrigerator anymore with the application in place. There is no plan in place if the sensors fail because there's no reason to believe that technology will fail in this process; - There will also be checks in the application to make sure daily cleaning is signed off by staff.

Based on observation, interview and record review, the facility failed to ensure assure staff treated residents in a manner that maintained their dignity, when staff did not serve all residents who sat at the same table during meals, which affected any resident who ate in the dining room, and failed to ensure one of the 18 sampled residents, (Resident #47), was free of facial hair. The facility census was 78. Review of the facility's policy titled, Resident Rights, revised 8/22, showed staff were directed to do the following: - The resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility; - A facility must treat each resident with respect and dignity and care of each resident in a manner and in an environment that promotes maintenance or enhancement of his/her quality of life, recognizing each resident's individuality; - The facility must protect and promote the rights of the resident. 47195 1. Review of Resident #47's Quarterly minimum data set (MDS), dated [DATE], showed: -The resident is severely cognitively impaired; -The resident displayed no behavioral symptoms directed towards others including hitting, kicking, pushing, scratching, or grabbing; -The resident required partial to moderate assistance with personal hygiene including shaving; -The resident was dependent on a wheelchair; -The resident required substantial or maximal assistance with rolling left and right; -The resident was dependent to move from sitting to lying, lying to sitting on side of bed, sit to stand transfers, chair to be transfers, and toilet transfers; -Diagnoses included: dementia (a decline in thinking, memory, or reasoning that interferes with daily life), Alzheimer's disease (a progressive brain disorder that causes memory loss, thinking problems, and behavioral changes), muscle weakness, hearing loss, reduced mobility. Review of care plan, revised 12/6/24, showed: -Staff are directed to provide assistance with hygiene; -The resident preferred hospice staff provide showers twice weekly. The facility staff will provide showers as requested or needed. Observation on 2/18/25 at 10:12 A.M. showed resident had one inch long facial hair coming out of his/her chin. Observation on 2/19/25 at 8:26 A.M. showed resident had facial hair on their chin. Observation on 2/21/25 at 10:44 A.M. showed resident had quarter inch facial hair on their chin. During an interview on 2/20/25 at 10:35 A.M., Certified Nurse Aide (CNA) E said: -The resident liked to be shaved; -The reisdent's facial hair is shaved every time staff provide a shower; -Hospice staff provides the residents showers; -Last week the resident was not shaved so facility staff completed residents shaving while the reisdent was up in his/her reclining wheelchair. During an interview on 2/21/25 at 9:57 A.M., Licensed Practical Nurse B said: -Female residents should have their facial hair trimmed; -The resident did not always let staff shave them because they would swat at staff members; -The hospice and facility staff will attempt to shave resident; -Facility staff did not document when they provided shaving to resident because hospice did all of residents showers; -The resident had been declining steadily and stopped talking in last few months; During an interview on 2/21/25 at 10:24 A.M., CNA H said the hospice staff shaved resident and they shave residents when showered. During an interview on 2/21/25 at 1:15 P.M., Director of Nursing said: -He/she expected female residents to be free from facial hair; -Shaving was provided to residents during bathing; -The resident could be challenging with their moods and at times would be resistive to cares; -She expected for staff to care plan residents who may resist cares, including shaving. During an interview on 2/21/25 at 1:15 P.M., Administrator said she did not expect female residents to want their facial hair to be shaved or removed due to the change of times in our culture. 50980 2. Observation of 400-500 hall dining room on 2/18/25 showed: - 12:05 P.M. three residents served all at different tables with other residents at those tables not being served; - 12:10 P.M. lunch service continues to be random as to who receives their meal and the tables are not all served at the same time leaving residents at each table watching others eat in front of them while they wait; Review of resident #22's Admission MDS, dated [DATE], showed: - Cognitive skills for daily decision making intact; - Diagnosis included: Hypertension (high blood pressure), GERD (acid reflux), diabetes (chronic disease when body can't produce insulin), hyperlipidemia (high cholesterol), thyroid disorder (a condition where the thyroid gland produces an abnormal amount of thyroid hormones), arthritis (joint pain, swelling, and stiffness), osteoporosis (bone disease); Observation of 100-300 Hall dining room on 2/19/25 showed: - 12:19 P.M. Resident #22 with a plate of food in front of them, no other residents at their dining table have been served; - 12:27 P.M. Residents at the table still have not been served (8 min elapsed since first person served); During an interview on 2/19/25 at 12:20 P.M., when asked about meal service, Resident #22 said he/she is frustrated, I don't know how they determine who gets served, it's all random. During an interview on 2/19/25 at 2:49 P.M. with the Resident Council, residents said: - Resident #38 felt it was confusing how residents are served at meals; - Resident #13 said it was frustrating how meal service is conducted when serving; - Resident #51 said they don't know when they are going to get served; - Resident #75 said the meal service selection of when residents are served doesn't make sense; - Resident #17 said it's like the staff chooses who gets fed at random; During an interview on 2/20/25 at 1:30 P.M., the Administrator and DON said all residents sitting at a table should be served meals at the start of dining service at the same time before moving onto a new table unless there is a diabetic resident that needs to be served;.

Based on observation, interview and record review, the facility failed to maintain the privacy of two of the 18 sampled residents, (Resident #43 and #73), when staff failed to post signage at the front door or outside each sampled resident's room to indicate 24 hour camera surveillance was in progress and failed to obtain consents from the responsible parties of the sampled residents. The facility census was 78. The facility did not provide a policy for video surveillance with or without audio. 1. Review of Resident #73's care plan, dated 9/20/24, did not address the use of video surveillance with audio. Review of the Resident's Quarterly Minimum Data Set (MDS), a federally mandated assessment tool, completed by facility staff, dated 11/20/24, showed: - Cognitive skills intact; - Dependent on the assistance of staff for toilet use, and transfers; - Required substantial to maximum assistance with showers, dressing, and personal hygiene; - Had a urinary catheter (sterile tube inserted into the bladder to drain urine); - Always incontinent of bowel; - No falls; - Diagnoses included cancer, diabetes mellitus, neurogenic bladder ( a dysfunction that results from interference with the normal nerve pathways associated with urination), Congestive Heart Failure (CHF, accumulation of fluid in the lungs and other areas of the body) and Coronary Artery Disease (CAD, a disease in which there is a narrowing or blockage of the coronary arteries). Review of the resident's Physician Order Sheet, (POS), dated 1/19/25 - 2/19/25, did not include an order for video surveillance with audio. Observation on 2/18/25 at 10:17 A.M., showed: - The resident sat in a Broda chair (reclining geri chair) in his/her room and the over the bed table was placed in front of him/her with a video monitor on it. Also had a monitor on the resident's bedside table and on the window ledge; - Did not have a sign outside the resident's room to indicate video monitoring with audio was in use; - No signage was posted at the entrance to the facility to indicate video/camera surveillance was in use; - The video monitor was at the nurse's station and the volume was turned down so you were unable to hear what was being said in the resident's room. Observation on 02/19/25 at 1:51 P.M., showed Certified Nurse Aide (CNA) A was on the phone with the resident's family because the recording device was not working correctly. A family member planned to fix it later in the day. 2. Review of Resident #43's Annual MDS, dated [DATE] showed: - Cognitive skills severely impaired; - Required substantial to maximum assistance with toilet use, showers, and transfers; - Frequently incontinent of bowel and bladder; - Diagnoses included Alzheimer's disease (a brain disorder that slowly destroys memory and thinking skills and , eventually, the ability to carry out the simplest tasks), non-traumatic brain dysfunction ( causes damage tot he brain by internal factors, such as a lack of oxygen, exposure to toxins or pressure from a tumor), arthritis and depression; - No falls. Review of the resident's care plan, dated 12/17/24 showed the resident had dementia (inability to think) which affected his/her safety skills and had a history of falls. The resident's daughter brought a V-tech baby monitor with screen so staff were able to keep an eye on the resident. Review of the resident's POS, dated 1/19/25 - 2/19/25, showed and order dated 1/4/21 for a VTECH monitor, on at shifts continuous for frequent falls. Review of the resident's medical record showed he/she did not have a consent signed by the responsible party for 24 hour camera surveillance. Observation on 2/18/25 at 9:43 A.M., showed: - A video monitor on the counter by the resident's sink; - No signage was posted outside the resident's room to indicate camera monitoring was in progress; - No signage was posted at the entrance to the facility to indicate camera surveillance was in use; - The VTECH monitor at the nurse's station showed the resident sat in the wheelchair in his/her room. During an interview on 2/19/25 at 7:46 A.M., the Director of Nursing (DON) said: - Resident #73 had several daughters and they wanted an audio camera so they could talk to him/her. Resident #73 was the only resident with audio on the video monitoring; - Resident #43 did not have audio on his/her video monitor. During an interview on 2/20/25 at 11:30 A.M., Licensed Practical Nurse (LPN) A said: - It should be care planned for a resident to have video surveillance; - They did not have a physician's order for video surveillance because the family had requested it; - Did not know there should be a sign about video surveillance outside the resident's room. During an interview on 2/20/25 at 1:11 P.M., CNA D said they were told about the video monitoring device by their charge nurse. During an interview on 2/21/25 at 12:15 P.M., the DON said: - The video monitoring devices are just baby monitors; - The family put the monitors in the residents' room, not the facility. - She never thought of the need to post signs or notify anyone about it; - She considered the device to be a communication tool; - She did not think a physician's order for video monitoring was needed; - Resident #73 used the device also for his/her family to call him/her.

Based on observations, interview, and record review, the facility failed to ensure staff developed and updated care plans consistent with resident's specific conditions and needs which affected five of eighteen sampled residents (Resident #23, #47,#71, #6 and #12 ), and failed to invite and document quarterly care plan meetings were held for three residents (Resident #23, #6, and #12). The facility additionally failed to provide an accurate care plan when a resident had multiple transfer types listed in the care plan and did not reflect the resident's current non-ambulatory status for one resident (Resident #47) and failed to ensure wheelchair use was care planned for one resident (Resident #71). The facility census was 78. Facility did not provide a policy on comprehensive care plans. 1. Review of Resident #23's Quarterly Minimum Data Set (MDS), a federally mandated assessment tool completed by facility staff, dated 12/11/24, showed: - Cognitively intact; - Dependent on a wheelchair for mobility; - Required partial to moderate assistance with personal hygiene, bathing rolling left and right, sit to lying and lying to sitting on side of bed mobility; - Dependent for transfers to the toilet or shower, sit to stand transfers and chair to bed transfers; -Diagnoses included: Dementia, diabetes, high blood pressure, and depression. Review of care plan, dated 9/12/24, showed the care plan was last updated on 9/12/24 when visual function and pressure ulcer/injury were added. During an interview on 2/18/25 at 9:05 A.M. the Resident said: -He/She did not think they had care plan meetings; -His/her daughter and granddaughter sometimes participated in their care. Review of the electronic medical record showed: -The last care conference was held on 3/29/23; -The next care conference was scheduled for 6/22/23. During an interview on 2/20/25 at 3:08 P.M., MDS Coordinator said: -He/She offered resident care plan meetings but they did not think resident came to meetings; -The last care plan conference was held March 2023; -When the resident's family member came to facility he/she talked to everyone while they were here; - The residents family member did not share any reason to have a care plan meeting held; - Care plan notes showed resident's family member had participated via phone March of 2023 for resident's care plan meeting. 2. Review of Resident #47's Quarterly MDS, dated [DATE], showed: - Severely cognitively impaired; - Dependent on a wheelchair and staff assist for mobility; transfers, and all ADLS (Activities of daily living); -Diagnoses included: Dementia. Review of care plan, dated 12/6/24, showed: -Hospice ordered the resident a reclining chair, dated 10/10/23; - Two staff are to assist with transfers with a gait belt, use a mechanical lift to transfer the reisdent in and out of bed, and use a sit to stand lift to transfer the resident when toileting, dated 10/10/23; -Ensure the reisdent wears non-skid footwear is worn, dated 10/10/23; -Ensure pathways are free and clear of clutter, dated 10/10/23 -Re-educated staff on proper gait belt use, dated 10/10/23; -Ensure the residents walker stays within him/her and is in reach, dated 10/10/23; -The care plan did not reflect the resident's current total dependence for all transfers via mechanical lift and that he/she was no longer ambulatory. Observation on 2/21/25 at 10:33 A.M. showed hospice staff used a mechanical lift to place the resident in their bed. During an interview on 2/21/25 at 9:57 A.M. Licensed Practical Nurse (LPN) B said: -The resident was transferred by a mechanical lift; -The resident had declined steadily and was no longer able to stand for transfers. During an interview on 2/21/25 at 10:24 A.M., CNA H said: -The resident was transferred by use of a mechanical lift; -The resident had not used the sit to stand mechanical lift on over eleven or twelve months; -The resident had not been able to stand and pivot for a long time; During an interview on 2/21/25 at 1:15 P.M., the Director of Nursing said a resident who was dependent on a mechanical lift for transfers should have a care plan that reflected the resident's current need for assistance. 3. Review of Resident #71's Admission MDS, dated [DATE], showed: - Severe cognitive impairment; - Did not use a mobility device; - Independent with walking up to 150 feet; - Independent with chair to bed transfers and sit to stand transfers; - Diagnoses included: Dementia, Back fracture,anxiety, dementia and history of falling. Review of care plan, dated 2/6/25, showed: - He/She wandered safely within specified boundaries; - He/She walked independently, had dementia, and required staff to remind them to use their walker; -He/She had difficulty processing information due to dementia and get easily distracted; -There was nothing care planned regarding use of a wheelchair. Observation on 2/19/25 at 9:33 A.M. showed the LPN A pushed resident from the dining room to the nurses station in their wheelchair. Observation on 2/19/25 at 9:57 A.M. showed the resident was pushed by hospice staff in their wheelchair to the shower room. Observation on 2/19/25 at 11:28 A.M. showed the CNA C pushed resident down hallway to the nurses station in their wheelchair. Observation on 2/20/25 at 12:48 P.M. showed the Social Services Designee pushed resident out of dining room in their wheelchair. During an interview on 2/21/25 at 9:57 A.M., LPN B said the resident would self-propel in their wheelchair; During an interview on 2/21/25 at 10:24 A.M., CNA H said the resident would self-propel themselves in their wheelchair. 4. During an interview on 2/20/25 at 3:08 P.M., MDS Coordinator said: -The facility had care plan meetings; -Social Service designee sent out care plan meeting letters to families and hospice monthly; -Social Service designee would notify residents of their care plan meetings by handing them a letter; -The facility did not have any documentation when a resident did not want to attend their care plan meeting; -The facility did not have any written documentation showing who participated in care plan meetings; -He/She expected resident's care plans to reflect the resident's current level of care status. During an interview on 2/20/25 at 3:20 P.M., Social Services Designee said: -He/She sent letters out to resident families or DPOA the month prior to the designated care plan meetings; -When residents were their own person they would hand deliver a letter about the care plan to the resident; -The care plan letters that were sent by facility did not have a designated date and time of meetings; -The letters only indicated that the DPOA could call if they wanted to have a meeting; -MDS Coordinator would document when care plan meetings were held; -He/She did not write care plans; -Care plans were not occurring quarterly with each resident; -Care plans only occurred if the DPOA requested the meetings; -Care plans should be updated with any new interventions to the residents cares; -The resident's care plan should be updated more frequently if significant changes occur with the resident. During an interview on 2/21/25 at 1:15 P.M., Director of Nursing said: -She expected care plan meetings to be offered quarterly and as needed with changes; -She expected residents to be invited to their care plan meetings; -Majority of their residents did not want to participate in their care plan meetings; -Facility staff have had care plan meetings every week; -Facility staff did not document those care plan meetings; -Facility should document if resident was invited to their care plan meeting and declined to participate in the meeting. -She expected care plans to be individualized and be current to residents care needs; -She expected that by looking at the resident's care plan; they could tell whom that resident was, and what care was needed to be provided to the resident. 31102 5. Review of Resident #6's Quarterly MDS, dated [DATE], showed: - Cognitive skills moderately impaired; - Lower extremity impaired on one side; - Dependent on the assistance of staff for toilet use, showers, dressing, personal hygiene, and transfers; - Always incontinent of bowel and bladder; - One fall, no injury; - Diagnoses included stroke, depression, hemiplegia (paralysis affecting one side of the body) and chronic obstructive pulmonary disease (COPD, obstruction of air flow that interferes with normal breathing). Review of the resident's care plan, revised 2/7/25 showed: - The last care conference was 10/31/24; - The next care conference was scheduled for 1/24/25. During an interview on 2/18/25 at 10:59 A.M., the resident said he/she was not for sure if they had been invited to or attended their care plan meeting. 6. Review of Resident #12's Admission MDS, dated [DATE], showed: - Cognitive skills moderately impaired; - Required partial to moderate assistance for toilet use, dressing and personal hygiene; - Required supervision or touch assistance with transfers; - Occasionally incontinent of urine; - Always continent of bowel; - No falls; - Diagnoses included depression, high blood pressure, arthritis, and atrial fibrillation (A-fib, an irregular heartbeat that occurs when the electrical signals in the atria (the two upper chambers of the heart) fire rapidly at the same time). Review of the resident's care plan, revised 11/26/24, showed the plan did not address when the resident's care conference was scheduled. During an interview on 2/18/25 at 11:18 A.M., the resident said he/she was not for sure if they had been invited or attended their care plan meeting. During an interview on 2/20/25 at 8:25 A.M., the MDS/Care Plan Coordinator said: - He/she was not for sure if Resident #12 had attended any care plan meetings; - He/she did not document if the resident was invited or if they attended; - He/she was unable to find a care conference for Resident #12; - Resident #6 had a care conference in October and was not for sure why they did not have one in January.

