Every finding on record at Lacoba Homes Inc

Based on observation, interview, and record review, the facility failed to provide appropriate infection control practices when staff failed to wash and/or sanitize hands before and during personal cares for one resident (Resident #8) out of 14 sampled residents. The facility census was 44. Review of the facility policy Hand Hygiene/Handwashing, undated, showed the following:-Hand hygiene will be regarded as the single most important means of preventing the spread of infections;-The use of alcohol-based sanitizers/had rub is an acceptable method of hand hygiene instead of soap and water in all clinical situations except when hands were visibly soiled (such as blood or body fluids), or after caring for a resident with known or suspected clostridium difficile(bacterial infection causing severe diarrhea or colon inflammation or Norovirus(infection causing sudden vomiting and diarrhea, stomach pain and highly contagious) during an outbreak, if infection rates of c. difficile infection (CDI) were high, then soap and water should be used;-Staff must perform hand hygiene (even if gloves were used) before and after contact with resident, after contact with blood, body fluids, visibly contaminated surfaces, or after contact with objects in the resident's room; and after removing personal protective equipment (gloves, gown, face mask). Review of the facility policy Routine Peri Care, updated 09/21/24, showed the following:-Peri care will be provided to residents after each incontinent episode and once per shift if resident was not incontinent;-Spray peri wash in perineal area, use a wet washcloth, cleanse perineal area and wipe downward from front to back;-Discard wash cloth in a plastic bag for dirty linen;-After each wipe, discard wash cloth in plastic bag for linen and get a clean washcloth;-After cleansing is complete, take off gloves disposing them in the plastic bag for trash, and wash hands;-Staff to wash their hands each time they changed their gloves. 1. Review of Resident #8's face sheet (admission information at a glance) showed the following:-admission date of 03/03/22;-Diagnoses included vascular dementia (decline in thinking skills from reduced blood flow to the brain which causes issues with reasoning, memory, judgement, and problem-solving) without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety; polyneuropathy (nerve damage affecting multiple peripheral nerves causing numbness, tingling, weakness, and pain), poly-osteoarthritis (affecting several joints with pain, stiffness, and inflammation in joints), and anxiety disorder.Review of the resident's care plan, revised 09/17/25, showed the following:-Activities of daily living (ADL - toileting, grooming, eating, etc.) care performance deficit related to impaired balance with fall risk and history of post-traumatic stress disorder (PTSD) in past;-Moderate staff assistance to do personal hygiene. Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff dated 11/14/25, showed the following:-Short and long-term memory problem;-Cognition was moderately impaired;-Did not reject cares;-Toileting hygiene required substantial/maximal assistance;-Personal hygiene included washing/drying face and hands required partial/moderate assistance. Observation on 01/12/26, at 3:12 P.M., showed the following:-Certified Nurse Aide (CNA) A came into the room to assist the resident who was restless and trying to sit up. CNA A put on gloves without performing hand hygiene;-CNA A helped the resident sit up and put on his/her shoes. The resident said he/she had to go to the bathroom. CNA A said he/she had to get someone to help him/her take the resident to the bathroom;-CNA B came into the room to assist CNA A. CNA A removed his/her gloves, did not perform hand hygiene, and then both CNAs assisted the resident. CNA B did not perform hand hygiene;-The CNAs transferred the resident into the wheelchair and pushed the resident to the doorway of the small bathroom, donned gloves without performing hand hygiene, and transferred the resident to the toilet;-CNA A removed the resident's brief as the resident sat on the toilet and placed a clean incontinence brief in the resident's pants;-CNA A and CNA B went assisted the resident to stand and had him/her lean over to hold on to the sink while CNA A took the washcloth with the peri wash and did perineal care to the back side of the resident;-The resident said, I'm going to fall!;-The CNAs quickly pulled up the resident's pants with the clean brief inside them and quickly transferred the resident to the wheelchair;-The CNAs did not change gloves or perform hand hygiene;-CNA B pushed the resident in the wheelchair over by the bed. Without removing gloves or performing hand hygiene, CNA B attached the call light to the resident's lower part of his/her shirt;-CNA B removed his/her gloves, did not perform hand hygiene, and picked up one of the soiled linen trash bag;-CNA A picked up one bag with trash after removing his/her gloves;-Both CNA A and CNA B used the hand sanitizer on the wall behind the resident's door before they left the room. During an interview on 01/15/26, at 1:43 P.M., Certified Medication Technician (CMT) G said the following: -They were to wash hands when visibly soiled and or after they use the hand sanitizer after the third time; -They were to wash hands before putting on gloves and after removing gloves and before or after with hand sanitizer. During an interview on 01/15/26, at 1:20 P.M., Registered Nurse (RN) F said he/she would expect staff to sanitize or wash their hands before gloving and between gloving, and to wash his/her hands if they were visibly soiled. During interview on 01/15/26 at 2:07 P.M., the Director of Nursing (DON) said staff were to wash hands before applying gloves, and then wash hands after removing gloves during perineal care. During interview on 01/15/2,6 at 2:45 P.M., the Administrator said the following:-Staff were to wash hands before and after they do cares with a resident;-During perineal care, they were to always wash hands before, during, and when hands got soiled;-They were to wash hands before applying gloves, when removing gloves, and before exiting their room.

Based on observation, interview, and record review, the facility failed to ensure an environment as free from safety hazards as possible when staff failed to transfer a with an appropriate placed gait belt (a transfer belt placed around the waist to assist with standing, walking, or transferring and to help prevent falls) and when staff were not aware of the best manner in which to transfer for one resident (Resident #8) out of 14 sampled residents. The facility census was 44. Review of the facility policy Assistive Lifting Devices, undated, showed the following:-The goal was to decrease possible injuries to all staff and/or residents when transferring, toileting, or ambulating;-Gait belt was to be implemented with all ambulation and transfer procedures. Staff was to explain procedure to resident;-Staff was to place the gait belt securely around the waist on all residents who ambulate;-The belt must be snug as it will loosen when standing;-Always protect women's breasts during placement of belt;-Staff to stand behind and slightly to the side of the resident, on the resident's strong side, and grasp the belt firmly with closed hand palm up. Review of the facility policy Transfer with Gait Belt, showed the following:-Transfer with gait belt was to be used with all transfers unless the resident refused to use the gait belt;-If resident had an ostomy (a surgical opening in the stomach rerouting waste (urine or stool) from the digestive or urinary tract to exit the body in a collection pouch), suprapubic catheter (tube inserted into the bladder through the abdominal wall to drain urine from the bladder) or abdominal incision, the gait belt should be placed around the resident's chest;-Explain procedure to resident;-Place gait belt on the resident. Belt must be snug since it will loosen when resident stands;-Instruct the resident to slide to edge of bed or chair;-For a two-person transfer, each staff should grasp the gait belt toward the resident's back;-Assist resident to stand by both lifting on the gait belt. Assist to pivot and sit down in the chair;-Remove the gait belt; -If a resident was a two-person transfer but needed more assistance, staff can use a mechanical lift if the resident was agreeable.Review of the Missouri Nurse Aide Candidate Handbook, effective January 2026, showed the following: -Properly place the gait belt around the resident's waist to stabilize the trunk; -Tighten the gait belt. Check the gait belt for tightness by slipping fingers between the gait belt and the resident;-Grasp the gait belt with both hands; -Bring the resident to a standing position using proper body mechanics;-Assist the resident in pivoting and sitting in the wheelchair in a controlled manner that ensures safety; -Remove the gait belt. 1. Review of Resident #8's face sheet (admission information at a glance) showed the following:-admission date of 03/03/22;--Diagnoses included vascular dementia (decline in thinking skills from reduced blood flow to the brain which causes issues with reasoning, memory, judgement, and problem-solving) without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety; polyneuropathy (nerve damage affecting multiple peripheral nerves causing numbness, tingling, weakness, and pain), poly-osteoarthritis (affecting several joints with pain, stiffness, and inflammation in joints), and anxiety disorder.Review of the resident's care plan, revised 09/17/25, showed the following:-Activities of Daily Living (ADL - dressing, toileting, eating) self-care performance deficit related to impaired balance with fall risk and history of post-traumatic stress disorder (PTSD) in past;-Moderate staff assistance to do personal hygiene;-Moderate assistance of two staff with getting in and out of bed;-Maximal assistance of two staff to transfer with use of a gait belt;-Unable to alert staff of need to toilet due to severe cognitive impairment. The resident was on a scheduled toileting program and needed two-person assist for transfers.(Staff did not care plan related to special placement of the gait belt on the resident.) Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment instrument) completed by facility staff, dated 11/14/25, showed the following:-Short and long-term memory problem;-Cognition was moderately impaired;-Did not reject cares;-Had impairment of both lower extremities;-Used wheelchair for mobility;-Toileting hygiene required substantial/maximal assistance;-Personal hygiene, which included washing/drying face and hands, required partial/moderate assistance-Dependent for transfers. Review of the resident's physician's order, dated 12/06/24, showed the resident was a two-person transfer.Observation on 01/12/26, at 3:12 P.M., showed the following:-The resident tried to get up out of his/her low bed with a fall mat on floor next to the bed;-Certified Nurse Aide (CNA) A came into the room to assist the resident who was restless and trying to sit up; -CNA A helped the resident sit up and put on his/her shoes. The resident said he/she had to go to the bathroom. CNA A said he/she had to get someone to help him/her take the resident to the bathroom;-CNA A placed the gait belt around on the resident's chest. The resident's knees were bent. The resident kept pulling at the gait belt and said he/she did not want this thing on him/her;-CNA B came into the room to assist CNA A. The resident was restless;-The CNAs transferred the resident into the wheelchair and pushed the resident to the doorway of the small bathroom. Both CNA A and CNA B went under the resident's arm and lifted the resident on both sides with the gait belt on the chest level. The belt slipped up on the resident's chest as they transferred the resident to the toilet;-The resident sat on the toilet and pulled at the gait belt on his/her chest;-CNA A removed the resident's brief as the resident sat on the toilet. They placed the clean incontinence brief in the resident's pants as the resident kept asking them to take the gait belt off him/her;-CNA A and CNA B went under the resident's arms on both sides and assisted the resident to stand and had him/her lean over to hold on to the sink while CNA A took the washcloth with the peri wash and did perineal care to the back side of the resident;-The resident said, I'm going to fall!;-They CNAs quickly pulled up the resident's pants with the clean brief inside them and quickly turned to pivot the resident to the wheelchair; -CNA B pushed the resident in the wheelchair over by the bed and attached the call light to the resident's lower part of his/her shirt.-Both CNA A and CNA B left the room. Review of the resident's progress notes, dated 01/12/26, showed the resident became combative when staff attempted to put a gait belt back on and resident transferred without gait belt to the wheelchair. Staff implemented intervention to respect resident's wishes while ensuring safe transfers using alternative safety measures. Staff will continue to comply with resident preferences and prioritize safe transfer techniques. Review of the resident's care plan, updated 01/12/26, resident can be combative at times, and sometimes refuses gait belts. Facility will comply with resident's wishes and transfer safely. Observation on 01/15/26, at 12:43 P.M., showed the following: -The resident sat in his/her wheelchair in his/her room;-CNA E went into the resident's room and CNA D put a gait belt around the resident's waist;-The resident grabbed the gait belt and said he/she was going to take it off;-CNA D placed the gait belt above the resident's waist on his/her chest;-CNA D pushed the resident in the wheelchair to the door of the resident's bathroom; -CNA D told the resident they were going to have him/her stand up;-CNA D and CNA E took one arm and went under the resident's arm on both sides, and lifted the resident under the arm and the other hand under the gait belt, and pivoted the resident from the wheelchair to the toilet with the resident's legs both bent at the knees;-The gait belt slipped up higher on the resident's chest during the transfer;-The resident urinated in the toilet as both aides waited for him/her;-CNA E asked the resident if he/she was ready to stand and hold on to the sink in front of the toilet. The resident refused to stand;-Both CNA D and CNA E put one arm under the resident's arms on each side, and held on to the gait belt to stand the resident with the gait belt which was up at chest leve;;-The gait belt slipped up some on his/her chest;-CNA E provided incontinence care, as CNA D held the resident up with his/her arm under the resident's arm and under the gait belt to the back of the resident;-The resident said he/she was going to fall as his/her right foot began to slide forward and he/she leaned back;-CNA E with one arm under the resident's right arm, grabbed the back of the resident's pants and pulled them up, as they both quickly pivoted the resident around to the wheelchair by the toilet;-CNA E removed the resident's gait belt;-The resident said, I didn't know that thing was on me. During interviews on 01/15/26, at 8:43 A.M. and 12:56 P.M., CNA E said the following:-If residents had a change in their transfer, they would talk to therapy who will evaluate the residents for transfers;-The resident's electronic medical record says what type of transfer for the resident;-The resident used to be a gait belt transfer and now was a sit to stand transfer;-On the resident's name card outside their room, the little red happy face sticker meant the resident was a two-person transfer;-They can use the gait belt in the daytime where he/she was more alert and will transfer easier;-They would use the sit to stand later in the day when the resident was more tired;-They were to place the gait belt on top of the breasts or bottom of breasts as taught in CNA class. They were to make sure they were not hurting his/her breasts;-The resident's bathroom was small. When they hold on to the gait belt, the gait belt slid up, and the resident was slipping, he/she had to grab his/her pants; -Sometimes the resident stands and sometimes he/she won't stand. It was hit and miss with him/her. It depended on how he/she was doing that time when he/she transferred;-The resident did bear weight some, but a lot of the resident's weight was on his/her arm during the transfer;-He/ did not like the sit to stand transfer. During interview on 01/15/26, at 1:14 P.M., CNA D said the following: -If a resident kept refusing for them to take to the toilet, they may have to get another staff to try; -The resident was sometimes weight bearing, and sometimes did better than other days; -If the resident will start to slide when they do a gait belt transfer, they will block the resident's feet with their feet to keep the resident from falling; -They can place the gait belt on the waist or above the waist especially if the resident had a fractured bone like a rib fracture; -They can take some of the lifts into the bathroom, and they can take the resident to the shower room and use the lift for them to use the toilet; During interview on 01/15/26, at 1:43 P.M., Certified Medication Technician (CMT) G said the following: -They were to transfer generally with the gait belt around the resident's waist; -If a resident's knees buckled during the transfer, he/she would let the nurse know and they would have therapy look at the resident. He/she would get a second person to assist or use the sit to stand lift to transfer the resident; -He/she had not transferred the resident since he/she had not worked on that hall.During an interview on 01/15/26, at 1:20 P.M., Registered Nurse (RN) F said the following: -For a gait belt transfer, if the resident required a one or two person assist or standby transfer, they were to use the gait belt; -Unless the resident had gastrointestinal surgery, they were to place the gait belt at the waist to transfer them. It was acceptable to place the gait belt above on breasts to transfer. If a resident refused the gait belt to be placed below on the waist, they can place the belt up on the chest. They were to try to tighten this belt snugly; -If the resident's knees were bent during a transfer, therapy should evaluate the resident for a lift transfer. They do have a referral form for this. Sometimes a resident has generalized weakness or has an upper respiratory infection or urinary tract infection, and/or had a change in their condition which can cause a temporary change in how they transfer;-The last time he/she saw the resident transfer, the resident stood up okay. With the resident's dementia, it depends on the way and his/her want to in general with transferring him/her;-If a resident was not bearing weight, they can move them up to a mechanical lift. Therapy does annual training for transfers. During interview on 01/15/26, at 2:07 P.M., the Director of Nursing (DON) said the following:-For a gait belt transfer, there was a gait belt on the back of each resident's door for them to use;-They were to place the gait belt higher up around the resident's waist; -She had never seen it up high on a resident's chest. She had only seen a gait belt around the resident's waist and not on his/her chest;-If the resident refused the gait belt, she expected staff to stop and try it again in a few minutes if the resident gets agitated;-They were to let the charge nurse or her know when this happens, and staff were to make sure the resident was safe. They were to treat residents with dignity and if the resident says, no, no, staff were to stop and give them time. During interview on 01/12/26, at 2:29 P.M., Physical Therapist (PT) H said the following:-The resident had asked staff to place the gait belt on his/her chest;-If staff can explain it, a resident will let them place it on their waist. He/she can't explain it to the resident. If he/she was anxious or upset, the resident won't let staff put a gait belt on him/her;-The resident's knees do buckle when the resident transfers. This was common, and he/she would go dead weight;-If the resident was upset, they should not engage him/her to transfer; -They do screen transfers quarterly on residents. They will screen a resident when staff report a decline or concern, and/or the resident had a fall; -The resident's transfer may be different depending on the time of day for the resident. The resident fluctuates mentally. During interview on 01/15/26, at 2:45 P.M., the Administrator said the following:-For gait belt transfers, 90% of the time, staff were to place the gait belt at the resident's waist or abdomen. If a resident had fractured ribs, tubes or drains on the abdomen, she would expect staff to place the belt above the waist and above on breasts or on the chest. Some residents will tell you they don't want it down at their waist;-She hadn't seen the resident transferred for the past couple of weeks. If the resident's knees were buckling, he/she may need to be a full transfer lift. The resident should be a sit to stand transfer or a full mechanical lift.