Based on observations, interviews and record review, the facility failed to ensure staff provided professional standards of quality in care. when staff failed to utilize the electronic medical record to verify orders when providing wound care for one of the 18 sampled residents, (Resident #72) and when obtaining blood sugars and administering insulin for two residents (Resident #49 and #11) and additionally when staff failed to obtain physician's orders for wound treatment for Resident #5. The facility census was 78. Review of the facility's undated policy titled, Medication Administration, showed staff were directed to do the following: - Medications are administered as prescribed, in accordance with good nursing principles and practices and only by persons legally authorized to do so; - Personnel authorized to administer medications do so only after sufficient information regarding the resident's condition and expected outcomes of medication therapy is known; - Medications are prepared, administered, and recorded only by licensed nursing, medical, pharmacy, or other personnel authorized by state laws and regulations; - Medications are administered in accordance with written orders of the attending physician; - Residents are identified before medication is administered: check identification band; check photograph attached to medical record, header card, or facility approved location; call resident by name; if necessary, verify resident information with other facility personnel; - Only the licensed or legally authorized personnel who prepare medication may administer it. This individual records the administraion on the resident's Medication Administration Record (MAR) at the time the medication is given; - During routine administration of medications, the medication cart is kept in the doorway of the resident's room, with open drawers facing inward and all other sides closed. No medications are kept on the top of the cart. The cart must be clearly visible to the personnel administering medications, and all outward sides must be inaccessible to residents or others passing by; - Prior to administration, the medication and dosage schedule on the resident's MAR is compared with the medication label. Review of the facility's undated policy titled, Ten Rights for Administration of Medications, showed staff were directed to do the following: - The right resident: before preparing the medication, identify each resident according to the facility's policies and procedures; - The right drug: verify each drug against the MAR before administering. Verify in at least three ways, such as by the drug's size, shape, color, or label; - The right dose and dosage form: verify against the MAR. 1. Review of Resident #49's Physician Order Sheet (POS), dated 1/19/25 - 2/19/25, showed: - Order date: 7/9/21 - Accu checks ( a blood glucose meter that monitors blood sugars) before meals and at bedtime for diabetes mellitus. Review of the resident's MAR, dated 1/20/25 - 2/19/25 showed and order with a start date of 7/9/21 - Accu checks before meals and at bedtime for diabetes mellitus. Review of the resident's care plan, dated 7/9/24 showed: - The resident was diabetic and took insulin at night if the resident's blood sugar was greater than 300; - Monitor blood sugars before meals and at bedtime. Observation on 2/19/25 at 11:08 A.M., showed: - At 11:15 A.M., Registered Nurse (RN) A obtained the resident's blood sugar and discarded the supplies appropriately; - RN A did not have a computer with him/her and did not verify the resident's order prior to obtaining the resident's blood sugar. During an interview on 2/19/25 at 11:18 A.M., RN A said: - He/she normally did not take the computer with him/her when obtaining blood sugars because the resident had been at the facility for so long. 2. Review of Resident #11's Care Plan, dated 1/3/25 showed:- The resident was on Fiasp insulin before meals and took Lantus (long acting) insulin at bedtime; - Monitor blood sugars before meals and at bedtime. Review of the resident's POS, dated 1/20/25 - 2/20/25, showed: - Start date: 3/20/20 - Check blood sugars before meals and at bedtime; - Start date: 11/17/24 - Fiasp Flex touch (fast acting) insulin pen, 10 units twice daily for diabetes mellitus. Review of the website, https:// www.medicalnews.com for the use of Fiasp insulin pen showed: - Fiasp is a rapid-acting insulin which should be taken at mealtimes; - Take at the start of the meal or within 20 minutes. Review of the resident's MAR, dated 2/6/25 - 2/20/25 showed: - Check blood sugars before meals and at bedtime; - Fiasp Flex touch insulin pen, 10 units twice daily for diabetes mellitus. Observation on 2/19/25 at 11:25 A.M., showed: - Licensed Practical Nurse (LPN) A obtained the resident's blood sugar and administered insulin to the resident; - LPN A did not have a computer with him/her and did not verify the resident's order prior to obtaining the resident's blood sugar or administering the insulin. During an interview on 2/19/25 at 3:08 P.M., LPN A said: - He/she should have looked at the computer to verify the order to check blood sugars and administer the insulin; - He/she did not have a laptop, just a computer at the nurse's desk. 3. Review of Resident #72's POS, dated 1/19/25 - 2/19/25 showed: - Start date: 12/18/24, discontinue (dc) date: 1/22/25; clean wound to right posterior hip, with wound cleanser, apply collagen powder (used to promote healing and tissue regeneration) to wound bed, calcium alginate (dressings used to treat wounds with moderate to heavy drainage), cover daily and as needed; - Start date: 2/19/25 - Collagen powder to right posterior hip wound and cover daily and as needed; - The order did not specify how much Collagen powder to use. Review of the resident's MAR, dated 1/20/25 - 2/19/25 showed and order with a start date of 2/19/25 for Collagen powder to right posterior hip wound and cover daily and as needed. Review of the resident's care plan, revised 2/13/25 showed: - The resident was at risk for a pressure ulcer (damage to an area of the skin caused by constant pressure on the area for a long time) due to moisture and limited mobility. Observation and interview on 2/20/25 at 1:42 P.M., showed: - LPN B washed his/her hands at the sink at the nurse's station and donned gloves then cleaned the surface of the south treatment cart, removed gloves and sanitized; - LPN B placed a piece of foil on the cart and placed the wound supplies on it; - LPN B sprinkled a little bit of Collagen powder in a med cup and said they are supposed to cover the wound bed and since it is done daily, he/she knew how much to put in the cup; - LPN B took the treatment cart to the resident's room and completed the wound treatment; - LPN B said they usually look at the computer before they do the wound treatments but he/she did not do that this time; - He/She is the wound nurse though so he/she knows the orders. - LPN B did not check the computer prior to starting the wound treatment and did not have a computer during the treatment. During an interview on 2/21/25 at 12:15 P.M., the Director of Nursing (DON) said; - He/she did not expect the staff to have a tablet to to verify the orders, the staff check the orders at the computer at the nurse's desk and then do the treatments, obtain blood sugars or administer insulin; - The orders will not change while the staff are doing the blood sugars; - The nurses look at the computer all day long; - The nurses should check the orders, obtain the blood sugars, administer insulin or do the wound treatment. The nurses know what they are supposed to do. 50980 4. Review of Resident #5's Quarterly MDS dated [DATE] showed: - Admission to the facility on [DATE]; - BIMS score of 14, indicating no cognitive deficit; - Diagnoses include: Heart Failure, high blood pressure; - Requires assistance for set up and clean up for meals; - Requires assistance or set up for toileting hygiene and dressing; - Requires partial/moderate assistance for showering/bathing. - Resident requires a walker for mobility; Review of resident's progress notes dated 12/14/24 showed: - Resident has an area on their right lower leg. It is draining a little, area cleansed A&D ointment applied and covered. Resident lower leg is red and slightly ware to touch. Resident told to elevate their leg as much as possible. The area is 1 cm x 2 cm. Review of the resident's physician order sheet (POS), dated, 2/19/25, showed no orders relating to wound care or bandage for resident's right calf; Review of the resident's medication administration record (MAR), dated, 2/1-2/19 2025, showed no record of bandage change or cares for resident's right calf wound; Review of the resident's care plan, showed: - 7/24/24 resident is on Anti-Coagulant and staff should observe for signs of active bleeding; - 7/24/24 resident is at risk for pressure ulcer and staff should perform a skin inspection every shift during cares and use moisture barrier ointments as needed; During an interview on 2/20/25 at 5:25 P.M., Primary Physician stated: - Wound was due to a dermatology issue and it was taking a long time to get an appointment from the dermatologist and he/she was aware of the situation; - Was not aware that there were no orders for the care of the bandage and wound on resident's right calf; - He/she said there should be some order for care of the wound and that they would review the issue on the next visit; During an interview on 2/21/25 at 1:30 P.M., Administrator and DON said the nursing staff are not expected to date the bandages when they are changed.

Based on observation, interview, and record review the facility failed to ensure staff provided quality of care and treatment in accordance with professional standards of practice when staff failed to reposition two residents and provide incontinent care to dependent residents (Resident #47 and #72) This affected two residents out of eighteen sampled residents. The facility census was 78. Facility did not provide policy on positioning. 1. Review of Resident #47's Quarterly minimum data set (MDS), a federally mandated assessment tool completed by facility staff, dated 12/26/24, showed: - Cognition severly impaired; - Dependent on a wheelchair for mobility and dependent of staff for turning, repositioning and transfers; - Total assist of all ADLS; - Diagnoses included: Alzheimer's disease (a progressive brain disorder that causes memory loss, thinking problems, and behavioral changes), muscle weakness, and reduced mobility. Review of care plan, revised 12/6/24, showed: -Decreased mobility and required staff dependence for turning and repositioning; High risk for skin injury and pressure sores. -Inspect skin daily with cares and report potential problems. -Keep bony prominences from direct contact with one another with pillows and wedges; -Keep clean and dry as possible; -Minimize exposure to moisture; -Report any signs of skin breakdown (sore tender , red, or broken areas). Review of physician's orders, dated 2/19/25, showed: -Start date 11/11/22, heel protectors on in bed; -Start date 11/21/23, admit to hospice Observation on 2/18/25 at 10:18 A.M. showed resident up in a reclining wheelchair. Air pressure mattress observed on residents bed. Sign hanging above resident's bed showed heel protectors on while in bed. Observation on 2/19/25 at 8:25 A.M. showed resident up in reclining wheelchair. Observation on 2/19/25 at 9:42 A.M. showed resident was sleeping and remained up in reclining wheelchair. Observation on 2/19/25 at 1:17 P.M. showed resident was was seated in reclining wheelchair at nurses station. Continuous observation on 2/20/25 at 7:40 A.M.-11:50 P.M. showed: -8:03 A.M., resident pushed down hallway by Certified Nurse Aide (CNA) F and returned to resident's room. Resident remains up in their reclining wheelchair with call light in reach. -9:05 A.M., resident remains in their reclining wheelchair, resident had not been laid down or repositioned in the chair. -9:44 A.M., observation showed hospice staff entered residents room for visit, resident was not repositioned or laid down. -10:21 A.M., resident remained up in reclining wheelchair, had not been repositioned or taken out of chair -11:49 A.M., resident remained sitting in reclining wheelchair, had not been repositioned or taken out of reclining wheelchair; -11:50 A.M., CNA E said they had no room in dining room currently for resident to be assisted to dine and resident would remain in their room. During an interview on 2/20/25 at 10:35 A.M., CNA E said Resident #47 would not get laid down until after lunch and had been up in their reclining wheelchair since prior to breakfast. During an interview on 2/21/25 at 10:24 A.M., CNA H said: -Resident #47 stayed in broda chair most of the day; did not really lay down and stayed in chair most of the day; -Resident was laid down at 8:30 A.M. and got back up right away. During an interview on 2/15/25 at 1:15 P.M., Director of Nursing (DON) said Resident #47 would need help to be repositioned by staff. During an interview on 2/21/25 at 1:15 P.M., Administrator said: -Resident #47 should be repositioned if resident allows staff; -Resident could be resistive to cares. 2. Review of Resident #72's Quarterly MDS, dated [DATE], showed: -Cognition severly impaired and unable to make needs known; - Dependent on a wheelchair for mobility; - Total assist of all ADLS, dependent of full staff support to include incontinent care, turning, positioning and transfers; -High risk of skin injury and pressure ulcers, and did have a stage 1 or higher pressure ulcer; -Documented one stage 4 pressure ulcer- A full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling; -Dcoumented 1 unstageable pressure ulcer - slough and/or eschar: known but not stageable due to coverage of wound bed by slough and/or eschar; -Had a pressure reducing device for chair, bed, were on a turning/repositioning program, nutrition or hydration intervention to manage skin problems, pressure ulcer care, application of nonsurgical dressings (with or without topical medications) other than to feet, and applications of ointments/medications other than to feet; -Received hospice care; -Diagnoses included: Alzheimer's ), collapsed vertebra and unspecified pain. Review of care plan, revised 2/13/25, showed: -Staff assist resident up in reclining wheelchair for meals and as tolerated. -Resident was two assist with Hoyer lift for transfers. -Resident was at risk for pressure ulcer due to moisture and limited mobility; -He/She was incontinent of bowel and bladder; -Dependent on staff for all cares. -Laydown after every meal. -Turn and reposition at least every 2 hours and as needed. Review of physician's orders, dated 2/19/25, showed: -Started 5/6/24, admit to hospice care; -Started 2/19/25, collagen powder to right posterior hip wound and cover daily and as needed, once a day. Observation on 2/19/25 at 1:19 P.M. showed resident up in reclining wheelchair. During a continuous observation on 2/20/25 from 8:03 A.M.-11:50 A.M., showed: -8:03 A.M., Resident pushed down to their room by CNA F and placed in their room. Resident remained in their reclining wheelchair with call light in reach; -9:33 A.M., Resident remained up in their reclining wheelchair, had not been repositioned; -10:23 A.M., Resident remained seated in reclining wheelchair, had not been repositioned; -10:48 A M., CNA B entered resident's room and reclined residents wheelchair to add a blanket between resident's legs. CNA B placed resident's reclining back in upright position. During an interview on 2/20/25 at 10:35 A.M., CNA E said: -Resident #72 was one of the residents that would stay up in their chair until after lunch; -Resident was placed in their chair prior to breakfast. During an interview on 2/21/25 at 10:24 A.M., CNA H said: -Resident #72 should be repositioned every two hours; -Resident was laying in bed now and they were about to get her back up out of bed. During an interview on 2/21/25 at 1:15 P.M., DON said Resident #72 required assistance with being repositioned and was unable to reposition themselves. 3. During an interview on 2/20/25 at 10:35 A.M., CNA E said: -Residents should be repositioned every two hours; -Residents in broda chairs were up in their chairs from before breakfast until right after lunch, then staff give residents a little nap time by laying them down, and residents come back up for dinner; During an interview on 2/20/25 at 10:51 A.M., CNA B said: -Residents should be repositioned every two hours at a minimum; -Depending on resident's orders they are sometimes repositioned sooner than every two hours. During an interview on 2/21/25 at 9:57 A.M. Licensed Practical Nurse (LPN) B said residents need to be repositioned every two hours. During an interview on 2/21/25 at 10:24 A.M., CNA H said residents should be respositioned every two hours. During an interview on 2/21/25 at 1:15 P.M., Director of Nursing said: -She expected residents to be positioned every two hours; -She expected residents in reclining wheelchairs to be offered incontinent care every two hours; -Incontinent care and repositioning offered before lunch and after lunch; -Expected repositioning to occur when residents were not able to move themselves. During an interview on 2/21/25 at 1:15 P.M., Administrator said she expected residents to be repositioned every two hours.