Based on record review and interviews, the facility failed to ensure all residents were free from significant medication errors when staff failed to clarify orders for an antibiotic the resident was listed as allergic to prior to administration for one resident (Resident #1) resulting in a negative reaction to the medication administered. A sample of nine residents was reviewed in a facility with a census of 45. Review of the facility's policy entitled Infection Prevention and Control Policies: Antibiotic Stewardship, not dated, showed the following: -The antibiotic stewardship program is a set of commitments and actions intended to optimize the treatment of infections while reducing adverse events associated with antibiotic use. -Nursing plays a key role in improving the appropriate use of antibiotics by assessing and monitoring residents and communicating with providers, residents, and families; -Residents suspected of having an infection are thoroughly assessed and referred to the provider with the following information: current situation including resident complaints, vital signs, recent laboratory results, relevant diagnosis; and relevant background information including disease state, renal function, drug allergies, recent antibiotic therapy, and use of potentially interacting medications; -Drug Interaction screens are run at the time of order entry. Severe interactions, those warranting the need for therapeutic monitoring or an adjustment in therapy, are conveyed to the prescriber; -All antibiotic-associated adverse drug events, including allergic reactions and adverse reactions and adverse antibiotic-drug interactions are reported to the prescriber. Antibiotic-associated adverse drug events which require a significant alteration in treatment, for example treatment to be stopped or changed, or a new form of treatment be commenced to address a clinical complication, will be reported to the Infection Prevention and Control committee for evaluation; -Pharmacy partnership ensures access to Clinical Pharmacists with advanced training in infectious disease and antibiotic stewardship. The Consultant Pharmacist is responsible for providing advice, education, and feedback on antibiotic prescribing. 1. Review of Resident #1's face sheet (shows basic profile information) showed the following: -admitted [DATE]; -Diagnoses included norovirus (intestinal virus), urinary tract infection (UTI), congestive heart failure (CHF - a chronic condition where the heart muscle is weakened and cannot pump blood efficiently), presence of cardiac pacemaker, type 2 diabetes , chronic kidney disease, asthma, severe obesity, generalized skin eruption due to drugs and medications taken internally, dementia without behavioral disturbance, insomnia, breathing disorder during sleep, gastro-esophageal reflux disease (GERD; stomach acid backs up into the esophagus), and major depressive disorder. Review of the resident's Allergies tab, on the electronic medical record (EMR), showed he/she was allergic to cefdinir (antibiotic), hydrocodone (pain medication), losartan (treats high blood pressure), penicillin (antibiotic), Sudafed (nasal decongestant), and sulfa antibiotics. Review of the resident's progress note, dated 01/30/25, showed staff notified the resident's child regarding the resident's UTI per lab results. Antibiotics ordered to start. Review of the resident's Physician Order Sheet (POS) showed an order, dated 01/30/25, for Bactrim DS (sulfamethoxazole/trimethoprim -combined antibiotic drugs, double strength, a sulfa antibiotic) oral tablet 800-160 milligram (mg). Staff to administer one tablet by mouth twice daily for UTI for 7 days. The physician electronically signed the order on 01/31/25 at 4:19 P.M. Review of the resident's Medication Administration Records (MARs), dated 01/30/2025 to 01/31/2025 and 02/01/25 to 02/28/25, showed staff documented administration of Bactrim DS to the resident twice daily for seven days (a total of 14 doses), beginning with the evening dose on 01/30/25 and ending with the evening dose on 02/06/25. Review of the resident's progress notes showed the following entries: -On 02/07/25, at 3:17 A.M., staff noted antibiotic for UTI completed the day prior with no adverse reactions and no UTI symptoms; -On 02/07/25, at 10:39 A.M., staff noted resident with head to toe rash, diarrhea, bilateral red swollen legs, and very weak. Vital signs within normal limits. Staff notified physician and received orders for STAT (immediate) labs .The family requested resident be transferred to hospital. Staff notified physician and resident transferred out via ambulance. Review of the resident's hospital record, dated 02/11/25, showed the resident had a generalized skin eruption due to drugs and medication taken internally, drug related from Bactrim allergy. During an observation and interview on 02/14/25, at 10:50 A.M., the resident sat on the edge of his/her bed using tissues to blot blood coming from open areas on his/her left forearm. The resident said he/she couldn't stop picking at the skin and scabs that were due to an allergic reaction to an antibiotic. The resident said the physician told him/her they were putting him/her on an antibiotic, but did not say which one. If they had told him/her that it was Bactrim, he/she would have said no. He/she had been allergic to sulfa drugs all my life; I break out all over my legs and upper body. The resident said nobody asked him/her about previous reactions to sulfa drugs before they gave him/her the Bactrim. During an interview on 02/14/25, at 11:25 A.M., Registered Nurse (RN) A said the Director of Nursing (DON) had called him/her at the facility and told him/her the physician had just called to give him/her a new order for an antibiotic for the resident and since the DON was out of the facility at the time asked RN A to enter the order. RN A said he/she entered the order for the Bactrim, but did not check the resident's allergy list. The electronic system does give pop-up warnings about allergies and any possible interactions with other medications, but he/she did not read any available warnings when he/she entered the order and probably flew through them. He/she should have checked the resident's allergies, but probably didn't think it was necessary since the DON had called him/her with the physician's order. RN A was aware that the resident did experience an adverse drug reaction, a rash breakout. During an interview on 02/14/25, at 11:45 A.M., Pharmacist B said Pharmacist C had called the facility to ask about the resident's sulfa drug allergy prior to dispensing Bactrim. Pharmacist C was told by RN D that the physician had given the order, so it was okay to give it. During an interview on 02/14/25, at 11:52 A.M., RN D said he/she took a call from the pharmacy regarding the resident's order for Bactrim. The resident showed an allergy to sulfa drugs. RN D said he/she looked at the order and told the pharmacy that the physician had given the order, so it was okay to give the drug. He/she did not ask the resident about his/her sulfa drug allergy. When staff enters medication orders the electronic system gives multiple pop-up warnings regarding allergies and any potential interaction with another medication, but the warnings don't pop up during medication administration. RN D said when staff asks the physician for an order, they should give the scenario including signs and symptoms, and review the allergy list with the physician. During an interview on 02/13/25, at 12:27 P.M., the Medical Director said the electronic medical system would flag a resident's allergy upon entering a new order, and the pharmacy would notify the facility staff if they noted an allergy or medication interaction. The physician said the pharmacy wouldn't send the ordered medication unless the resident verified a previous drug reaction wasn't an allergy, but something like an upset stomach. During an interview on 02/14/25, at 12:06 P.M., the DON said when staff should call the physician with lab results when requesting medication orders they should review possible drug allergies with the physician. When entering a new order, the electronic system will give pop up warnings regarding any listed allergy or medication interaction. The staff should notify the physician of warnings and clarify orders if necessary. The pharmacy would also call prior to dispensing a medication if there was a concern regarding a listed allergy or a notable interaction with another medication. Staff should notify the physician of any pharmacy alerts or concerns. While he/she was out of the facility and was driving, he/she received a call from the physician, who had reviewed lab results while in the facility. The physician gave an order for Bactrim for the resident. The DON called back to the facility and asked the charge nurse, RN A, to enter the order. During an interview on 02/14/25, at 3:35 P.M., the Administrator said when receiving and/or entering a new medication order, staff should notify the physician if there is a drug allergy listed for a resident. Staff should also clarify orders if the pharmacy has concerns regarding allergies or possible medication interactions. MO00249283

Based on observation, interview, and facility policy review, the facility failed to date bread products, lettuce, and cheese stored in the facility's kitchen. This had the potential to affect all 59 residents who consumed food prepared from the kitchen. Review of the facility's policy titled, Food Storage and Supply, undated, showed food is properly stored to preserve flavor, nutritive value, and appearance. Review of the undated storage instructions from the facility's bread vendor showed upon delivery store in freezer or thaw and store at room temperature for immediate use. Best used within seven days of thawing. 1. Observation during the initial kitchen inspection on 04/08/24, from 9:30 A.M. to 10:00 A.M., of bread products stored on the kitchen's bread racks, with the Dietary Manager (DM) present, showed the following: -One undated package of hamburger buns; -Three undated packages of hot dog buns. One package contained one bun with mold growth present. The second package contained three buns with mold growth present. The third package contained three buns with mold growth present; -Three undated packages of bread which had no manufacturer's use by date or expiration date on their packages. During an interview on 04/08/24, at 9:55 A.M., the DM confirmed the packages of hamburger buns, hot dog buns, and bread stored on the kitchen's bread racks were not dated, and the hot dog buns had mold growth on them. The DM stated staff were expected to date bread products when they removed them from the freezer to thaw. During an interview on 04/11/24, at 11:05 A.M., the DM said the facility's bread vendor recommended for bread products to be used within seven days after being thawed. 2. Observation during the initial kitchen inspection on 04/08/24, from 9:30 A.M. to 10:00 A.M., of food stored in the kitchen's walk-in refrigerator showed the following: -An opened and undated five-pound bag of shredded mild cheddar and Monterey [NAME] cheese; -An opened and undated large bag of shredded lettuce. The undated lettuce had started to turn brown in color. During an interview on 04/08/24, at 10:30 AM, the DM confirmed the opened bag of cheese and opened bag of lettuce stored in the walk-in refrigerator were not dated. The DM also confirmed the lettuce had started to turn brown. The DM stated staff were expected to date food when opened.