Based on observation, interview, and record review, the facility staff failed to ensure residents remained free from accident hazards when staff pushed residents in their wheelchairs without foot pedals for four (Resident #1, #68, #71, and #58) residents. This affected four of eighteen sampled residents. The facility census was 78. Facility did not provide a policy on accidents. 1. Review of Resident #1's Quarterly minimum data set (MDS), a federally mandated assessment tool completed by facility staff, dated 12/19/24, showed: -Cognition severly impaired; -No impairment to upper or lower extremities; -Required assistance for Activities of Daily living to include transfers, mobility, hygiene needs. -Diagnoses included: Alzheimer's osteoarthritis , low back pain, unsteadiness on feet, and dementia Review of care plan, revised 9/12/24, showed: -He/She was ambulatory with assist; -Ensure assistive devices were available and in good condition (example included wheelchair); -Ensure proper footwear when they ambulated; -Resident was at risk of falls, and recently had a fall that fractured their pelvis; -He/She had cognitive impairment and could be impulsive which increased their risk for falls; -He/She had an anti roll back device on wheelchair; Observation on 2/18/25 at 10:42 A.M. showed resident self-propelled in their room. Resident had no leg rests observed on their wheelchair. Observation on 2/19/25 at 12:26 P.M. showed Certified Nurse Aide (CNA) C pushed resident's wheelchair into the dining room. Residents tops of their feet were dragged on the floor as staff pushed resident down the hall toward the dining room. Resident observed with no foot pedals on their wheelchair. During an interview on 2/21/25 at 9:57 A.M., Licensed Practical Nurse (LPN) B said: -Resident self-propelled themselves in their wheelchair; -Resident had an auto lock brake on their wheelchair and an anti-tip device in place because they had a history of falling when getting into their chair. During an interview on 2/21/25 at 10:24 A.M., CNA H said: -Resident could self-propel themselves in their wheelchair; -Staff would push resident without foot pedals because resident could hold their feet up. During an interview on 2/21/25 at 12:15 P.M., Director of Nursing (DON) said: -Resident could walk and took off on their own in their wheelchair; -The resident should not have foot pedals on their wheelchair because resident could hold their feet up while being pushed in wheelchair. 2. Review of Resident #58's quarterly MDS, dated [DATE], showed: -Cognition severly impaired; -He/She had no upper or lower extremity impairment; - Dependent on a wheelchair; -Required substantial or maximal assistance with toileting, bathing, lower body dressing putting on and off footwear, rolling left and right, sit to lying, lying to sitting on side of bed, sit to stand transfers, chair to bed transfers, tub transfers, and toilet transfers; - Required partial to moderate assistance wheeling fifty feet with two turns in wheelchair; -Diagnoses included: dementia, Alzheimer's Disease, and muscle weakness. Review of care plan, revised 8/29/24, showed: -Resident used their wheelchair for mobility and propelled themselves, resident would loose their way so staff needed to assist them; -Resident needed assistance to their destinations during the day; -He/She had dementia and did not ambulate, but propelled themselves in their wheelchair. Observation on 2/19/25 at 10:13 A.M. showed resident being pushed by CNA D down center hall without foot pedals on their wheelchair. Observation on 2/19/25 at 1:13 P.M. showed LPN C pushed resident out of dining room with no foot pedals on resident's wheelchair. Observation on 2/20/25 at 7:27 A.M. showed CNA E pushed resident out of their room with no foot pedals and proceeded to push resident from their room to the dining room. During an interview on 2/21/25 at 10:24 A.M., CNA H said: -Resident held their feet up well while staff were pushed them in their wheelchair. During an interview on 2/21/25 at 9:57 A.M., LPN B said: -Resident would self-propel in their wheelchair; -Resident had no falls from their wheelchair. 3. Review of Resident #68's Quarterly MDS, dated [DATE], showed: - Cognition was severely impaired; -He/She had functional limitation in range of motion on both sides of lower extremities; -He/She was dependent on a wheelchair; -He/She was dependent for mobility of sitting to lying, lying to sitting on side of bed, sit to stand, chair to bed transfers, toilet transfers, and tub/shower transfers; -Resident required substantial/maximal assistance rolling left and right; -Diagnoses included: dementia, advanced age, unspecified pain. Review of care plan, dated 1/20/25 , showed: -He/She had senile degeneration of the brain and dementia, were not able to bare weight anymore, and their legs were contracted at the knees; -Resident relied on others for their needs and cares; -Was at risk for falls and had a history of falls with fractures; -Took medication that could affect their level of consciousness, and had dementia with lack of safety skills; -Staff to ensure foot rests were set aside when not being propelled. Observation on 2/18/25 at 10:26 A.M. showed resident's foot pedal was observed under the sink in their resident room. Observation on 2/18/25 at 11:17 A.M. showed resident was sitting in front of nurses station with no foot pedals on their wheelchair. Observation on 2/19/25 at 10:00 A.M. showed CNA F pushed resident from dining room to nurses station. Resident had no foot pedals on their wheelchair. Feet were on the ground as they was pushed. Resident was wearing socks and white sandals. Observation on 2/19/25 at 2:08 P.M. showed CNA D pushed resident down hallway to their room. Resident did not have foot pedals on their wheelchair. Residents feet were observed touching the floor. Resident taken into their bedroom. Observation on 2/19/25 at 2:17 P.M. showed CNA D pushed resident out of their room and down the hallway with no foot pedals on their wheelchair. Resident was placed in front of nurses station. Residents feet were observed moving back and forth in a walking motion as resident was pushed down the hallway. Observation on 2/20/25 at 8:53 A.M. showed hospice staff A pushed resident down hallway to their room with no foot pedals on residents wheelchair. Observation on 2/20/25 at 9:32 A.M. showed hospice staff B pushed resident out of their room in their wheelchair, their feet were observed skimming across the floor as they pushed resident down hallway toward the nurses station. During an interview on 2/21/25 at 10:24 A.M., CNA H said: -Resident could not keep their feet up very well; -Resident had foot pedals on their wheelchair. Observation on 2/21/25 at 9:57 A.M., showed LPN B said: -Resident would self ambulate in their wheelchair; -Resident slid out of her chair on 2/7/25 and it was determined that the foot pedals were the cause of the fall. 4. Review of Resident #71's Admission MDS, dated [DATE], showed: -Severe cognitive impairment; - Did not use a mobility device; - Independent with walking up to 150 feet; - Independent with chair to bed transfers and sit to stand transfers; Diagnoses included: Dementia, displaced fracture of seventh cervical vertebra (a broken bone in the seventh cervical vertebra in the neck), anxiety, and history of falling. Review of care plan, dated 2/6/25, showed: - He/She would wander safely within specified boundaries; - Resident was at risk for falls; - Walked independently and had dementia, and required staff to remind them to use their walker; - Had difficulty processing information due to dementia and get easily distracted; -Required staff to set up, cueing, support and assistance level for activities of daily living; -There was nothing care planned regarding use of wheelchair. Observation on 2/19/25 at 9:33 A.M. showed LPN A pushed resident from dining room to nurses station without foot pedals on their wheelchair. Observation on 2/19/25 at 9:57 A.M. showed resident was pushed by hospice staff without foot pedals to shower room. Observation on 2/19/25 at 11:28 A.M. showed CNA C pushed resident down hallways to nurses station without foot pedals on wheelchair. Observation on 2/20/25 at 12:48 P.M. showed Social Services Designee pushed resident out of dining room with no foot pedals on residents wheelchair. During an interview on 2/21/25 at 9:57 A.M., LPN B said the resident would self-propel in their wheelchair. During an interview on 2/21/25 at 10:24 A.M., CNA H said: -Resident could hold their feet up well when staff push them in their wheelchair; -Resident could self-propel themselves in their wheelchair. 5. During an interview on 2/20/25 at 10:35 A.M., CNA E said: -Some residents could hold their feet up on their own and push themselves around -Before we move a resident without their foot pedals we ask the resident if they could hold their feet up; -Staff would make sure the residents foot pedals are out; -Residents should have foot pedals when being pushed in their wheelchairs; -They sometimes could not locate foot pedals because residents would hide their foot pedals under their beds. During an interview 2/20/25 at 10:51 A.M., CNA G said: -Residents could be pushed without foot pedals on their wheelchairs if the resident could hold their feet up; -He/She knew which residents were able to hold their feet up on their own; -A resident would ask for foot pedals when they felt they needed them by saying they were weak on that day; -He/She did not worry about residents hurting or falling cause they would notify staff if they needed their foot pedals; -Foot pedals were not something on the care cards they use for knowing resident specific cares; During an interview on 2/21/25 at 9:57 A.M., LPN B said: -Residents could be pushed in their wheelchairs without foot pedals if the resident could hold their feet up; -Many residents self-propelled themselves in their wheelchairs; -Foot pedals could create a fall hazard for some residents to have them on their wheelchairs. During an interview on 2/21/25 at 10:24 A.M., CNA H said: -Foot pedal use was dependent on whether the resident could lift their feet for facility staff while they pushed them. During an interview on 2/21/25 at 1:15 P.M., Director of Nursing (DON) said: -The facility had multiple residents who self-propel themselves in their wheelchairs; -He/She expected residents being pushed in their wheelchairs and was dependent on staff for mobility had the ability to hold their feet up; -Foot pedals on wheelchairs should be individualized per resident preference; -Residents could obtain skin tears from their foot pedals and it could increase the residents fall risk by having foot pedals on their wheelchair. During an interview on 2/21/25 at 1:15 P.M., Administrator said: -The expectation for residents having foot pedals on their wheelchairs was dependent on the individual resident situation; -She had multiple residents who obtained skin tears as a result of their foot pedals.