Based on observation, interview, and record review, the facility failed to provide thickened liquids in the prescribed consistency for one of one resident (Resident #37) who had a diagnosis of dysphagia (difficulty with swallowing) and received thickened liquids. A sampled of 21 residents was reviewed. Review of the facility's policy titled, Thickened Liquids, dated 2017, showed the following: -Thickened Liquids are often needed for individuals with difficulty swallowing; -The individual is evaluated by a speech language pathologist (SLP) and, after evaluation, the SLP orders the appropriate diet consistency and liquid consistency as needed. 1. Review of Resident #37's Speech Language Pathologist (SLP) Discharge Summary, dated 12/07/23, showed the SLP discharge recommendations were for the resident to receive pureed consistencies food and nectar thick liquids. Review of the resident's medical diagnoses sheet, located in the resident's electronic medical record (EMR) under the Med Diag [Diagnosis] tab, showed the following: -The resident was admitted on [DATE]; -The resident's diagnoses included dysphagia and dementia. Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment tool completed by facility staff), with an Assessment Reference Date (ARD) of 01/14/24, showed the following: -Severe cognitive impairment; -Required a mechanically altered diet (e.g., pureed food, thickened liquids); -Held food in mouth/cheeks or residual food in mouth after meals; -Required supervision or touching assistance with eating. Review of the resident's Care Plan, located in the EMR under the Care Plan tab, dated 01/26/24, showed the following: -The resident had a nutritional problem related to being at risk for aspiration (when something enters the airway or lungs by accident) and required a mechanically altered diet; -Provide and serve a pureed texture diet with nectar thickened liquids and fortified foods as ordered. Review of the resident's current Physician's Orders, located in the EMR under the Orders tab, showed the following: -An order, dated 10/09/23, for regular diet with fortified foods, pureed texture, and nectar fluid consistency. Observation on 04/09/24, at 3:36 P.M., showed the resident was in bed with a pitcher of unthickened water and ice on his/her over bed table. The pitcher of unthickened water contained a straw and was within the resident's reach. Observation on 04/10/24, at 12:25 P.M., showed the resident was eating her lunch in the facility's dining room. The resident was observed to independently consume nectar thickened liquids from a cup using a straw without difficulty. Observation on 04/10/24, at 3:40 P.M., showed the resident was in bed with a pitcher of unthickened water and ice on his/her over bed table. The pitcher of unthickened water contained a straw and was within the resident's reach. Observations on 04/11/24, at 8:50 A.M. and at 9:35 A.M., showed the resident was in his/her room seated in a wheelchair with a pitcher of unthickened water and ice on his/her over bed table. The pitcher of unthickened water contained a straw and was within the resident's reach. Also, within the resident's reach on the over bed table was a cup of water with a straw which contained a minimal amount of thickener which had settled to the bottom of the cup. The water in the cup was not thickened to a nectar consistency. During an interview on 04/11/24, at 9:35 A.M., Certified Nursing Assistant (CNA) 1 confirmed the water in the cup and the water in the pitcher positioned on the resident's over bed table were within the resident's reach and were not thickened to a nectar consistency. CNA1 said the resident's fluids should have been thickened to a nectar consistency. During an interview on 04/11/24, at 9:45 A.M., the Administrator confirmed the water in the cup and the water in the pitcher on the resident's over bed table were within the resident's reach and were not thickened to a nectar consistency. During an interview on 04/11/24, at 11:05 A.M., the Dietary Manager (DM) said the resident should have received nectar thickened liquids per his/her current diet order. The DM explained the dietary department provided the nursing staff with the thickening agent and the nursing staff were responsible for thickening fluids provided to residents in their rooms. During an interview on 04/11/24, at 1:10 P.M., the facility's SLP said he/she previously worked with the resident related to his/her dysphagia diagnosis. The SLP explained the resident consumed fluids independently and his/her fluids should have been thickened to a nectar consistency. The SLP said the resident could consume nectar thick liquids safely using a straw, but should not have unthickened fluids within her reach. During an interview on 04/11/24, at 3:10 P.M., the facility's Medical Director said the resident had difficulty swallowing and should have received nectar thickened liquids as ordered.

Based on observation, record review, and interview, the facility failed to prevent the misappropriation of residents' medications in the possession of the facility when one staff member (Licensed Practical Nurse (LPN) A) had medication in his/her possession that were for residents, including one resident (Resident #1) who the LPN took medication from the emergency kit (e-kit - a medication cart that contains emergency medication for residents) for and placed the medication packet in his/her wallet. Five residents were sampled and the facility census was 47. The facility Administrator and the Director of Nursing (DON) were notified of the Past Non-Compliance which occurred on 09/05/23. The facility staff began an investigation on 09/05/23 and suspended LPN A. The facility began immediate in-servicing of all staff who were on-site and as they arrived for work prior to beginning their shift. The facility also notified the Department of Health and Senior Services (DHSS) and the local law enforcement agency of the event. The facility completed medication audit and implemented additional medication procedures. The noncompliance was corrected on 09/07/23. Review of the facility's policy titled Abuse, Neglect, and Misappropriation Reporting and Investigation, dated 09/28/22, showed the following: -Residents of the home will be free from abuse by staff, volunteers, agency staff, family members, legal guardians, friends, contract staff, or other residents; -The facility will not tolerate verbal, sexual, physical and mental abuse, corporal punishment, involuntary seclusion, neglect, or misappropriation of resident property, by employees, family members, visitors, or other residents, and will establish an atmosphere conducive to reporting any indications of abuse, neglect, mistreatment, or misappropriation of resident property and develop and implement a system for identifying, investigating, preventing and reporting any incident, or suspected incident, of abuse, neglect, mistreatment, or misappropriation of resident property; -Misappropriation of resident property is defined as the deliberate misplacement, exploitation, or wrongful, temporary or permanent use of a resident's belongings or money without the resident's consent; -At the time of admission, each resident, or their representative should the resident not have the capacity to understand, shall be informed of their right to be free of abuse, neglect, mistreatment, or misappropriation of property. Further, at the time of admission, each resident, or their representative should the resident not have the capacity to understand, shall be told and encouraged to report immediately any indication of abuse, neglect, mistreatment, or misappropriation of property. 1. Review of Resident #1's face sheet (a document that gives a patient's information at a quick glance) showed the following: -admitted [DATE]; -Diagnoses included diabetes, spinal stenosis (a narrowing of the spinal canal), radiculopathy (a range of symptoms produced by the pinching of a nerve root in the spinal column), and low back pain. Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated comprehensive assessment instrument completed by facility staff), dated 09/14/23, showed the following: -The resident was cognitively intact; -The resident required total dependence on staff for locomotion, extensive assistance from two staff for bed mobility, transfers, dressing and toilet use and no assistance from staff for eating and personal hygiene; -The resident used a wheelchair for locomotion; -The resident was on a scheduled pain medication regimen and received as needed (PRN) pain medication; -The resident had pain present frequently and pain limited his/her day to day activities. Review of the resident's care plan, revised 09/21/23, showed the following: -The resident had an activities of daily living (ADL - dressing, grooming, bathing, eating, and toileting) self-care performance deficit related to spinal stenosis. The resident required two staff extensive assistance for all transfers. The staff may use a [NAME] lift (a mechanical lift that lifts the patient from a sitting position to a standing position, allowing for transfers to/from the bed or chair) as needed; -The resident was on pain medication therapy related to back pain due to a history of surgeries to the back and diagnoses of spinal stenosis, peripheral neuropathy (nerve damage caused by several different conditions) and gout (a form of arthritis characterized by severe pain, redness, and tenderness in joints); -Administer pain medications as ordered by the physician. Monitor and document side effects. Notify the physician if he/she had an increase in frequency or severity of pain. Review of the resident's Physician's Order Sheet (POS), dated 10/04/23, showed the following: -An order, dated 06/07/23, for staff to ask resident to rate pain using 1 to 10 scale and if unable use facial scale every shift; -An order, dated 06/07/23, for Celebrex (an nonsteroidal antiinflamatory and antirheumatic medication) oral capsule 200 milligrams (mg), give one capsule by mouth two times a day for pain; -An order, dated 06/08/23, for gabapentin (an anticonvulsant medication) oral capsule 300 mg, give two capsules by mouth three times a day for pain; -An order, dated 06/07/23, for Percocet (medication used to treat moderate to severe pain) oral tablet 5-325 mg (oxycodone with acetaminophen), give one tablet by mouth two times a day for pain; - An order, dated 06/07/23, for Percocet oral tablet 5-325 mg (oxycodone with acetaminophen), give one tablet by mouth every four hours as needed for pain. Review of the resident's September 2023 Medication Administration Record (MAR) showed the following: -On 09/04/23, night shift, LPN A documented the resident's pain as 0 out of 10; -On 09/04/23 and 09/05/23, the resident did not receive any PRN Percocet 5-325 mg. During an interview on 10/04/23, at 9:02 A.M., the resident said the following: -He/she did not remember asking for pain medications on 09/04/23 or 09/05/23; -Two other staff members asked him/her about this and he/she told them he/she did not remember asking for medications on these dates as well; -He/she had not been in pain, because he/she received his/her pain medications. Review of the facility's investigation, dated 09/08/23, showed the following: - At 2:18 A.M., the Registered Nurse (RN) Manager received a call from Certified Nursing Assistant (CNA) B, night shift. The CNA said he/she had an issue that needed immediate attention. The CNA said that LPN A's wallet had been knocked over at the nurses' station and medications had fallen out of it. The CNA was concerned because the medication pack had a resident's name on it. The RN Manager immediately notified the Director of Nursing (DON) and the Administrator; -At 2:56 A.M., the Administrator notified the police. Then the DON and the Administrator entered the building to remove LPN A, contract nurse from the building; -At 3:05 A.M., police entered the building and interviewed staff on site. LPN A was interviewed by police, he/she denied any knowledge of medications in his/her purse, had no logical explanation of how the medication would have got in his/her purse, he/she was not ok with police searching belongings or self, and stated he/she has never had allegations brought against him/her before. Police stated they had reasonable suspicion and then searched LPN A's belongings while he/she was being questioned by an additional officer. Police found additional medication: three loose hydrocodone (a prescription narcotic), one oxycodone pulled from E-kit by LPN A on 09/04/23 at 11:34 P.M. for Resident #1 and a muscle relaxer belonging to former resident. LPN A was then arrested and taken by the police; -The resident had been interviewed multiple times by administration staff throughout the morning of 09/05/23. The resident denied any pain, stated he/she was not denied any pain medication, nor did he/she request any during the timeframe in question; - In summary, LPN A had been working as an agency nurse consistently, part time for the last nine months. Prior to current contract he/she had been an employee several years ago as a CNA. During the investigation it was noted that he/she had not accessed the E-Kit often. Prior to this incident on 09/05/23, he/she had last accessed the E-kit on 08/17/23. He/she had worked several times in between these dates without assessing the E-kit, which appears to be an isolated incident. Through interviewing other residents, no other pain medication issues or concerns were noted. We have not had any complaints concerning his/her conduct or any suspicious behaviors from families, staff or residents prior to the incident, other than 11 P.M.-7 A.M. staff that his/her demeanor had changed over the last week and that was brought to facility's attention during this investigation. The evidence does indicate that he/she did have residents' medications in his/her personal belongings while on duty. Review of the facility's video dated 09/04/23, at 11:38 P.M., showed the following: -LPN A accessed the e-kit in the medication room; -The LPN pulled one packet of medication off a roll of packets and then returned them to the drawer; -The LPN appeared to tap on a screen, pulled the roll of medication out again, and appeared to count the medication and then placed them back into the drawer and shut the drawer; -The LPN again appeared to tap on a screen, removed a pen from his/her pocket and wrote something down; -The LPN walked to another counter behind him/her, appeared to tear open a package, grab a small white pill cup and dump the contents of the torn package into the cup; -He/she carried the cup in his/her left hand and walked back across the room with what appeared to be an open package in his/her right hand. He/she appeared to throw the open package away; -He/she then walked back to the counter with the medication cup still in his/her left hand, picked up what appeared to be another package of medication, placed the package in the cup and walked out of the medication room. During an interview on 10/04/23, at 9:48 A.M., CNA C said the following: -On 09/05/23, around 2:30 A.M., he/she got on the computer at the nurses' station to do some charting and he/she noticed the corner of a medication packet coming out of LPN A's wallet. He/she could see a last name on it and it belonged to the resident; -He/she pulled on the packet and knew immediately it should not be in the LPN's wallet. When he/she pulled on it, pills came out with the packet; -He/she saw CNA B coming down the hallway and waved the CNA over and told CNA B about the packet and pill and that they needed to call the RN Manager; -He/she took pictures of the packet and pills and sent them to the RN Manager; -CNA B called the RN Manager and the RN Manager said he/she would handle the situation; -He/she and CNA B started doing rounds and he/she heard the front door open and saw LPN A walk out the door; -The Administrator and DON arrived at the facility followed by the police; -A police officer escorted the LPN out of the facility; -He/she could not recall the resident requesting pain medication or being in pain that night; -The medications should not be in the LPN's wallet. The medications should remain in the medication room or the medication cart until staff dispensed them to a resident. -If he witnessed misappropriation or a resident reported misappropriation, he/she reported to the charge nurse immediately. If the charge nurse was the suspected perpetrator, he/she called the DON reported to the DON immediately; -The DON reported allegations of misappropriation to the Department of Health and Senior Services (DHSS) within twenty-four hours. During an interview on 10/04/23, at 12:08 P.M., CNA B said the following: -On 09/05/23, he/she provided resident care when CNA C told him/her that LPN A's wallet was open and CNA C saw resident narcotics inside it; -He/she immediately called the RN supervisor; -The RN supervisor had CNA B take a picture and send it to the RN supervisor; -Shortly after he/she called the RN supervisor, the Administrator, DON, and police department came to the facility and a police officer escorted LPN A out of the facility; -He/she considered the medication being in the LPN's wallet misappropriation; -The medication belonged to Resident #1; -The resident did not complain of any pain that night and the resident had not put their call light on to request any medication; -Misappropriation was a type of abuse; -If he/she witnessed misappropriation or a resident reported misappropriation, he/she reported to the DON