Based on observation, interview and record review, the facility failed to ensure staff provided proper respiratory care when staff failed to date when oxygen tubing was cleaned and left oxygen tubing lying on the ground for two residents (Resident #44, #21) resulting in possible exposure to bacteria during oxygen usage. Additionally the facility failed to keep water in the oxygen humidifier for proper humidity control for one resident (Resident #44) resulting in minor discomfort. This affected two of 18 sampled residents. The facility census was 78. Review of the facility's Oxygen administration policy not provided; 1. Review of Resident #44's Annual Minimum Data Set (MDS, a federally mandated assessment completed by the facility staff), dated 12/2/24, showed: - Cognitive skills intact; - Minimal difficulty hearing, clear speech, makes self understood, has clear comprehension, and impaired vision; - Diagnoses: Anemia, heart failure, high blood pressure, diabetes, seizure disorder, asthma, and cataracts. Review of the resident care plan, revised 12/3/24, showed: - Resident requires oxygen therapy with exertion due to dyspnea (shortness of breath) on exertion, COPD (chronic obstructive pulmonary disease). Staff will administer oxygen at 2L via nasal canula during exertion; - Oxygen per physician order 12/2/24 Review of the resident's Physician Order Report, dated 1/19 - 2/19/25, showed an order for Oxygen 2 Liters per nasal cannulat and adjust to keep O2 saturation percentage over 90% with exertion; Review of the resident's Medications Administration History, dated 1/1 - 2/19/25, showed: - No record of Oxygen administration or cleaning of tubing; Review of the resident's Treatment's Administration Record, dated 1/1 - 2/19/25, showed: - No record of Oxygen administration or cleaning of tubing; Observation on 2/18/25 at 4:09 P.M. showed: - Oxygen tubing lying on the resident's floor, water container in oxygen humidifier 1/3 full, no dates on tubing or water bottle indicating last change or cleaned date; Observation and interview on 2/21/25 at 8:55 A.M. showed oxygen tubing lying on the resident's floor, water container completely empty while resident is using the oxygen humidifier and oxygen tubing is inserted in resident's nose; - The resident said their nose hurt slightly due to it being very dry; 2. Review of Resident #21's Significant Change in Status MDS, dated [DATE], showed: - Resident was cognitively moderately impaired; - Independent for eating; - Set-up assistance for oral hygiene; - Partial/moderate assistance for toileting, bathing, and dressing; - Supervisor for personal hygiene; - Diagnosis: atrial fibrillation (heart rhythm disorder), coronary artery disease (condition in which the arteries that supply blood to the heart become narrowed or blocked), heart failure, peripheral vascular disease (narrowing and blockage of arteries), GERD (acid reflux), MRDO (resistant to multiple antibiotics), diabetes (chronic disease when body can't produce insulin), hyperlipidemia (high cholesterol); Review of resident's care plan, revised 2/11/25, showed no care planning for oxygen therapy at night; Review of resident physician orders dated 11/29/24, showed an order for O2 2L/NC while sleeping, no end date; Observation on 2/21/25 at 9:10 A.M. showed oxygen tubing lying on the ground with nose cannula completely exposed and making contact with the dirty surface of the floor. No dates of last tube change or cleaning were taped to the tubing; During an interview on 2/20/24 at 12:45 P.M., CMT B said maintenance cleans the filters on the oxygen humidifiers in resident's rooms. Tubes and water cannisters get cleaned weekly. There are orders on the MAR or TAR to change and date the tubing. Tubing is not to be left on the floor and staff are to Ziplock bag the tubing so it doesn't touch the floor. The proper name for the device is an O2 nasal cannula. Water level should be at least above the minimum line on the water cannister and the water helps prevent residents from getting a bloody nose from dry oxygen; During an interview on 2/21/24 at 1:30 P.M., the administrator and DON said: - Oxygen tubing and nasal cannula should not be on the ground; - When oxygen tubing is cleaned or changed staff should put a piece of tape with their initials and date to show when it was changed;

Based on observation, interview, and record review, the facility failed to ensure staff maintained a medication error rate of less than five percent when nursing taff made two medication errors out of 25 opportunities for error, which resulted in a medication error rate of 8%, which affected two of the 18 sampled residents, (Resident #64 and #11). The facility census was 78. Review of the facility's undated policy titled, Medication Administration, showed staff were directed to do the following: - Medications are administered as prescribed, in accordance with good nursing principles and practices and only by persons legally authorized to do so; - Personnel authorized to administer medications do so only after sufficient information regarding the resident's condition and expected outcomes of medication therapy is known; - Medications are prepared, administered, and recorded only by licensed nursing, medical, pharmacy, or other personnel authorized by state laws and regulations; - Medications are administered in accordance with written orders of the attending physician; - Residents are identified before medication is administered: check identification band; check photograph attached to medical record, header card, or facility approved location; call resident by name; if necessary, verify resident information with other facility personnel; - Only the licensed or legally authorized personnel who prepare medication may administer it. This individual records the administration on the resident's Medication Administration Record (MAR) at the time the medication is given; - During routine administration of medications, the medication cart is kept in the doorway of the resident's room, with open drawers facing inward and all other sides closed. No medications are kept on the top of the cart. The cart must be clearly visible to the personnel administering medications, and all outward sides must be inaccessible to residents or others passing by; - Prior to administration, the medication and dosage schedule on the resident's MAR is compared with the medication label. Review of the facility's undated policy titled, Ten Rights for Administration of Medications, showed staff were directed to do the following: - The right resident: before preparing the medication, identify each resident according to the facility's policies and procedures; - The right drug: verify each drug against the MAR before administering. Verify in at least three ways, such as by the drug's size, shape, color, or label; - The right dose and dosage form: verify against the MAR. 1. Review of the website, https://www.clevelandclinic.org for the administration of artificial tears showed: - Wash your hands; - Tilt your head backward, look up and pull down your lower eyelid with your finger; - With the other hand, position the bottle over your open eye and squeeze out the correct number of drops; - Don't touch the tip of the bottle or let it touch your eye; - Close your eye and keep it closed for a little while; - Put a finger on the part of your eye nearest to your nose to keep the medicine in your eye; - Avoid rubbing your eyes right after using artificial tears. Review of Resident #64's Physician's Order Sheet (POS), dated 2/5/25 - 3/5/25 showed: - Start date: 11/3/23 - Geri Care Artificial Tears, instill one drop in both eyes twice daily for dry eyes. Review of MAR, dated 2/6/25 - 2/20/25, showed: - Start date: 11/3/23 - Geri Care Artificial Tears, instill one drop in both eyes twice daily for dry eyes. Observation on 2/19/25 at 8:57 A.M., showed: - Certified Medication Technician (CMT) A washed his/her hands, and donned gloves; - The resident pulled down both lower eyelids; - CMT A placed one drop in the left eye and one drop in the right eye; - The tip of the eye dropper touched the resident's eye lids and eye lashes; - The resident closed his/her eyes for 30 seconds; - CMT A removed gloves and washed his/her hands. During an interview on 2/19/25 at 12:18 P.M., CMT A said: - The tip of the eye dropper should not touch the resident's eye lids or eye lashes. During an interview on 2/21/25 at 12:15 P.M., the Director of Nursing (DON) said: - The tip of the eye dropper should not touch the eye lid or eye lashes. 2. Review of the website, https:// www.medicalnews.com for the use of Fiasp insulin pen showed: - Fiasp is a rapid-acting insulin which should be taken at mealtimes; - Take at the start of the meal or within 20 minutes. Review of Resident #11's plan, dated 1/3/25 showed: - The resident was on Fiasp insulin before meals and took Lantus (long acting) insulin at bedtime; - Monitor blood sugars before meals and at bedtime. Review of the resident's POS, dated 1/20/25 - 2/20/25, showed: - Start date: 3/20/20 - Check blood sugars before meals and at bedtime; - Start date: 11/17/24 - Fiasp Flex touch (fast acting) insulin pen, 10 units twice daily for diabetes mellitus. Review of the resident's MAR, dated 2/6/25 - 2/20/25 showed: - Check blood sugars before meals and at bedtime; - Fiasp Flex touch insulin pen, 10 units twice daily for diabetes mellitus. Observation on 2/19/25 at 11:31 A.M., showed: - Licensed Practical Nurse (LPN) A obtained the resident's blood sugar which was 243; - At 11:43 A.M., LPN A administered Fiasp insulin, 10 units to the resident and informed the dietary staff the resident had taken his/her insulin; - At 12:14 P.M., the resident had his/her tray and started eating, 31 minutes after he/she received the fast acting insulin. During an interview on 2/19/25 at 3:08 P.M., LPN A said after the resident received fast acting insulin, they should be served a meal within 15 minutes. During an interview on 2/21/25 at 12:15 P.M., the DON said the resident should be served their meal immediately after getting the insulin.

Based on observation, interview and record review, the facility failed to store medications in a locked storage area to ensure medications for two residents (Residents #5, #44) were inaccessible to unauthorized staff and residents and failed to keep medications secured when the key was left in the lock of the medication treatment cart. Additionally the facility, failed to destroy expired and loose medications in the medication room and cart. This affected two out of 18 sampled residents. The facility census was 78. Review of facility Policy and Procedure for Physicians Orders, revised 1/15/12, showed - An interdisciplinary team determines the resident's ability to self-administer medications by means of a skill assessment; - If the resident demonstrates the ability to safely self-administer medications, a further assessment of the safety of bedside medication storage is conducted; - A physician order is obtained to self-administer medications if the storage and skill assessment has been approved for the resident by the interdisciplinary team. The order is recorded on the Medication Administration Record (MAR); - Noncompliant residents are informed by the nurse or nurse supervisor that they may not self-administer medications or treatments; -Update the residents care plan quarterly of the resident's knowledge and ability to self-administer medications; Review of facility policy, medication storage in the facility, undated, showed: -Medications and biologicals are stored safely, securely, and properly following the manufacturer or supplier recommendations. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. -Medication carts are locked or attend by person with authorized access;; -External medications including ointments for skin irritations and medication for application to wounds should be kept in a treatment cart, or in a separate drawer in the medication cart which is labeled as such. 1. Review of Resident #44's Annual Minimum Data Set (MDS, a federally mandated assessment completed by the facility staff), dated 12/2/24, showed: - Cognitive skills intact; - Minimal difficulty hearing, clear speech, makes self understood, has clear comprehension, and has impaired vision; - Independent for eating, oral hygiene, and toileting; - Substantial/maximal assistance needed for bathing and dressing - Diagnosis: Anemia (blood disorder), heart failure, hypertension (high blood pressure), GERD (acid reflux), pneumonia, diabetes, hyperlipidemia (high cholesterol), seizure disorder, asthma (chronic lung disease), cataracts (clouding of the lens of the eye): Review of resident's care plan dated, 12/3/24, showed: - Resident's vision is highly impaired due to Macular degeneration and Glaucoma; - No record of resident being allowed to self-administer medications; Review of resident's Physician Order Report (POR), dated 1/19 - 2/19/25, showed: - No orders for Refresh eye drops; Observation of resident room on 2/20/25 at 7:46 AM., showed: - 0.5 oz bottle of Refresh Tears at bedside within reach of resident; During an interview on 2/20/25 at 7:48 A.M., the resident said: - His/her daughter [NAME] the bottle around 1/21/25 after a medical procedure and that he/she uses the medication when their eyes get dry; 2. Review of Resident #5's Quarterly MDS dated [DATE] showed: - Admission to the facility on [DATE]; - Cognition intact; - Diagnoses include: Heart Failure, Hypertension (high blood pressure); - Requires staff to provide medications. Review of Resident care plant revised, 1/17/25, showed: - No orders for self-administrator of medication; Observation of resident room on 2/20/25 at 11:15 A.M., showed: - One plastic med cup sitting in front of the resident containing 3 pills (2 white and 1 blue); During an interview on 2/20/25 at 11:16 A.M., resident said: - Staff came into his/her room and gave them their morning medication and when he/she asked the staff member what pills they were, the staff member did not reply and left the room; - The resident said he/she would not take the last three pills until they knew what they were; During an interview on 2/20/25 at 11:45 A.M., CMT B said: - Medications at beside are not allowed unless the resident has an order and this would apply even to over the counter medications; - If he/she saw medications at bedside they would confiscate them and put them in the med storage room; - He/she administered medications to Resident #5 on the morning pass of 2/20/25 and had given the resident their medications. He/she left the room thinking the resident had taken all of their pills but said they must have been mistaken since the resident still had 3 pills at bedside when the surveyor entered the room at 11:15 A.M. that same morning; - He/she said the CMT is supposed to make sure the resident takes all of their medications prior to leaving the room or take them and destroy them if the resident refuses to take the medication; During an interview on 2/21/25 at 12:15 P.M., the DON said: - They would not expect resident's to have over the counter medications at bedside without an order; - They would expect resident's without a bedside order for medications to take all of their medications before the med tech leaves the room; 47195 3. Observation on 2/18/25 at 11:14 A.M. showed the medication treatment cart was left with key in the lock. Cart is located parked outside nurses station and no staff was observed near the cart. There was a sharps container resting on top of the medication treatment cart. Observation on 2/18/25 at 11:16 A.M. showed Licensed Practical Nurse (LPN) C obtained cart with key in it and pushed medication treatment cart down 200 hallway to a resident room. Observation on 2/18/25 at 2:45 P.M. showed medication treatment cart is parked beside nurses station with key left in the lock. No staff observed near the medication cart. During a continuous observation of medication treatment cart on 2/19/25 at 9:35 A.M.-10:35 A.M., showed: -9:35 A.M., showed medication treatment cart was left with key in lock on unit. Staff were observed sitting down at nurses station. Medication treatment cart was outside of nurses station accessible to residents. -9:36 A.M., showed LPN A obtained treatments from cart, removed key from cart. Key was observed left hanging on blue lanyard on side of trash can on the cart. -9:44 A.M., Observation showed key in treatment cart - blue lanyard in the key lock. -10:02 A.M. showed medication treatment cart was left unattended with key in the lock of the medication cart. LPN A observed walking up to the treatment cart and obtained a topical cream out of cart. LPN A walked away from cart and left key remaining in treatment cart. -10:10 A.M., key to cart remained in lock of medication treatment cart, no staff members near cart; -10:22 A.M., key to cart remains in lock of treatment cart with no staff members directly at cart; -10:27 A.M., LPN A returned to medication treatment cart. LPN A opened cart, cut off ace bandage with scissors, and removed key from the lock of cart. Key was left hanging on side of cart from trash can on a blue lanyard. Observation on 2/19/25 at 2:33 P.M. showed medication treatment cart had key left in lock with no staff around medication cart. Observation on 2/20/25 at 11:53 A.M. showed the medication treatment cart had key left in lock, the blue lanyard remains attached to the key to the side of the cart. No staff near cart or accessing treatment cart. The medication cart was parked outside of nurses station. Observation on 2/20/25 at 3:18 P.M. showed key was left in treatment cart on lanyard, no staff observed near the cart. Observation on 2/21/25 at 9:56 A.M. showed treatment cart was unattended with key left in the lock on cart. The key remains attached to blue lanyard which lanyard connects to side of cart by trash can. During an interview on 2/21/25 at 9:57 A.M., LPN B said: -The medication treatment cart key should no be left in treatment cart lock; -The treatment cart contained medicated treatments; -The facility always left the key hanging on the side of the treatment cart. During an interview on 02/21/25 10:47 A.M., LPN A said: -Medication treatment card should be locked; -Licensed Nursing staff should not leave the key stuck in treatment cart lock; -The medication treatment cart should not be left unlocked and unattended; -He/She always leaves the key hanging on side of treatment cart on blue lanyard. During an interview on 2/21/25 at 1:15 P.M., Director of Nursing said: -She expected the medication treatment cart to be secured and locked when it was unattended; -Staff should be within arms reach if it the medication treatment cart was left unsecured; -She expected the medication cart key not be left in the lock and the cart to be unattended; -The treatment key could be left hanging on the medication treatment cart if staff was standing at the treatment cart perparing a medication treatment; -She expected staff to pull key out of the lock when they were not at treatment cart. 31102 4. Observation on 2/19/25 at 8:19 A.M., of the North medication cart and the North medication room showed: - One loose oblong while capsule in the medication drawer; - Resident #44 had an opened bottle of Age Related Eye Disease Studies (AREDS), an eye vitamin and mineral supplement, expired 1/25; - Resident #44 had an opened bottle of Coreg 3.125 milligrams (mg.) (used to treat high blood pressure), expired 1/16/25. During an interview on 2/19/25 at 12:18 P.M., Certified Medication Technician (CMT) A said: - The CMTs check the medication carts and the medication rooms at least weekly and the pharmacist comes in monthly; - Should not have any loose pills in the medication drawer, it should be destroyed; - Should not use expired medications, they should be destroyed. During an interview on 2/21/25 at 12:15 P.M., the DON said there should not be any loose pills or expired medication in the medication carts or the medication rooms, they should be destroyed.

Based on interview and record review, the facility failed to provide required state approved training for paid feeding assistants which affected 18 residents. The facility census was 78. 1. A policy on paid feeding assistants was not provided for review. Review of a list of paid feeding assistants provided by the facility, dated 2/20/25, showed 5 feeding assistants with no state approved formal paid feeding assistant training. During an interview on 2/20/24 at 3:30 P.M., Nurse Aide (B) said: - He/she did not attend any formal state approved course for feeding assistant but instead got one on one training with the DON and experienced staff members; - He/she has been a feeding assistant for a few months and assists residents on the floor with meals; During an interview on 2/20/24 at 5:00 P.M., Director of Nursing (DON) said: - Each feeding assistant goes through one on one training over a very specific list of topics before going to the floor; - She was not aware of the requirement of a state approved training course for paid feeding assistants but would investigate and get her staff enrolled.

Based on observations, interviews, and record review the facility failed to provide proper infection control when facility staff did not immediately place one resident (Resident #23) on contact isolation precautions after readmitting to the facility with a positive test for influenza (a highly contagious respiratory illness of nose, throat, and lungs) A, did not have signage in place for (Resident #23) when on transmission based precautions, and did not cover clean laundry during transportation to prevent contamination. The facility census was 78. Review of facility policy, infection prevention and control policy and program, dated 3/12/21, showed: -Staff will reference the Centers for Medicare and Medicaid Services (CMS) guide and Center for Disease Control and Prevent (CDC) guidelines. These references will serve as the facilities guidelines to infection control. Review of CDC guidance titled interim guidance for influenza outbreak management in long-term care and post-acute care facilities, dated September 2024, showed: -Ill residents should be placed on droplet precautions with room restriction and be excluded from participating in group activities as prescribed below: -Droplet Precautions should be implemented for residents with suspected or confirmed influenza for 7 days after illness onset or until 24 hours after the resolution of fever and respiratory symptoms, whichever is longer, while a resident is in a healthcare facility. -Placing ill residents in a private room. If a private room is not available, place (cohort) residents suspected of having influenza residents with one another; -Wear a facemask (e.g., surgical or procedure mask) upon entering the resident's room. Remove the facemask when leaving the resident's room and dispose of the facemask in a waste container. If resident movement or transport is necessary, have the resident wear a facemask (e.g., surgical or procedure mask), if possible. 1. Review of Resident #23's Quarterly minimum data set (MDS), a federally mandated assessment tool completed by facility staff, dated 12/11/24, showed: -Cognition intact; -He/She was dependent on a wheelchair; -He/She required substantial or maximal assistance with toileting and lower body dressing; -Resident required partial to moderate assistance with personal hygiene, bathing rolling left and right, sit to lying and lying to sitting on side of bed mobility; -He/She was dependent for transfers to the toilet or shower, sit to stand transfers and chair to bed transfers; -Diagnoses included: Dementia, diabetes, high blood pressure, depression and weakness. Review of physician's orders, dated 1/19/25-2/19/25, showed: -Started 2/17/25, ended 2/19/25, levogloxacin tablet (tab); 750 milligram (mg); amount (amt): 1 tab; oral, diagnosis: bronchiectasis, once a day: 7:00 A.M.-10:00 A.M.; -Started 2/17/25, ended 2/18/25, oseltamivir capsule; 30mg; amt: 1 cap by mouth, diagnosis: influenza due to other identified influenza virus with other respiratory manifestation, twice a day 7:00 A.M.-10:00 A.M., and 6:00 P.M.-9:00 P.M.; -Started 2/17/25, ended 2/19/25, prednisone tablet; 20mg; amt: 2 tabs; oral, diagnosis: influenza due to other identified influenza virus with other respiratory manifestations, once a day, 7:00 A.M.-10:00 A.M. Review of census report showed resident discharged from facility on 2/13/25 and returned 2/17/25. Review of nursing progress notes for the month of February., showed: -2/13/25 at Licensed Practical Nurse (LPN) E wrote resident's family member came to nurse regarding concern for residents breathing. Residents oxygen saturations on room air was 82%. Physician was notified and resident was sent to the hospital for evaluation and treatment. Resident's family member called the facility later to advise that the resident was admitted to hospital with influenza type A. -2/17/25 at 1:45 P.M., LPN D wrote resident returned to facility. Report was received from hospital indicating resident had been admitted on [DATE] for shortness of air and testing positive for influenza A. During an interview on 2/18/25 at 9:03 A.M. resident said they just got out of the hospital after having influenza. Observation on 2/18/25 at 9:03 A.M. showed resident had no transmission based precautions in place inside or outside of residents room or posted on residents door. Observation on 2/18/25 at 9:44 A.M. showed resident had a three drawer cart added outside their room with gloves, masks, gowns and hand sanitizer. There was no posting on door to indicate why precautions were being followed for this resident room. Observation on 2/18/25 at 9:54 A.M. showed two red barrels were now located outside resident's room. Observation on 2/18/25 at 9:56 A.M. showed two hospice workers pushing two red barrels into residents room from the hallway. Observation on 2/18/25 at 9:57 A.M. showed Nurse Aide (NA) A and Certified Nurse Aide (CNA) C outside resident's doorway and advising resident that they were asked to keep residents door closed and asking for residents consent to close their bedroom door. Observation on 2/19/25 at 8:31 A.M. showed no signage on resident's door. Personal protective equipment remained outside residents room. During an interview on 2/19/25 at 8:31 A.M., Resident said he/she was on quarantine but did not know why. Observation on 2/19/25 at 8:31 A.M. showed two red barrels were in residents room had gowns sticking out over top of container and the lids would not fit on the barrels due to the overflowing containers of doffed personal protective equipment. During an interview on 2/19/25 at 8:33 A.M., CNA C said: -The resident had been hospitalized for influenza; -The resident was on droplet precautions until they were symptom free; -He/she was not sure how long resident was on precautions. During an interview on 2/20/25 at 10:35 A.M., CNA E said: -Resident had influenza currently; -Resident had been hospitalized a week ago with influenza A and returned to facility yesterday; -When residents had influenza staff were to be gowning up and gloving before all cares; -He/She determined the difference between transmission-based precautions and enhanced barrier precautions by the signage on the residents door; -The residents on transmission-based precautions had a sign that read stop and check with nurse prior to entering resident room; -He/She was not sure why resident did not have a sign indicating stop on their door to their room. During an interview on 2/20/25 at 10:51 A.M., CNA G said he/she did not know difference between transmission based precautions and enhanced barrier precautions; During an interview on 2/20/25 at 2:08 P.M., Infection Preventionist said: -He/She worked in the facility full time as the facility infection preventionist; -Resident #23 returned to facility from hospitalization on [DATE]; -Transmission based precautions should have been implemented on 2/17/25 for Resident #23; -He/She had to work as a nurse on the floor on 2/17 and did not know Resident #23 had returned to facility; -He/She did not know expectation for transmission-based precautions when the resident #23 returned to facility with influenza and had a roommate in same room; -Resident #23's roommate had been residing in the same room with resident on transmission based precautions; -Resident #23's roommate had been in dining room and out and about in facility while Resident #23 was on isolation precautions in their room; -Facility in past would offer open single rooms to residents who were on transmission-based precautions or move residents into rooms with residents on same transmission based precautions. During an interview on 2/20/25 at 2:08 P.M., Director of Nursing (DON) said: -When resident has influenza, they expected signage on resident door that read to stop see the nurse; -Facility did not put on their signage what precaution the resident was on; -Resident #23 was coming off transmission-based precautions on 2/21, because they tested positive for influenza on 2/13/25; -The red barrels or doffing containers in transmission-based precaution rooms should not be overflowing; -Red barrels or doffing containers were emptied at end of each shift; During an interview on 2/21/25 at 1:15 P.M., DON said: -She expected transmission-based precaution signage to be posted outside resident's door; -Facility used a sign that said stop and see the nurse; - She expected doffing barrels to be covered and not overflowing During an interview on 2/21/25 at 1:15 P.M., Administrator said: -He/She expected facility policy to be followed; -He/She expected a stop see the nurse sign posted on resident doors on transmission based precautions. 2. Facility did not provide a policy on linen transport. Review of CDC guidance, Laundry and Bedding Guidelines for Environmental Infection Control In Health Care facilities, Parameters of the laundry process, dated 2003, showed: -Placing clean linen in a properly cleaned cart and covering the cart with disposable material or a properly cleaned reusable textile material that can be secured to the cart. Observation on 2/19/25 at 9:35 A.M. showed Laundry Aide A transporting clean laundry to include resident gowns, clean underpads, and resident clothes being wheeled on an uncovered metal cart down 200 hall way and returning clean items to resident rooms and linen storage closets. Observation on 2/19/25 at 9:46 A.M. showed Laundry Aide A transporting clean laundry including resident clothes on hangars that were uncovered. Observation on 2/19/25 at 2:22 P.M. showed Laundry Aide A transporting clean linens including underpads and blankets in an uncovered metal cart. During an interview on 2/20/25 at 2:57 P.M, Laundry Aide B said: -The metal carts were used for clean laundry carts only -Clean laundry was transported to resident rooms using metal cart; -Clean laundry in metal cart were not covered prior to transport to hallways and resident rooms. During an interview on 2/21/25 at 1:15 P.M., DON said she expected laundry to be protected clean laundry to be protected from contamination. During an interview on 2/21/25 at 1:15 P.M., Administrator said she did not expect clean laundry to be protected from contamination during transport.

Based on observation, record review, and interviews, the facility failed to store, prepare, and serve food in accordance with professional standards of food service safety when staff failed to store, prepare, distribute, and serve food in accordance with professional standards for food safety. This had the potential to impact all residents in the facility. The facility census was 68. Facility posted meal times included: Breakfast 7:00 A.M., hall trays at 9:00 A.M.; lunch at 12:00 P.M., hall trays start at 11:30 A.M., and supper at 5:00 P.M. with hall trays at 4:30 P.M. Review of facility policy- Three Sink Method of Sanitizing, dated [DATE], included: -In using a chemical sanitizer, the sanitizer must be mixed at the proper concentration of 200 parts per mission (PPM). During an observation on [DATE] at 11:15 A.M. showed sanitizer bucket tested at 0 parts per mission (PPM). During an interview on [DATE] at 8:47 A.M., Dietary Aide B said: -He/she did not do any changing of sanitizer buckets; -He/she did wash dishes using sanitizer machine and did not know how to test to ensure dishwasher is working properly. During an interview on [DATE] at 8:55 A.M., Dietary Aide C said: -There is a three sink method that is followed for sanitation including chemicals added and the right temperature is maintained; -He/she tested sanitizer buckets by using sanitizer strips; -Sanitizer strip are supposed to show 200 ppm; -He/she tested dishwasher before, during, and after use; -A log book is maintained of all sanitizer readings. During an interview on [DATE] at 9:20 A.M., Cook A said: -Sanitizer bucket is changed every couple of hours; -Test strips are used to test the sanitizer bucket. Review of facility policy- Food Storage, dated [DATE], included: -All food stock will be rotated and consumed in the sequence obtained. First in-first out. -Close attention will be paid to open dates marked on all products. No new food will be brought into the building on a date that is beyond any dates marked on the product. -Perishable foods will be held no longer than the time frames listed on the attached schedule. The schedule will be posted outside both the cooler and the freezer. -Prior to use of food, the dietary cooks will check dates to ensure the food is not expired. -Food storage areas will be checked on a weekly basis to ensure that foods are being dated when opened and foods are being discarded in a timely manner. All food dates will be checked prior to each use. -Food storage items -Luncheon meats - opened package or deli sliced - refrigerator 4 days -Hot dogs - freezer - 1 to 2 months -Leftovers - 3 days Review of facility policy, untitled, undated, showed -Dispose of uneaten leftovers -Properly handled leftovers usually be kept in refrigerator for three to four days. If not eaten within that time, they should be discarded. During an interview on [DATE] at 8:47 A.M., Dietary Aide B said: -He/she began employment on [DATE]; -He/she had no meetings on food service or training's since starting employment; During an observation on [DATE] at 11:15 A.M., showed: In walk in cooler: -Opened box of bologna lunch meat covered with saran wrap dated opened ,d+[DATE], use by ,d+[DATE] -Opened, 2% milk undated with no opened date; -Opened, white cranberry juice undated with no opened date; -Opened, demi danish box with four danishes removed with no opened date; -Two cottage cheese in serving cups sitting on tray with saran wrap with no use by or opened date; -Two containers of peaches in a serving cup covered with saran wrap with no use by or opened date; In dry storage room: -Opened and undated bag carton Italian special elbow macaroni ; -Opened and undated creamy classic mashed potatoes; -Opened and undated complete pancake mix in 5 lb box; In walk in freezer: -Opened and undated box of hot dogs, exposed to freezer burn with no cover; -Opened and undated frozen carrots. During an interview on [DATE] at 8:47 A.M., Dietary Aide B said: -There is stickers for dating food which he/she would write what item is, when it was stored, and circle what day item should be changed; -He/she is unsure when leftover or opened food items should be discarded. During an interview on [DATE] at 8:55 A.M., Dietary Aide C said: -Food should be dated when received off truck and opened; -Juices and drinks are dated for one week due to going through them real fast; -If food is expired it is thrown out -Do not usually save leftovers, a tray is left out for employees to eat; -He/she did not know how long items could be stored in fridge after it was cooked; -Any item that has been opened should have a date; -Any item that goes in cooler had to have a date; -Old items on shelf are brought forward and new items placed in back of shelves; -He/she had worked in kitchen for eight years -His/her training involved learning how to make drinks, setting up North hall for meal sure, and ensuring North hall always had coffee; -Food safety means ensuring foods are at right temperature, ensuring residents do not get burned, making sure food is right temperature when gets to residents at table, and ensuring dating food. During an interview on [DATE] at 9:20 A.M., Cook A said: -Food should be dated whenever it is opened; -Food items are also dated when they arrive off the food delivery truck; -Leftovers can be kept and stored for three days During an interview on [DATE] at 9:31 A.M., the Dietary Manager said: -When storing foods fevering had to be wrapped, labeled, dated -Food should be dated with date it is received and an opened date -Items that come in boxes with date already on it we do not add an additional date to; -Food should be thrown out three days from when it has been opened. During an interview on [DATE] at 2:40 P.M., the Administrator said: -Food should be dated when opened -Aware some items arrive with dates on box and they go by storage dates on box Review of facility policy on Hot Food Temperature Requirements, dated [DATE], included: -Major causes of foodborne illnesses are improper cooking, cooling, reheating, hot holding, and cold holding of foods. when hot foods are held in the temperature danger zone (41 degrees-135 degrees Fahrenheit), disease-causing organisms that are naturally present in the foods as well as those introduced through incidental contamination, will grow more rapidly ad progressively. A larger number of disease causing organisms increases the risk of possible foodborne illness. That is why hot foods must be maintained at or above 135 degrees Fahrenheit at all times. -Hot hold all foods at or above 135 degrees and check temperatures frequently. -Always check final temperatures with a probe thermometer. During a continuous observation on [DATE] from 11:09 P.M.-12:45 P.M. showed: -Cook A did not temperature check foods prior to plating meals from steam table at 11:23 A.M. when hall trays left kitchen at 11:44 A.M. when dining room trays were being plated; -Food temperatures were recorded on food log included turkey sandwiches 40 degrees, coleslaw 45 degrees, mashed potatoes, 150 degrees. During an interview on [DATE] at 12:28 P.M., Cook A Said: -Food temps are checked before they go on steam table; -He/she documented food temperatures on the log hanging on fridge; During an interview on [DATE] at 8:47 A.M., Dietary Aide B said: -He/she did not know anything about temperature checking food During an interview on [DATE] at 8:55 A.M., Dietary Aide C said: -Food temperature checks are completed as soon as breakfast, lunch or supper is placed on steam table; -Food is on steam table thirty to forty minutes before food is served -Some foods like noodles will cook on steam table, so cooks do not fully cook them on oven; During an interview on [DATE] at 9:31 A.M., the Dietary Manager said: -Food temperature checks should occur when food had been cooked -Food temperature checks should also occur when food is put on steam table -and before food service to ensure food is holding its temperature. -Lunch is usually on the steam table an hour before it is served; -We do hall trays at 11:30 A.M. and Cook B temperature checked them at or before 11:30 A.M. prior to food being served to dining room. During an interview on [DATE] at 2:40 P.M., the Administrator said: -Food should be temperature checked at beginning of meal and before meal is served. Facility provided no policy on kitchen sanitation. During an observation on [DATE] at 11:32 A.M., showed: -Food crumbs on food cart with hot plate food covers -Grease container on griddle was full; -Clear plastic shoe box container full of grease and grime residue sitting next to griddle -Yellow oily substance pooled on floor behind stove/griddle where cook was standing to serve from steam table During an observation on [DATE] at 11:11 A.M., showed -Yellow oily substance pooled on floor still present as observed on [DATE] During an interview on [DATE] at 8:55 A.M., Dietary Aide C said: -Kitchen had cleaning process; -Sweep and mop floors every night and after every meal -Deep clean once or twice a week; During an interview on [DATE] at 9:31 A.M., the Dietary Manager said: -He/she delimed dish machine once a week; -Steamer gets delimed once a month; -Grease trap gets cleaned once a week under the dishwasher; -Daily cleaned included wiping off counters, sweeping and mopping, scrubbing sinks; -At end of each day is when most of cleaning is completed -Evening shift sweeps and mops the walk in cooler, ensures all shelves are cleaned -Walls are cleaned once a week -He/she writes a to do list of assignments and magnets the task assignment to the fridge -Grease trap on stove has a hole in back of it and sometimes grease will splatter out off it, the grease will fall out of back of hole. Facility provided no policy on facility utensils for food service. Observation on [DATE] at 12:03 P.M. showed dessert of brownies being served on plastic cup lids. During a continuous observation on [DATE] from 11:09 P.M.