immediately. During an interview on 10/04/23, at 12:39 P.M., Nursing Assistant (NA) E said the following: -Types of abuse included misappropriation; -If he/she witnessed or a resident reported misappropriation, he/she reported to the charge nurse immediately and if the alleged perpetrator was the charge nurse, he/she reported to the DON immediately; -The DON reported to DHSS immediately. During an interview on 10/04/23, at 12:31 P.M., Certified Medication Technician (CMT)/CNA D said the following: -Types of abuse included misappropriation; -If he/she witnessed or a resident reported misappropriation, he/she reported immediately to the charge nurse and they reported to DHSS within two hours. During an interview on 10/04/23, at 12:49 P.M., CMT F said the following: -When he/she changed shifts with another CMT or nurse, they counted medications and if there was a discrepancy, they stopped and called the DON; -LPN A at times only signed the medication off in the narcotic book and did not put in the computer. He/she had instructed the LPN to do both; -If he/she witnessed misappropriation or a resident reported misappropriation, he/she reported to the charge nurse immediately. If the alleged perpetrator was the charge nurse, he/she reported to the DON immediately; -The DON reported allegations of misappropriation to DHSS within 24 hours. During an interview on 10/04/23, at 1:03 P.M., LPN G said the following: -Types of abuse included misappropriation; -If he/she witnessed or a resident reported misappropriation, he/she reported to the DON immediately; -The Administrator reported to DHSS within two hours. During an interview on 10/04/23, at 1:13 P.M., the RN Manager said the following: -On 09/05/23, the CNA's from night shift called him/her concerned about some narcotics in LPN A's purse; -He/she called the DON and Administrator and they went to the facility and notified the police department; -The Administrator suspended the LPN; -The LPN had pills laying beside his/her purse. The purse had been knocked over; -The CNA's showed him/her a photo of the medications with Resident #1's name on the package of oxycodone 5-325 mg. and two loose pills that were white and oval. He/she was not sure what medication the loose pills were; -The medications should not have been in the LPN's purse; -The CNA's that worked night shift did not have access to the medication cart, medication room, or e-kit where the oxycodone 5-325 mg. came from; -LPN A accessed the e-kit that night for the oxycodone for Resident #1; -Types of abuse included misappropriation; -If a CNA or CMT witnessed or a resident reported misappropriation to them, they should report to him/her immediately. He/she reported to the DON and Administrator immediately and to DHSS within two hours. During an interview on 10/04/23, at 1:44 P.M., the DON said the following: -On 09/05/23, the CNA's on duty called the RN manager and reported possible misappropriation of medication. The RN manager called him/her and he/she called the Administrator. The Administrator called the police department; -He/she, the Administrator and the police officers met at the facility parking lot and LPN A was in the parking lot upon their arrival; -The e-kit showed the LPN pulled out oxycodone 5-325 mg. He/she believed the LPN wrote the resident's name on the packet; -He/she reported the allegations to the staffing agency the LPN worked for and suggested they contact the board of nursing; -After the LPN left the building, he/she did not get in the narcotic drawer until two counts were made to ensure the counts were correct before any medications were passed again. During an interview on 10/04/23, at 1:44 P.M., the Administrator said the following: -When he/she and the DON arrived to the facility, he/she pulled the CNA's in for an interview with a police officer present; -The DON went with the other officers to the nurses' station; -The police officers wanted to look at the LPN's purse. The LPN had moved his/her wallet from where it was and the LPN had another canvas bag as well; -The police searched the wallet and canvas bag and found three loose narcotics and a packet that had Resident #1's name on it containing one oxycodone 5-325 mg. in it. They also found a packet that contained tizanadine (a muscle relaxer) that belonged to a former resident that had discharged from the facility in the middle of August; -Camera footage showed the LPN retrieved the oxycodone out of the STAT safe, left the medication room, and went down 200 hall, not 400 hall where the resident resided; -The camera showed no other staff accessed the e-kit and the CNA's who worked did not have access to the medication room or e-kit. MO00223961

Based on interview and record review, the facility failed to provide a bed-hold policy for two residents (Residents #15 and #22) who transferred to the hospital. The facility census was 42. Record review of the facility's (undated) policy titled Bed Hold showed the following: -The home will permit residents to retain their beds when they are discharged to the hospital or for therapeutic leave; -The facility will provide written information to the resident or their representative that specifies should the resident be transferred or discharged from facility with the intent of returning, the bed will be held upon request of the resident, their representative or responsible party; the facility must contact the resident or family representative to verify holding of the bed within twenty-four (24) hours of the transfer or discharge and document all attempts to notify; the resident will be billed for the number of days the bed was held at daily room rate depending upon the type of room to be held; should the resident or their representative decide that the room is to be released, notice must be provided to the Business Office at that time; request for holding or releasing the bed will be stored in the resident's record; and if a resident chooses not to hold their bed, they may be readmitted to the first available bed in a semi-private room, if the services required are offered by by the home; -In case of emergency transfer, the home will send a copy of the transfer form with the bed-hold information along with the transfer papers accompanying the resident to the facility in which they are being taken. Record review of the facility's (undated) Discharge Checklist Emergency Discharge showed the checklist did not address the Bed Hold Transfer Notice/Policy. 1. Record review of Resident #15's face sheet (a document that gives a patient's information at a quick glance) showed the following: -admitted [DATE]; -The resident had a responsible party. Record review of the resident's nurse's incident note dated 5/29/22, at 2:11 P.M., showed the following: -The resident's family member called the Certified Medication Technician (CMT) and this nurse out to the courtyard. The resident had been eating lunch with his/her family and started choking. Upon arrival to the courtyard, the nurse noted the resident's lips to be dark blue, as well as had blue skin. The resident tried but unable to breathe or cough. The CMT and family member assisted the resident to stand. The nurse immediately initiated the [MEDICATION(S)] maneuver. After approximately 45 seconds of abdominal thrusts, a large piece of pizza expelled from the resident's airway and the resident began breathing spontaneously. The resident's color returned to his/her lips and skin. The resident's oxygen saturation was 96% on room air. While the nurse performed the [MEDICATION(S)] maneuver, the CMT called Emergency Medical Services (EMS). EMS arrived after the resident expelled the foreign object from his/her airway and the resident returned to stable condition. EMS recommended the nurse send the resident to the emergency room (ER) for evaluation in case of possible retained food in the resident's lungs and/or broken ribs. The resident and family agreed to this. The resident left the facility via a stretcher with EMS at 1:45 P.M. (Staff did not document regarding a bed hold transfer form/policy sent with the resident.) Record review of the resident's transfer documents, dated 5/29/22, showed no bed hold policy. During interview on 6/14/22, at 2:25 P.M., Business Office Assistant (BOA) B said the following: -He/she did not have a bed hold form for the for 5/29/22. During an interview on 6/14/22, at 2:31 P.M., BOA C said the following: -He/she should have completed the bed hold policy on 5/29/22 for the resident, but did not because the resident only went out to the ER. During an interview on 6/15/22, at 10:27 A.M., the Director of Nursing (DON) said the following: -He/she did not believe a bed hold policy completed for the resident on 5/29/22. 2. Record review of Resident #22's face sheet showed the following: -admitted on [DATE]; -The resident was his/her own responsible party. Record review of the resident's nurse's health status report showed the following: -On 4/9/22, at 8:43 A.M., the nurse sent the resident to the ER via ambulance per the nurse practitioner with a standing order from the physician for suspected infection or clot. (Staff did not document regarding a bed hold transfer form/policy sent with the resident.) Record review of the resident's transfer documents, dated 4/9/22, showed no bed hold policy. During an interview on 6/14/22, at 2:25 P.M., BOA B said the following: -He/she did not have a bed hold form for the resident for 4/9/22. During an interview on 6/14/22, at 2:31 P.M., BOA C said the following: -He/she should have completed the bed hold policy on 4/9/22 for the resident but did not because the resident only went out to the ER. During an interview on 6/15/22, at 9:06 A.M., the Assistant Director of Nursing (ADON) said the following: -He/she sent the resident to the hospital on 4/9/22 and did not send a bed hold policy. 3. During an interview on 6/14/22, at 1:42 P.M., Licensed Practical Nurse (LPN) A said the following: -He/she sent Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] -He/she documented in a nurse's progress note when a resident sent out and all the information he/she sent with the resident. 4. During an interview on 6/14/22, at 2:25 P.M., BOA B said the following: -If facility staff transferred a resident to the hospital, they did not send the bed hold policy. They send a bed hold policy only if the resident discharged from the facility. He/she did not know when facility staff transferred a resident to the hospital if the resident would stay at the hospital or come back to the facility; -The bed hold form only said discharge. 5. During an interview on 6/14/22, at 2:31 P.M., BOA C said the following: -The bed hold policy said facility staff should send it if a resident transferred or discharged ; -He/she only sent the bed hold policy if the resident discharged from the facility; -He/she was responsible for completing the bed hold policies, but BOA B completed them now. 6. During an interview on 6/15/22, at 9:06 A.M., the Assistant Director of Nursing (ADON) said the following: -The nurses followed a checklist when they transferred/discharged a resident to the hospital. The checklist included completing an assessment, change of condition form, current physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The nurse made three copies of the information, one for the EMS, one for the hospital, and one for the facility; -He/she never sent a bed hold policy with a resident when he/she transferred a resident to the hospital. 7. During an interview on 6/15/22, at 10:27 A.M., the DON said the following: -When a nurse sent a resident to the hospital they sent a transfer form, H & P, significant labs and anything they felt the hospital needed to care for the resident; -The nurses had a checklist of what to send, charting requirements, and who to notify; -The nurses did not send a bed hold policy, the Business Office completed that; -The Business Office staff called the family to ask if they wanted to hold the resident's bed; -If the Business Office staff was not in the facility when a nurse transferred a resident, the Business Office staff completed this when they returned to work the next business day; -The Business Office staff should complete the bed hold policy when the resident transferred to the hospital; -If a resident is sent to the emergency room , he/she considered that a transfer, but usually they waited to see if the resident stayed at the hospital before completing the bed hold policy. 8. During an interview on 6/15/22, at 5:12 P.M., the Administrator said he/she expected facility staff to send the bed hold policy with a resident when they transferred to the hospital.