-12:45 P.M. showed: -12:11 P.M., Cook A requesting for Dietary Aide to go locate paper plates when ran out of regular plates during food plating; -12:14 P.M., Cook A observed cutting tops off of foam food boxes and serving last eight plates on foam to go box food containers; During an interview on [DATE] at 11:25 A.M., Dietary Manager said: -He/she did not have enough serving bowls for desserts currently. During an interview on [DATE] at 12:13 P.M., Cook A said he/she did run out plates. Cook A stated during the last few weeks there had been less and less plates available. He/she is unsure if staff are keeping plates in resident rooms or what is going on. During an interview on [DATE] at 8:47 A.M., Dietary Aide B said: -Facility is short on silverware; -Facility was short on cups, but more cups had been obtained -Plates are an issue and he/she had seen facility run out of them; -He/she did serve dessert on disposable lids; During an interview on [DATE] at 8:55 A.M., Dietary Aide C said: -There was issue with having enough plates for meal service due to COVID; -He/she stated when find out resident had COVID they have to throw away all dishes that were used by that person as it is too hard to wash it, the facility did not run items through sanitizer; During an interview on [DATE] at 9:20 A.M., Cook A said: -There is shortage of plates, but is unsure why -Utilize disposable utensils and Styrofoam plates and cups for COVID positive residents meal service; During an interview on [DATE] at 9:31 A.M., the Dietary Manager said: -He/she is aware of shortage of plates; -He/she believes shortage of plates is related to an increase in census; -Shortage of plates is also related to open dining in which facility did not wake residents for meals and allows them to wake up and have breakfast when they want us, then some breakfast plates are not returned to kitchen prior to lunch service; -Disposable utensils are used for residents on transmission based precautions. During an interview on [DATE] at 2:40 P.M., the Administrator said: -He/she was not aware of a shortage of plates Review of handout, when to wash hands, undated, showed: -Wash hand before: beginning work and after breaks, preparing and serving food, putting on or changing gloves, assisting a customer with dining, handling medication. -Wash hands after: using the restroom, touching raw meat, poultry, fish or eggs, or other potentially hazardous foods; eating, smoking, or chewing gum; touching soiled plates, utensils or equipment; sweeping, mopping or wiping counters; touching your nose, mouth or any part of your body; sneezing or coughing; handling trash, money, the phone, or other unclean objects; using chemicals. Review of handout, glove-ology, undated, showed: -Glove use in food service can be a very confusing concept. The following will help you use gloves properly to assure safe food to your customers. -Wash hands thoroughly before and after wearing or changing gloves is most important thing you can do to reduce surface bacteria, sweat, dirt, and grim build-up on skin and under nails. -Scrub with a nail brush 20 seconds before putting on new gloves. -Glove use in itself does not guarantee food safety. always wash hands before and after using disposable gloves. -Glove size is important for safety and comfort. -Use gloves for designated food tasks only. Disposable gloves are task-specific and should never be worn continuously. -Food contact gloves should not be used for non-food tasks such as handling money, garbage removal, cleaning services, etc. -The FDA Food Code stipulates no bare hand contact with ready-to-eat foods; therefore use gloves with salad bar items, fruits, sandwiches, cooked foods, deli meats, cheeses, breads or ice. -Use vinyl, synthetic, or latex gloves when handling food near a heat source cooking area, rather than ply gloves which are not resistant to heat. -If you handle raw meats, poultry, or seafood with gloves on, do Not touch ready-to -eat or cooked foods without washing hands and changing gloves. -Always wash hands between glove changes. -When using a cut resistant glove with ready-to -eat food, wear a disposable glove on top to avoid cross-contamination. -Change gloves after sneezing, coughing, or touching your face or hair. -Always wear gloves if you have a bandage, infection, cut or sore, and avoid direct food handling duties temporarily. -Always remove disposable gloves correctly, grasp at the cuff and peel them off inside out. -FDA food code states that workers wearing artificial nails or fingernail polish must wear disposable gloves. -None-latex gloves are recommended for food workers, to help avoid possible latex allergic reactions Observation on [DATE] at 11:52 A.M. showed food service staff entering and leaving kitchen wearing latex gloves, not sanitizing between residents plates being served to them. Aides observed assisting residents with cutting up foods, obtaining drinks, and providing condiments. During a continuous observation on [DATE] from 11:09 A.M.-12:45 P.M. showed: -Dietary Aide D entered kitchen, did not wash hands, exited into dining room -Dietary Aide B washed hands, applied gloves, scratched head and hair net with gloved hands, exited kitchen at 11:14 A.M.; -Dietary Aide D entered kitchen, did not wash hands, put dirty dish in sink, left kitchen; -Dietary Aide B entered kitchen wearing gloves, did not wash hands or sanitize, advised cook ready to start meal service to dining room. -Dietary Aide D takes first plate into dining room, re-enters kitchen wearing same gloves. -Dietary Aide B took out second meal plate to dining room, re-enters kitchen wearing same gloves, opens may packet out of box, tears open with gloves, exits kitchen with another plate. -Dietary Aide D takes plate out to dining room, returns to kitchen, did not sanitize, opens up mayo packet places mayo packet on plate on top of steam table, and goes back out into dining room; -Dietary Aide A entered and exited kitchen multiple times while wearing the same gloves and serving residents their meals. Dietary Aide A washed hands only one time at 12:01 P.M. after entering and exiting the freezer. He/she was observed serving multiple residents and assisting with meal service. -Dietary Aide B washed hands at sink and used clean hands to turn off faucet at sink at 12:22 P.M. During an interview on [DATE] at 8:47 A.M., Dietary Aide B said: -Hand washing should be completed after serving every three to four residents; -He/she would take off gloves and wash hands; -He/she did help residents cut up their food in between gloves changes; -He/she is aware of cross contamination; -If he/she had gloves on and touched chicken he would need to go change gloves and wash his/her hands or if he/she completed dishes, he/she would need to take gloves off, wash hands, and apply new gloves before served food. During an interview on [DATE] at 8:55 A.M., Dietary Aide C said: -He/she had received hand washing training; -His/her hands should be washed every time enters kitchen; -He/she sings the ABC song as he washes hands and ensures washed between fingers, goes up to elbows; -Whenever washed hands then applied gloves prior to taking out plates and drinks for meal service; -If he/she touches resident's items such as their drink cup while serving plates then he/she would take off gloves, wash hands or sanitize and apply new gloves. During an interview on [DATE] at 9:20 A.M., Cook A said: -He/she completed hand washing training during orientation; -Hand washing should be completed anytime entering the kitchen; -He/she washed hands while singing the happy birthday song, and grabbed papertowel to use to turn off faucet; -Rewashes hands any time there is cross contamination. During an interview on [DATE] at 9:31 A.M., the Dietary Manager said: -Employees are to wash hands as frequently as possible and applying gloves; -He/she wants employees to ensure they are not overusing their gloves by changing gloves when changing tasks; -Employees should wash hands every time they change their gloves; -Training is completed every month when the dietician comes into the facility; -He/she did not keep a current log of training with employees. During an interview on [DATE] at 2:40 P.M., the Administrator said: -Staff should wash hands between everything touched from clean to dirty; -If staff is touching resident then they should not touch a clean tray and would be expected to wash hands in between; -Gloves are good until touch something is considered dirty.

Based on interview and record review, the facility failed to prevent one resident (Resident #1) from eloping from the facility through a door where the alarm was turned off and exiting from the facility for approximately one hour with the temperature 23 degrees Fahrenheit (F). The resident was admitted to a local hospital with hypothermia. The facility census was 64. The Administrator was notified on 1/19/22 at 3:48 P.M. of an Immediate Jeopardy (IJ) which began on 1/19/22 . The IJ was removed on 1/20/22 as confirmed by surveyor onsite verification. 1. Review of the undated facility policy on Wandergard (a bracelet worn by residents and sets off an alarm when a resident approaches the exit) showed: - Resident safety was the first priority. - Staff provided adequate supervision to provide the safest environment. - Staff will assess all residents for behaviors that put them at risk for elopement. - Residents that are assessed by staff to be at risk for elopement will wear a Wandergard bracelet at all times. - Staff must check the Wandergard bracelet every night and document the test. - The Maintenance Supervisor (MS) will check and perform a weekly test of the door alarms. Review of Resident #1's care plan, dated 4/16/21, showed: - The resident had cognitive issues due to dementia. - The resident waited in the common room thinking he/she could go home. - The resident required a Wandergard. - The resident took blood thinners due to a cardiac issue which placed the resident at risk for increased bleeding. Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 8/25/21, showed: - Unable to complete cognitive assessment due to inattention. - Delusions; - Wandered one to three days; - Required staff assistance for transfers, dressing, eating, and hygiene; - Independent of walking; - Used a walker; - Diagnoses included non-traumatic brain dysfunction, heart failure, kidney insufficiency, Alzheimer's disease, and anxiety; - Received antipsychotic, antidepressant, and blood thinning medications. Review of the local weather history, dated 1/19/22, showed the outdoor temperature was: - 27 degrees Fahrenheit (F) at 6:53 A.M. - 23 degrees F at 7:53 A.M. Review of the resident's nurses' notes, dated 1/19/22 at 7:59 A.M., by the Director of Nursing (DON) showed: - The last time staff saw the resident was at 6:30 A.M. - Staff notified Licensed Practical Nurse (LPN) A at 7:35 A.M. that they could not find the resident. - Staff began searching for the resident in the facility. - Staff found the resident outdoors at 7:50 A.M. lying on the ground and fully dressed. - Staff immediately covered the resident with blankets and with the assist of four staff members transferred the resident to a wheelchair. - The resident responded to staff by opening his/her eyes and moving his/her legs. - Emergency medical services (EMS) arrived at the facility at 7:59 A.M. - The resident left the facility at approximately 8:15 A.M. for a emergency department (ED). Review of the resident's ambulance form, dated 1/19/22 at 8:20 A.M., showed: - Chief complaint hypothermia; - Second complaint laceration to right forearm; - Staff applied supplemental oxygen, an intravenous (IV) access with IV fluids, and external warming applied; - Assessment showed the resident was mottled, cold, with decreased capillary refill (indicates how well tissues were perfused), mental status unchanged for resident; - The resident was cold to touch with several pieces of ice on clothing. - The blankets were blood soaked from a deep laceration on the right forearm. - The resident was emergently transported to a local ED. Review of the resident's medical records, dated 1/19/22, from the local hospital showed: - History of present illness showed the facility stated staff last saw the resident around 6:30 A.M. - Staff found the resident outside around 8:00 A.M. - The outdoor temperature was 20 degrees F. - The resident's core temperature was 86 degrees F (normal temperature 97-99 degrees F). - Multiple lacerations on right hand and forearm requiring repair. - ED staff immediately began warming with warm IV fluids and blankets. - The resident had multisystem organ failure due to hypothermia, evidence of muscle injury, acidosis (caused by acute illness or injury) and a urinary tract infection (UTI). - The resident was admitted to intensive care unit (ICU). During an interview on 1/19/22 at 12:05 P.M., Certified Nurse Assistant (CNA) A said: - He/she started his/her shift at 6:45 A.M. - He/she started doing resident rounds. - CNA B and CNA C said they could not find the resident. - They started looking for the resident. - The resident frequently went into other residents' rooms and slept in other residents' beds. - Typically in the morning the resident was at the nurses' station. - They did not find the resident in the facility. - He/she went outside the 400 hall exit and found the resident outside the chain link fence lying on the snow covered ground. -The 400 hall door alarm was turned off. - He/she immediately got help and bought blankets. - With the assist of four staff, they placed the resident in a wheelchair. During an interview on 1/19/22 at 12:40 P.M., CNA C said: - He/she arrived for work at 6:45 A.M. - Received report from the off-going shift. - They did not view each resident prior to starting work. - CNA C said he/she could not find the resident. - They started looking for the resident. - He/she checked resident rooms and bathrooms. - CNA A found the resident outdoors. - The 400 door exit was not alarming. - He/she went to the laundry and got blankets out of the dryer. - He/she should view every resident prior to starting duties. During an interview on 1/19/22 at 12:50 P.M., CNA B said: - He/she started work at 6:45 A.M. - He/she started getting residents up. - He/she did not view all residents prior to starting to get residents up. - He/she should have viewed all residents prior to getting residents up. - The 400 hall door alarm was turned off. - He/she went outside to help with getting the resident back into the facility. During an interview on 1/19/22 at 1:00 P.M., LPN A said: - He/she was the resident's charge nurse. - He/she did not see the resident at change of shift. - He/she should have seen all residents prior to starting work. - The night shift said they saw the resident in the dining room around 6:30 A.M. - When staff said the resident was missing, he/she immediately started searching for the resident. - The resident frequently went into other resident's rooms and slept in their beds. - CNA A found the door alarm on 400 hall exit was turned off. - CNA A found the resident lying in the snow outside the chain link fence outside the 400 hall. - Staff placed blankets underneath and on top of the resident. - With assist of four staff, the resident was placed in a reclining chair and brought into the facility. - Staff called 911. - Could not obtain a body temperature or an oxygen saturation. - Emergency Medical Services (EMS) arrived by 8:00 A.M. and promptly transported the resident to the hospital. During an interview on 1/19/22 at 1:10 P.M., the DON said: - He/she arrived around 7:20 A.M. - Around 7:30 A.M. LPN A told him/her the resident was missing. - He/she started to assist with finding the resident. - CNA A found the resident outside the 400 hall exit beyond the chain link fence lying in the snow. - CNA A yelled for help and staff promptly responded. - The resident was lying on the lightly snow covered ground on his/her back. - The resident was wearing a short sleeved shirt, pants, shoes, and socks. - The resident opened his/her eyes when staff spoke. - Staff put blankets under and on top of the resident. - Four staff lifted the resident into a reclining chair and took the resident into the facility. - Staff could not obtain a body temperature or an oxygen saturation. - Staff did not routinely view every resident prior to starting duties. - Staff should view each resident prior to starting duties. - The last time a staff member saw the resident was around 6:30 A.M. in the dining room. - He/she interviewed all staff and none of them knew how the 400 door alarm got turned off. Observation on 1/19/22 at 1:10 P.M., of the facility door exits showed: - The main exit door and the exit door by the kitchen were Wandergard alarmed. - The exit door by the gazebo and the 400 hall had a key plate on the side of the door with the key removed. (The key turned the alarm on and off. After the resident eloped staff removed the key.) - The rest of the exit doors alarmed when opened. During an interview on 1/19/22 at 3:00 P.M., the Maintenance Supervisor (MS) said: - The main exit door and the exit door by the kitchen were Wandergard alarmed. - The exit door by the gazebo and the 400 hall had a key plate on the side of the door with the key removed. - The rest of the exit doors alarmed when opened. - He/she checked the door alarms weekly. -The door alarm used the key system. It had an on and off position when the resident got out. During an interview on 1/20/22 at 12:30 P.M., the Facility Medical Director said: - The resident wandered. - The 400 hall exit should have alarmed. - The resident was ill due to exposure to the extreme cold weather. MO196089, MO196111 NOTE: At the time of the abbreviated survey, the violation was determined to be at the immediate and serious jeopardy level J. Based on observation, interview and record review completed during the onsite visits, it was determined the facility had implemented corrective action to remove the IJ violation at the time. A final revisit will be conducted to determine if the facility is in substantial compliance with participation requirements. At the time of exit, the severity of the deficiency was lowered to the D level. This statement does not denote that the facility has complied with State law (Section 198.026.1 RSMo.) requiring that prompt remedial action to be taken to address Class I violation(s).

Based on observations, interviews, and record review the facility failed to provide the necessary care and services to maintain the highest practicable physical, mental, and psychosocial well-being for one of 13 sampled residents (Resident #3) when staff failed to assess the resident, and provide break-through pain medication, for severe pain associated with his/her [DIAGNOSES REDACTED]. The facility census was 69. 1. Review of the facility's policies showed the facility did not provide a pain assessment policy. Review of the facility's undated Prevention of Pressure Ulcers (PU) policy, showed: - Goal: To prevent PU by identifying residents at risk and provide prompt intervention. - All residents will be monitored by the charge nurse during daily cares and will assess for problems which required additional nursing interventions. Review of the facility's undated policy to Identify and Treat Residents with Constipation showed: - Purpose: Good digestive health is extremely important in maintaining good physical health and well being. This policy was written to provide a plan for identification and intervention to promote this concept. - Procedure: The night shift charge nurse was responsible for checking the activities of daily living (ADL) sheets for all residents to determine which residents did not have a bowel movement for three days. The names of these residents would be provided to the day shift charge nurse who would be responsible for initiating treatment. - The policy did not provide instruction for the certified nurse's aides (CNA) in how to document bowel movements such as formed stool, liquid stool, soft or hard stool, or the size of a stool such as small, medium, large, or extra large. 2. Review of Resident #3's physician's orders [REDACTED]. - [MEDICATION NAME] (a narcotic made up of Tylenol and [MEDICATION NAME], used to treat moderate pain) 5 milligrams (mg)/325 mg; - [MEDICATION NAME]((long-acting [MEDICATION NAME] tablets used to treat severe pain; a narcotic) 15 mg A.M., mid day, and at bedtime; - [MEDICATION NAME] mg at A.M. and bedtime; - Milk of Magnesia (MOM, a laxative) 30 cubic centimeters daily for constipation x seven days per facility protocol. Review of Resident #3's admission Minimum Data Set (MDS), a federally-mandated assessment instrument completed by facility staff, dated 6/21/12, showed: - A Brief Interview for Mental Status (BIMS) score of nine which indicated poor decision making, supervision needed. - Always continent of bladder and bowel; - No bowel program; - No falls since admission; - Scheduled pain medication regimen; - No "as needed" (PRN) pain medications needed; - No pain present at time of interview; - No risk for PU development; - [DIAGNOSES REDACTED]. Review of the care plan, dated 6/22/12, showed: - Problem: Needed assistance with ADLs; - Approaches: Needed assistance with dressing, bathing, and grooming; staff transported in wheelchair; ambulated with therapy only; - Problem: At risk for PU; in bed most of day, self limited mobility, poor nutrition, cancer; admitted with reddened area to coccyx and Stage II (partial thickness loss of skin presenting as a shallow crater with a red, pink wound bed, without slough, and may present as an intact fluid filled blister) PU on the right buttock; - The care plan did not address pain or constipation. Review of a telephone order, dated 7/13/12, showed: - Hospice to evaluate for admission for metastatic (cancer that spreads to other parts of the body) cancer of the prostate. Review of a fax sent to the resident's physician, Physician A, dated 7/14/12, showed: - Open area to the left inner buttock, 1 centimeter (cm) x 2.1 cm; Review of a social service note, dated 7/17/12, showed: - Family starting the process of finding hospice care for the resident; - Social service designee will provided assistance as needed. Review of a fax, dated 7/18/12, to Physician A showed: - Very tearful this A.M.; - [MEDICAL CONDITION] in bilateral lower extremities; - Resident crying and shaking, and was short of air. Review of a hospice nurse's note, dated 7/25/12, showed: - admitted to hospice; appetite poor; rarely incontinent of bowel and bladder, but episodes of each have increased; had daily break-through pain; confused; complained of pain in left buttock wound; open area to buttock which is a source of pain; facility nurse administered scheduled pain medication. Review of the care plan, updated 7/26/12, showed: - The care plan did not address any type of pain or constipation. Review of the significant change MDS, dated [DATE], showed: - Short- and long-term memory problems; - Rarely understood; - Poor decision making, supervision needed; - Extensive assist of one staff for bed mobility; - Always continent of bowel and bladder; - No bowel program; - Pain management: PRN pain medications; - Moderate pain almost constantly; - No falls since admission; - At risk for PU development; - Three unstageable (full-thickness tissue loss in which the base of the PU is covered by slough - yellow, tan, gray, green or brown - and/or eschar - tan, brown, or black, dead tissue- in the wound bed) PUs; - One Stage II PU which was not present with the previous assessment; - Hospice (provided palliative care for the terminally ill resident); - [DIAGNOSES REDACTED]. Review of the Care Area Assessment (CAA, used by staff to develop a resident's plan of care using their individual MDS assessments) Summary, dated 8/1/12, showed: - Findings for activities of daily living (ADLs: bathing eating, dressing, transfers, and bed mobility) included: unable to perform self care, overall health decline, depressed, ate very little, weakness and poor balance; decline in transfer ability; acquired skin issues, up for meals and showers only determined by nursing judgment, metastatic [MEDICAL CONDITION]; - Care plan considerations: Anticipate needs and provide comfort measures; hospice ordered 7/25/12; staff assist with all ADLs and transfers; - Findings for falls: At risk for falls, overall health decline, not eating well, weakness and poor balance; - Care plan considerations: No injuries related to falls through next review, continent of bowel and bladder. - Findings for nutritional status: Not eating well, skin issues, history [MEDICAL CONDITION]; - Findings for PUs: Currently had three skin issues related to potential factors of pressure and friction and overall health decline, weakness, scooting/sliding in bed/chair, poor nutrition/inadequate fluid intake, [MEDICAL CONDITION], psychiatric, and pain medications; metastatic [MEDICAL CONDITION]; - Care plan considerations: Skin issues will improve, referred to hospice on 7/25/12, low air loss mattress (an air filled mattress which alternated inflation and deflation of cells to constantly change the pressure points on the skin and promoted circulation), turn and reposition every two hours and PRN, use pillows/padding for comfort and to reduce pressure, remind staff to not scoot/slide when providing cares, continent of bowel and bladder, pain addressed with MS Contin. - Findings for pain: Metastatic [MEDICAL CONDITION], daily moderate pain, often refuses PRN pain medications; -Care plan considerations: Will utilize PRN pain medications, assist with repositioning using pillows/padding to alleviate pain and pressure, pain addressed with MS Contin, nursing assessment daily for pain, hospice to assess pain, offer and encourage pain medications, and monitor PRN pain medications for effectiveness. Review of the July/August 2012 medication administration record (MAR) showed: - From 7/29/12, through 8/2/12, staff administered [MEDICATION NAME] (a stool softener) 200 mg daily. - Staff administered MOM 30 ml on 7/18/12, 7/29/12, 8/2/12. and 8/14/12. - Staff administered [MEDICATION NAME] SL 0.5 ml on 8/13/12 and 8/14/12. - Staff administered [MEDICATION NAME] 5/325 mg PRN on 7/18/12, 7/20/12, 7/23/12, 7/25/12, 7/28/12, 8/1/12, 8/2/12, 8/3/12, 8/6/12 two times, 8/7/12, 8/8/12, 8/10/12, 8/11/12, 8/12/12 two times, and on 8/14/12. - Staff administered scheduled [MEDICATION NAME] mg every morning and every night at bedtime, and [MEDICATION NAME] mg every day at midday, Review of the care plan, updated 8/1/12, 8/2/12, and 8/8/12, showed: - 8/1/12: Hospice; - 8/2/12: Staff to provide oral care, give medications in applesauce due to difficulty swallowing, hi/low bed, bed to floor when in bed with fall mats, mattress with side bolsters (raised areas to prevent falls), check frequently for toileting needs. Review of an updated hospice care plan, dated 8/2/12, showed: - Constipation, always incontinent, hypoactive bowel sounds, digital exam (felt for stool in rectum with fingers) by hospice registered nurse (RN); extra large impaction or hard stool found and removed; large amount of stool left in rectum; - Abdominal pain with impaction; - Give laxative/softener as ordered, assess for bowel sounds each visit, check for impaction PRN; MOM per facility protocol by mouth for seven days. - Depressed and anxious; [MEDICATION NAME] (an anti-anxiety medication) 2 milligrams (mg)/milliliter (ml), give 0.25 ml to 1.0 ml sublingual (SL) every one to two hours PRN for anxiety. Review of a nurse's note, dated 8/2/12, showed: - Hospice nurse removed a large amount of hard stool; MOM given in prune juice. Review of a nurses' note, date 8/8/12, showed: - Unstageable wound to the right outer ankle; measured 0.5 cm x 0.5 cm with dry eschar; - Unstageable wound to the left outer ankle; measured 1.2 cm x 1 cm with dry eschar; - Unstageable wound to left buttock; measured 4 cm x 3.5 cm x 1.7 cm with 1.5 cm tunneling (course or pathway that can extend in any direction from the wound and results in dead space), black eschar center of wound, foul odor from the wound, large amount of serous drainage - The nurse's note did not document an assessment of pain or the administration of pain medications other than [MEDICATION NAME] Spray to the the wound during the dressing change. Review of a hospice nurse's note, dated 8/7/12, showed: - Pain rated a one to two on a pain scale of zero to 10 with 10 being the worst pain. - The resident whines, moans, and grimaces with pain; - Pain all over with movement and buttock wound pain; - [MEDICATION NAME] (a synthetic [MEDICATION NAME] and Tylenol for moderate pain), [MEDICATION NAME] (a steroid for treatment of [REDACTED]. - Hospice nurse requested facility staff to administer [MEDICATION NAME] to the resident. Review of the facility's MAR, dated July/August, 2012, showed: - Staff administered scheduled [MEDICATION NAME] mg in the A.M. and at bedtime daily; and [MEDICATION NAME] mg mid-day daily as ordered. - On 8/7/12, at 9:45 A.M., staff administered a PRN break-through medication, [MEDICATION NAME] 5/325 mg but did not document the number of tablets administered; the MAR showed staff could give one or two tablets every four hours PRN. how - On 8/8/12, at 11:00 P.M., staff administered [MEDICATION NAME] 5/325 mg but did not document the number of tablets administered. Review of a telephone order, dated 8/8/12, showed: - Bactrim DS (an antibiotic), one capsule daily for 10 days for wound infection; -[MEDICATION NAME] (an antibiotic spray used for wound infections and to decrease odor due to infection) 1% twice daily (BID) to buttock wound after cleansing wound; - [MEDICATION NAME] 0.2%/ [MEDICATION NAME] 2% (a narcotic pain relief spray used on PU), spray to wound prior to providing wound care/dressing change and PRN; - Discontinue Pixie Dust (which was ordered on [DATE] to decrease the odor of the wound caused by infection). Review of the facility's MAR, dated July/August, 2012, showed staff documented the following: - Staff did not document they administered any breakthrough pain medication on 8/9/10. - On 8/10/12, at 10:00 P.M., [MEDICATION NAME] 5/325 mg but did not document the number of tablets they gave. - On 8/11/12, at 9:30 P.M., [MEDICATION NAME] 5/325 mg but did not document the number of tablets they gave. - On 8/12/12, at 12:45 A.M., [MEDICATION NAME] 5/325 mg but did not document the number of tablets they gave. . - On 8/12/12, at 9:30 P.M., [MEDICATION NAME] 5/325 mg but did not document the number of tablets they gave. - On 8/14/12, at 1:00 A.M., [MEDICATION NAME] 5/325 mg but did not document the number of tablets they gave. - From 7/29/12, through 8/2/12, staff administered [MEDICATION NAME] (a stool softener) 200 mg daily. - Staff administered MOM 30 ml on 7/18/12, 7/29/12, 8/2/12. and 8/14/12. Review of a facility nurse's note, dated 8/15/12, for the evening shift showed: - The resident spit out [MEDICATION NAME] other medications; hospice notified. Review of a hospice nurse's note, dated 8/16/12, at 9:15 A.M., showed: - Contact physician for change in pain medication because the resident spits out his/her medications. - No non-verbal signs of pain this visit. Review of a telephone order, dated 8/15/12, showed: - [MEDICATION NAME] (a liquid anti-anxiety medication placed under the tongue for quicker absorption and effectiveness) 2 mg/ ml, administer 0.25 ml to 1 ml sublingual (SL, under the tongue) every one to two hours PRN for anxiety; - Continue [MEDICATION NAME]/[MEDICATION NAME] spray to wound. Review of the wound sheet, dated 8/16/12, showed: - Unstageable left buttock wound; measured 4 cm x 3.8 cm x 1.5 cm with 3.4 cm tunneling area, pink center with granulation (new, healthy tissue); -[MEDICATION NAME] and [MEDICATION NAME]/[MEDICATION NAME] spray to wound, [MEDICATION NAME] rope to tunneling area and [MEDICATION NAME] AG cover to center of wound daily; - Unstageable left ankle wound; - Unstageable right ankle wound. - Review of facility nurse's note, dated 8/16/12, showed staff did not document a pain assessment of the resident for any shift. Review of the MAR for August/September, 2012, showed: - On 8/17/12, at 12:15 A.M., staff administered [MEDICATION NAME] 2 mg/ml, 1 ml SL to the resident for anxiety. Review of telephone orders, dated 8/17/12, showed: - At 4:00 P.M. staff received an order for [REDACTED]. - Hold [MEDICATION NAME] mouth and wait for a discontinue order. - At 5:00 P.M. staff received an order to discontinue MS Contin. Review of a facility nurse's note, dated 8/18/12, at 1:20 A.M., showed: - The resident complained of right knee pain and requested pain medication. - LPN F administered [MEDICATION NAME] 5/325 mg for pain. Review of an untimed telephone order, dated 8/18/12, showed: - [MEDICATION NAME] 20 mg/ml, administer 0.25 ml to 1 ml SL every 1 hour PRN. - Licensed Practical Nurse (LPN) G, the day shift charge nurse, wrote the order. Review of facility nurses' notes for the day shift, dated 8/18/12, showed: - No staff documented an assessment of pain for the resident and did not document an assessment of a BM. Review of a facility nurse's note, dated 8/18/12, at 8:50 P.M., showed: - LPN E (the evening charge nurse) documented the resident was tearful at times on the evening shift; - Did not document complaints or signs of pain; - At 8:50 P.M., LPN E administered [MEDICATION NAME] SL and [MEDICATION NAME] SL and the resident talked about dead fish. - LPN E left the resident's room and was in another resident's room when he/she heard a loud noise. - LPN E went back to Resident #3's room and found the resident laying on the floor between the bed and the recliner in his/her room and the resident's head rested on the recliner's seat edge. - Air mattress had bumpers to prevent him/her from rolling out of bed. - Staff assisted the resident back to bed and he/she did not complain of pain. - The resident's blood pressure was 103/104, pulse was 103, and respirations were 20 (which could be an indication pain.) - Floor mats were placed by the resident's bed; closely monitored. - At 10:00 P.M.: LPN E notified the physician and family member. Review of the August/September, 2012 MAR showed: - On 8/18/12, at 8:50 P.M.: LPN E administered PRN [MEDICATION NAME] 0.5 ml and [MEDICATION NAME] 0.5 ml to the resident. Review of facility nurses' notes, dated 8/19/12, showed the day shift and the