Based on observation, interview, and record review, the facility failed to ensure one resident (Resident #39) had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility census was 42. Record review showed the facility did not provide a policy regarding catheter orders. 1. Record review of the Resident #39's face sheet (admission data) showed the following: -admitted [DATE]; -diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the resident's progress note dated 5/17/22, at 1:30 P.M., showed the following: -The resident has a Foley catheter in place with leakage noted; -The resident had no bladder distention (the act of swelling) noted on palpation (exam by pressing on the surface of the body to feel the organs or tissues underneath); -Staff provided Foley catheter care with soap and water; -The catheter was patent (open and unobstructed), draining and in proper position. Record review of the resident's admission Minimum Data Set (MDS - a federally mandated comprehensive assessment instrument completed by facility staff), dated 5/23/22, showed indwelling catheter. Record review of the resident's care plan, revised on 5/24/22, showed the following: -The resident has an indwelling Foley catheter due to urinary retention, [CONDITION(S)] and benign (not cancer) prostatic [CONDITION(S)] (condition which overgrowth of the prostate tissue pushes against the bladder blocking the flow of urine - [CONDITION(S)]); -Change catheter monthly per order; -Certified nurse aides (CNA) provide catheter care every shift. Record review of the resident's May/June 2021 physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Observation and interview on 6/14/22, at 11:22 A.M., showed the resident sat in his/her wheelchair with the urinary catheter bag in a privacy bag. The resident said staff clean the catheter and empty the urine. During interviews on 6/14/22, at 1:48 P.M. and 2:18 P.M., Assistant Director of Nursing (ADON) said the following: -Residents should have an order for [MEDICAL RECORD OR PHYSICIAN ORDER] -The catheter order for a catheter should be on the POS, TAR, and care plan; -Nursing staff enters all new orders into the computer; -He/she does not see an order for [MEDICAL RECORD OR PHYSICIAN ORDER] -The resident's urologist changes the resident's catheter monthly; -Staff should know the size and type of the catheter in case they need to change the resident's catheter. During an interview on 6/14/22, at 4:07 P.M., the Director of Nursing (DON) said the following: -Staff should have an order for [MEDICAL RECORD OR PHYSICIAN ORDER] -Catheter care should be every shift and be on the POS and TAR; -The catheter order should have the size and type of catheter on the POS; -The resident's catheter order and catheter care was not on the resident's POS and TAR.

Based on interview and record review, facility staff failed to ensure the required two step [CONDITION(S)] (TB-a communicable disease that affects the lungs characterized by fever, cough, and difficulty breathing) screening test was administered timely, per facility policy, for one staff member. The facility census was 42. Record review of the facility's Infection Prevention and Control Policy, [CONDITION(S)] Surveillance, undated, showed the following: -To prevent the spread of [CONDITION(S)] by completing [CONDITION(S)] testing on all employees; -All employees will have a two step TB testing with the first step being administered and read prior to starting to work. The second TB step will be administered within three weeks of the first step; -Employees will have annual testing thereafter; -There will be documentation completed for employees; -Any employee who has had a previous positive TB test will have screening annually by completing a TB screening questionnaire. 1. Record review of Dietary Utility ([NAME]) D's personnel file showed the following: -Hire date of 11/8/21; -Staff documented administration of the first step of the TB test on on 11/4/21 and read the test on 11/7/21; -Staff documented they restarted the two step process due to a positive COVID-19 (Coronavirus Disease 2019 - an infectious disease caused by severe acute respiratory syndrome Coronavirus 2 ([CONDITION(S)]-CoV-2)) result; -Staff documented administration of the first step of the restarted TB testing series on 1/16/22 and read the test on 1/19/22; -Staff documented administration of the second step on 2/10/22 and read the test on 2/12/22. During an interview on 6/15/22 at 3:17 P.M., the Dietary Manager (DM) said the following: -He/she marked the [NAME] off the schedule beginning 12/8/21 and he/she returned on 12/17/21; -He/she believed the [NAME] tested positive on 12/6/21; -The [NAME] worked up until 12/6/21 and worked again after 12/17/21; -The [NAME] should have had his/her second step of the TB test before he/she tested positive for COVID-19; -The DM coordinated new hires in the kitchen for their first step of the TB testing series prior to them starting work and then the Ward Clerk tracked and told him/her when the employee's second step was due. During interviews on 6/15/22 at 3:35 P.M. and 3:51 P.M., the Ward Clerk said the following: -[NAME] D tested positive for COVID-19 on 12/6/21; -[NAME] D's second step TB test was due the week before he/she tested positive for COVID-19. Staff should have completed the second step the week before he/she tested positive; -The Ward Clerk did not know why the [NAME]'s second step TB test did not get completed and did not know why they did not restart the series until 1/16/22; -He/she tracked staff TB tests; -Staff completed the first step of the TB test before they started work and the second step completed within three weeks. The staff read the TB test within 48 to 72 hours after administered; -He/she coordinated the staff for testing and the nurses administered and read the tests; -He/she gave the nurses a list and TB test forms for staff that needed TB tests weekly on a clipboard and checked the forms for completion. During interviews on 6/15/22, at 1:52 P.M. and 5:12 P.M., the Director of Nursing (DON) said the following: -Staff should have restarted [NAME] D's two-step TB testing before 1/16/22. -The Ward Clerk monitored to ensure TB tests were completed timely for staff; -The facility completed the first step of the TB test prior to a staff members hire date and the second step of the TB test within three weeks of the first step. During an interview on 6/15/22, at 5:12 P.M., the Administrator said the first step TB test should be administered and results read and documented prior to a new employee working in the facility. The second step should be administered in about three weeks.