night shift staff did not document they assessed the resident for pain or for a BM. Review of the August/September, 2012 MAR showed: - On 8/19/12 at 9:40 A.M.: Staff administered PRN [MEDICATION NAME] SL to the resident. Review of hospice nurse's notes, dated 8/19/12, showed: - At 9:50 A.M.: Facility staff notified hospice nurse the resident fell out of bed last night; no injury noted; no complaints of pain or discomfort. Review of hospice nurse's notes, dated 8/19/12, showed: - At 10:30 A.M.: The resident was tearful, wanted to see family, no complaints of pain or discomfort. Review of the August/September, 2012, MAR showed: - On 8/19/12 at 12:00 P.M.: Staff administered PRN [MEDICATION NAME] SL to the resident. Review of a nurse's note, dated 8/19/12, at 6:00 P.M., showed: - LPN E documented the resident's bed alarm sounded and he/she found the resident on the floor mat beside of the resident's bed. - The resident was confused, incontinent of urine, and a head to toe assessment did not show any injury. - The resident's blood pressure was 100/75, pulse was 73, and respirations were 20. - Call placed to a family member, and to hospice. Review of hospice nurse's notes, dated 8/19/12, showed: - At 8:51 P.M.: Hospice nurse notified by facility of non-injury fall tonight. - At 9:45 P.M.: Hospice nurse arrived at the facility to assess the resident; no signs and symptoms of pain or discomfort. Resident teary-eyed tonight. Review of the Nurses' 24 Hour Assessment Form, dated 8/19/12, on the night shift showed: - LPN F (the night shift charge nurse) documented ongoing leg pain; medicated with scheduled [MEDICATION NAME] gel at 12:00 A.M. Resident sleeping at 1:00 A.M. LPN F did not document he/she administered the PRN [MEDICATION NAME]. Review of the facility nurse's notes showed LPN F did not document an entry for 8/19/12 for the night shift of continued leg pain or the administration of PRN [MEDICATION NAME]. During initial tour of the facility on 8/20/12, at 6:30 A.M., an unidentified staff member said the resident was very depressed, had a wound to the left buttock, ate and drank poorly, and did not indicate the resident complained of pain. Review of the current Controlled Substance record, dated 8/20/12, for the resident showed: - On 8/20/12, at 12:00 A.M.: LPN F administered scheduled [MEDICATION NAME] gel 1 ml to the resident's inner wrist. - On 8/20/12, at 1:20 A.M.: LPN F administered 0.5 ml of PRN [MEDICATION NAME] to the resident. - On 8/20/12, at 2:30 A.M.: An unidentified staff administered PRN [MEDICATION NAME] 0.5 ml to the resident. - On 8/20/12, at 4:30 A.M.: LPN F administered scheduled [MEDICATION NAME] gel 1 ml to the resident's inner wrist. - On 8/20/12 at 6:00 A.M. and 12:00 P.M.: Certified Medication Technician (CMT) B administered the scheduled [MEDICATION NAME] gel 1 ml to the resident's inner wrist. Observation on 8/20/12, at 10:35 A.M., during a medication pass showed: - The resident's face grimaced and he/she said he/she "hurt" in a very low voice. - CMT B said he/she administered [MEDICATION NAME] gel at 6:00 A.M. to the resident for pain. - CMT B did not administer PRN pain medication. Review of the August/September 2012, MAR showed: - On 8/20/12, at 8:30 A.M.: CMT B administered PRN [MEDICATION NAME] SL to the resident. - On 8/20/12, at 2:35 P.M.: LPN E administered PRN [MEDICATION NAME] 0.5 ml SL to the resident. - Staff documented they administered [MEDICATION NAME] 200 mg on 8/15/12, 8/16/12, 8/17/12, the resident refused on 8/18/12, 8/19/12, and 8/20/12, administered on 8/21/12, and the resident refused on 8/22/12 and 8/23/12. The [MEDICATION NAME] was discontinued on 8/23/12. - MOM was not documented on the MAR from 8/15/12 through 8/23/12. Review of facility nurses' notes for 8/20/12, showed: - No day shift, evening shift, or night shift staff documented any pain, medications administered to the resident, or assessment of leg pain or abdominal pain. Review of the current Controlled Substance Record, dated 8/21/12, showed: - 8:50 A.M.: CMT C administered scheduled [MEDICATION NAME] gel to the resident's wrist. - 12:15 P.M.: CMT B administered PRN [MEDICATION NAME] SL, to the resident. Review of a facility nurse's note, date 8/21/12, at 8:20 A.M., LPN A documented the following: - Resident found on floor next to bed on fall mat. - The resident stated he/she accidently rolled out of bed. - Resident found laying on right side, no marks or bruising noted; - No complaints of pain; - Incontinent of stool; - Assist of three staff with a gait belt to get the resident off the floor. Review of a hospice nurse's note, dated 8/21/12, from 8:15 A.M. until 9:00 A.M., showed: - Facility staff notified Hospice RN A the resident just fell out of bed onto floor mat; no injury, assisted back to bed, resident had large bowel movement during and after fall; - Resident non-verbal throughout nursing assessment by Hospice RN A - Whining, grimacing, and moaning, pulling right knee up; any touch caused pain. During an interview on 8/21/12, at 9:00 A.M., Hospice RN A said: - The resident was really in pain this A.M. - He/she was writhing with pain, and flailing his/her legs; - He/she would not let Hospice RN A touch him/her; - diagnosed with [REDACTED]. - Much grimacing this A.M.; - The resident had really deteriorated since last Tues (8/14/12) when Hospice RN A last assessed him/her. Review of a facility nurse's noted, dated 8/21/12, at 8:20 and 9:30 A.M., LPN A documented the following: - 8:20 A.M.: LPN A documented staff found the resident on the floor by the bed on the fall mat; the resident stated he/she rolled out of bed accidentally, no injury noted; the resident laid on his/her right side; the resident was incontinent of loose stool; notified Hospice RN A, the director of nursing (DON), and the physician of the fall. - At 9:30 A.M.: Hospice RN A reported the resident now having increase pain in the right knee; - Last fall noted on 8/18/12, when the resident complained of knee pain; - Order for right knee X-ray obtained by Hospice RN A. Review of the August/September, 2012, MAR showed: - On 8/21/12 at 9:50 A.M., staff administered [MEDICATION NAME] 5/325 mg and did not administer [MEDICATION NAME] SL. Review of a hospice nurse's note, dated 8/21/12, from 10:00 A.M. until 11:10 A.M., showed - Hospice RN A requested pain medication to be administered; - [MEDICATION NAME] 5/325 given at 10:00 A.M. (9:50 A.M. actual time administered by facility staff); - The resident gave some information to Hospice RN A: Pain is more "bone pain;" - Movement of leg, asked Hospice RN A to remove cloth boot from right foot; - Moments of intense pain, in right knee every two to five minutes, grimaces, whining, clenches teeth, right leg fidgeting, pulls leg up and off of bed, and bends leg, continues to say knee and bone pain; - Order for knee X-ray obtained - At 10:15 A.M.: Resident still for 10 minutes, leg still, general body twitches; - At 10:45 A.M.: Beginning to grimace and moan every two to four minutes, facility staff turned to clean resident of stool; resident moaning and groaning and crying in pain; - At 11:10 A.M., Hospice RN A requested PRN [MEDICATION NAME] be given to the resident. Review of the current Controlled Substance Record, dated 8/21/12, showed: - 11:10 A.M.: Hospice RN A administered PRN [MEDICATION NAME] 0.25 ml to the resident. Review of a hospice nurse's note, dated 8/21/12, from 11:15 A.M. until 12:15 P.M., showed: - At 11:15 A.M.: The resident rested, no leg movements, no non-verbal signs of pain. Hospice RN A talked with family member about fall this A.M. and pain; family member very supportive of steady pain medications to keep the resident comfortable; - At 11:30 A.M.: Portable X-ray of right knee performed; the resident tolerated positioning well and remained comfortable; - At 12:15 P.M.: Appeared comfortable; scheduled [MEDICATION NAME] gel administered; no moaning or grimacing. During an observation and interview on 8/21/12, at 2:45 P.M., LPN D did and said the following: - LPN D performed wound care on the resident; Hospice RN A assisted LPN D with the dressing change; - The resident expelled a large amount of liquid light brown stool; the resident's rectal area was bright red and he/she moaned with pain when facility staff cleaned him/her of the liquid stool and during application of barrier cream; - LPN D removed the old dressing, sprayed the open wound with [MEDICATION NAME]/[MEDICATION NAME] spray, and performed the dressing change. - The surveyor approximated the wound measurements to be 3.5 cm x 3.5 cm x 1.5; - LPN D sprayed [MEDICATION NAME]/[MEDICATION NAME] spray to the open wound which helped with the resident's pain during the dressing change. Review of a hospice nurse's note, dated 8/21/12, at 2:45 P.M.: - The resident tolerated the dressing change to the left buttock wound better than incontinent care for diarrhea; - PRN [MEDICATION NAME] 0.5 ml requested to be administered by Hospice RN A. During an interview on 8/21/12, at 3:00 P.M., Hospice RN A said the following: - The resident had severe pain most of the day; - He/she was writhing in pain and flailing his/her legs when Hospice RN A arrived this A.M. - The resident grimaced and his/her hands shook during this time due to the pain. - Hospice RN A increased the [MEDICATION NAME] (a strong narcotic pain reliever) 20 mg/ml to give 0.5 ml to 1 ml every hour PRN on 8/18/12 to help control the break through pain; the resident also received scheduled pain medication. - Hospice RN A said he/she did not think facility staff gave the resident PRN [MEDICATION NAME] frequently enough to control his/her severe pain. - After LPN D completed the dressing change, he/she asked Certified Medication Technician (CMT) D to administer [MEDICATION NAME] 0.5 ml SL to the resident to relieve his/her pain. Review of a hospice nurse's note, dated 8/21/12, at 6:15 P.M., showed: - A facility staff reported the resident started to fidget again; - Hospice RN A and CMT D discussed administering the [MEDICATION NAME] 0.25 ml to 0.5 ml SL every 2 hours and alternating [MEDICATION NAME] SL on the off 2 hours so that the resident would be medicated with something every 1 hour to keep pain and anxiety controlled. - Hospice RN A told CMT D to get the opinion of the charge nurse for the dosage of [MEDICATION NAME] SL to give; nursing judgment should be used to determine dose related to signs and symptoms of pain; CMT D verbalized understanding of the recommendation. Review of the current Controlled Substance Record, dated 8/21/12, showed: - 3:00 P.M.: CMT D administered [MEDICATION NAME] 0.5 ml SL per Hospice RN A's request. - 6:00 P.M.: CMT D administered [MEDICATION NAME] 0.5 ml to the resident. - No staff documented they administered [MEDICATION NAME] SL after 6:00 P.M. Review of the August/September 2012, MAR showed: - On 8/21/12 at 6:50 P.M.: CMT D administered [MEDICATION NAME] SL. - No staff documented they administered the [MEDICATION NAME] SL after 6:50 P.M. During an interview on 8/24/12 at 2:00 P.M. CMT D said the following: - Hospice RN A talked with him/her about "staying ahead of the resident's pain;" - Hospice RN A suggested alternating [MEDICATION NAME] SL and [MEDICATION NAME] SL per the judgment of the charge nurse; - Hospice RN A told him/her to not wake the resident if sleeping, but to give if he/she noticed the resident needed the medication; - He/she reported the recommendation to the evening charge nurse and he/she should have reported this to the oncoming charge nurse; - He/she gave a dose of [MEDICATION NAME] at 3:30 P.M. and gave a dose of [MEDICATION NAME] later, because the resident became very anxious. Review of facility nurse's notes for 8/21/12, showed: - The evening and night shift staff did not document an assessment of the resident's pain or pain medication administered. Review of the August/September 2012, MAR showed: - On 8/22/12 at 3:30 A.M. facility staff administered [MEDICATION NAME] SL, but did not record the dose was not recorded on the Controlled Substance Record. Review of the BM sheet showed staff document a small BM on 8/21/12, for the day shift and a large BM on 8/22/12, on the day shift. Staff did not document if the BMs were liquid, formed, hard or soft. Review of the current Controlled Substance Record, dated 8/22/12, showed: - 6:00 A.M., and 12:00 P.M., CMT C administered scheduled [MEDICATION NAME] gel. - 8:47 A.M., CMT C administered [MEDICATION NAME] 0.5 ml SL; - 1:00 P.M., CMT C administered [MEDICATION NAME] 0.5 ml SL; - 11:40 P.M., LPN F administered [MEDICATION NAME] SL; - Staff did not document they administered the [MEDICATION NAME] and [MEDICATION NAME] every 2 hours alternating for pain as recommended by Hospice RNA. Observation on 8/22/12, at 12:45 P.M., showed: - The resident sat in a wheelchair in his/her room as Hospice CNA A and B shaved and bathed the resident; - During care, the resident's face grimaced, and he/she moaned with pain and discomfort. - Hospice CNA A said, "He/she is in so much pain; I feel so sorry for him/her." - Hospice CNA B said the resident asked to go outside to sit, but he/she now wanted to go back to bed because he/she hurt so badly. Review of a hospice social service note, dated 8/22/12, at 12:45 P.M., showed: - Social worker gave emotional support to resident as facility staff provided care due to the resident's pain. During interviews on 8/22/12, at 1:00 P.M. and 2:00 P.M., LPN B said the following: - Staff [MEDICATION NAME] for the wound infection and odor and [MEDICATION NAME]/[MEDICATION NAME] spray to help with pain during dressing changes; Review of a nurse's note for 8/22/12, showed: - Day shift staff did not record an assessment of pain or administration of pain medications. - Evening shift charge nurse, LPN E documented the resident was somnolent, restful and no PRN pain medications were administered; family member called for update on pain and medications given and condition of the resident. Review of a nurse's note, dated 8/23/12, at 3:30 A.M., showed LPN F documented: - The resident yelled, "Help me." - An unidentified CNA found the resident face down on the fall mat next to the bed; - The resident's face hit the trash can, and a reddened area was noted to the resident's right cheek; - The resident sustained [REDACTED]. - Steri strips were applied to the skin tear; - Blood pressure was 140/78, pulse was 72, and respirations were 20; - The resident denied pain at either site of injury; - Neurological checks (alertness, pupil reaction to light, hand grips) were within normal limits; - The resident stated he/she tried to get up to the bathroom; - The physician and family were notified. - The note did not document assessment of generalized pain and the loose stool the resident passed during the fall; the note did not document the fecal impaction LPN F removed digitally from the resident or pain associated with the fecal impaction. During an interview on 8/24/12, at 5:30 A.M., LPN F said the following: - On 8/23/12, at 3:30 A.M., the resident yelled out, "Help me!"An unidentified CNA found the resident face down on the fall mat, and he/she was on his/her knees by the bed. - The resident hit his/her face on the trash can and a red mark was found on the resident's right cheek; he/she also sustained a skin tear to the right wrist. - The resident's vital signs were normal, he/she denied pain, and his/her neurological checks were within normal limits. - LPN F thought the resident got out of bed to go to the bathroom, because he/she had liquid BM all over him/her when he fell ; - Staff took the resident to the shower to clean him up and the resident pushed and strained very hard to have a BM without success. - LPN F checked the resident digitally and felt a hard lump of stool in the resident's rectum; - LPN F removed a very large, hard stool from the resident's rectum; - LPN F thought the resident might have torn the rectum during the removal of the hard stool; - The resident felt better after removal of the stool; - LPN F medicated the resident just befor