Based on record review, observation, and interview, the facility failed to ensure one resident's (Resident #29) code status (if resident wished to receive cardiopulmonary resuscitation (CPR) to be given in case of respiratory or cardiac failure) was consistently documented throughout the resident's medical record. The facility census was 42. Record review of the facility's policy titled, Advanced Directives, no date, showed the following information: -It is the policy of this facility to ensure that a resident's choice concerning the development of advance directives relative to his/her refusal of medical surgical treatment be followed in accordance with the facility's advance directive policies and procedures; -Prior to, or upon admission, a representative of the social services office will provide residents with written information concerning the resident's right under state law to accept or refuse medical or surgical treatment and the resident's right to prepare an advance directives and applicable state law; -Advance directives are defined as preferences regarding treatment options and include, but not limited to: Do Not Resuscitate (DNR - Indicates that, in case of respiratory or cardiac failure, the resident, legal guardian, healthcare proxy, or representative (sponsor) have directed that no CPR to be used); -The Director of Nursing (DON) Services will notify the attending physician of a resident's changes in advance directive. The attending physician will be responsible for issuing appropriate orders that coincide with the resident's advance directive. The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . 1. Record review of Resident #29's hospital discharge plan, dated [DATE], showed the resident's discharge code status was full code (wishes CPR to be given in case of respiratory or cardiac failure). Record review of the resident's electronic health records (EHR), on [DATE], showed the following: -admitted [DATE] with initial admitted [DATE]; -Face sheet (a document that gives a resident's information at a quick glance) did not show a code status; -Profile sheet (a written or electronic record of individual patient information created in a pharmacy practice for use by a pharmacist), did not show a code status; -The resident's current physicians order sheet did not show the resident's code status. Observation on [DATE], at 10:10 A.M., showed there was no name tag or CPR indicator on the resident's door to their room. Record review of the resident's EHR, on [DATE], showed the following: -Face sheet did not show a code status; -admitted [DATE] with initial admitted [DATE]; -Profile sheet did not show a code status; -The resident's current physicians order sheet did not show the resident's code status. Observation on [DATE], at 12:56 P.M., showed there was no name tag or CPR indicator on the resident's door to their room. Observation on [DATE], at 11:12 A.M., showed there was no name tag or CPR indicator on the resident's door to their room. Record review of the resident's EHR, on [DATE], showed the following: -Face sheet showed a code status of CPR; -Profile sheet showed a code status of CPR; -The resident's current physicians order sheet showed a code status of CPR. Record review of the resident's Resuscitate/Do Not Resuscitate form showed the following; -On [DATE], the Durable Power of Attorney (DPOA) signed Resuscitate-Do Not Resuscitate Policy and marked X on blank that showed CPR will be initiated in the event of cardiac arrest, respiratory arrest, or any other life threatening situation that might demand resuscitation. Observation on [DATE], at 1:29 P.M., showed there was no name tag or CPR indicator on the resident's door to their room. Record review of code status book at the nurses' station showed the resident listed as full code (wishing to receive CPR). During an interview on [DATE], at 1:07 P.M., Certified Nursing Assistant (CNA) E said the following: -A person would look at advance directives to see if a resident wanted to be resuscitated; -If a resident was not breathing, he/she would yell for a nurse; -Advance directives could be found on the computer or stickers by the resident name tag, but he/she was not sure what each color of dot means on the name tag. During an interview on [DATE], at 1:07 P.M., Nursing Assistant (NA) H, said the following: -DNR is do not resuscitate and CPR is full code; -CPR is completed by the nurses; -Code status is on the residents' doors, -Colored dots shows code status of the residents, but he/she is not sure what the dot's colors stand for; -NA H looked at a cheat sheet on her name tag and said light blue means CPR and DNR does not have a dot; -You could find a code in the directory book at the nurses' station or in the computer by their names by the allergies. During an interview on [DATE], at 1:11 P.M., CNA F, said the following: -DNR means do not resuscitate; -Full code means to give the resident CPR; -If a resident was not breathing, he/she would yell for a nurse; -To find status code, you could look in EHR, or stickers on the door; -He/she did not know what the sticker's color meant on the door; -He/she did not know if there was a book at the nurses' station that had residents codes in them. During an interview on [DATE], at 1:18 P.M., Registered Nurse (RN) G, said the following: -Advance directives mean to give CPR or not to resuscitate; -The nurse would start CPR if the resident was full code; -A blue dot on the door means full code and if there is not a dot, that means DNR; -If there was not a dot, the RN would go to the EHR and check the resident's orders and face sheet for code status; -When the residents were moved to the COVID (Coronavirus Disease 2019 - an infectious disease caused by severe acute respiratory syndrome Coronavirus 2 ([CONDITION(S)]-CoV-2)) Hall, staff brought their name tags with code status to the hall; -The resident does not have a dot, then RN G would have somebody check or look at code status, if no dot, and no directives on face sheet or orders, then they would think it was DNR; -The CPR sheet says full code, should have a blue dot, but it looks like DNR; -Discharge paperwork from the hospital says full code from [DATE]. During an interview on [DATE], at 1:40 P.M., the Director of Nursing (DON) said the following: -Social services is responsible to get advance directives from the residents to show if they are DNR or CPR; -Advance directives are reviewed every care plan meeting by the social worker; -A nurse will use the hospital discharge paperwork until the social worker gets the information from the resident; -There is a book at both nurses desk with advance directives in case the computer goes down; -The nurse doing the advance directories should write the order and send it to the doctor for the orders; -The doctor would only sign the code sheet if the resident was DNR; -The orders would have the advance directives and when the code is put in, it will automatically goes to the face sheet to reflect the code status; -When a person opens the chart on the computer, it will have the resident's code status; -If a resident has chosen full code, a blue dot sticker is placed on their name tag on their door; -The resident should have a blue dot on their name tag and it should be on her orders and EHR; -There is a book at the nurses' station that should have full code sheet. During an interview on [DATE], at 2:00 P.M., the Social Worker, said the following: -When a resident comes to the facility, she is responsible to get a code or no code status for advance directives and to do any changes in code status; -DNR goes in the doctor's box to sign and she will let the DON know the code status so the nurses can put it into the EHR; -Code status should be on the face sheet in EHR and the resident's is not there; -The resident was admitted on [DATE] and the code sheet shows full code. During an interview on [DATE], at 3:42 P.M., Medical Records said the following: -Code status could be found in scanned in paperwork or in a book at the nurses' station; -Code status is part of the Admissions paperwork when residents get to the facility; -If a resident wants CPR, they sign their paperwork and it is given to the DON or Minimum Data Set (MDS - a federal mandated assessment tool completed by facility staff) Coordinator and they put it into EHR records; -It is scanned and put into the resuscitation book and can be located under miscellaneous in the EHR; -A DNR requires a doctor's signature; -CPR or DNR should be located on the doctor's orders. During an interview on [DATE], at 3:56 P.M., Assistant Director of Nursing (ADON), said the following: -Code status starts on admission and should be uploaded in each resident's chart; -It will be on the EHR and into the books of advance directives; -There should be a blue dot on the doors of the residents if they are full code; -Before the ADON, goes into any resident room, she will glance at their code status on their door even if it is for insulin or any care; -If there is not a sticker on the door, it means DNR; -Stickers are updated on admissions, readmissions, or changes of status; -Every Monday, they do a building walk through and check stickers to make sure they are up to date; -If there was not a sticker, she would not start CPR and would have medical technician or another nurse check the computer for directives on the computer; -Code status should be on the face sheet on EHR, pull paperwork from the hospital or check hard chart at the nurses' station; -If it was the status was unknown, she would start CPR; -She has never seen a no code status in EHR before; -Staff can get code status from the hospital discharge paperwork or from the physician if they come from the community. During an interview on [DATE], at 4:06 P.M., the MDS Coordinator said the following: -The social services person talks to the resident, family, or guardian and gets status code and fills out the form to have signed; -MDS coordinator gives the form to the DON and the DON gets the order from the physician; -MDS coordinator will put information into the care plan, then the form goes to medical records to be scanned and put into the system: -After the order has been written for status code, it goes on top of the file in EHR; -The social worker will still double check with the resident to make sure the information is right; -A nurse can get the order from the physician too; -If the code status is not in the computer, she would find the social worker to have her verify the code, call the doctor to get an order to put into the computer; -Light blue dot is CPR and no dot means DNR. During an interview on [DATE], at 4:13 P.M., the Social Worker said the following: -She did not speak with the resident after the return on [DATE] to check with the CPR because they just had a meeting on [DATE] and reviewed the code status; -Code status is reviewed at annual plan unless a change of status is needed; -The social worker did not know why there wasn't a code status in the computer and feels like it was there before the resident went to the hospital. During an interview on [DATE], at 5:11 P.M., the Administrator and the DON, said the following: -Code status can be found in binders in alphabetical listing at the nurses' stations or the computer; -The resident's door would have a blue dot if they were ordered CPR; -The DON said she wouldn't trust the blue dot and would look in the binder; -The DON would not trust a CNA to look in the binders and would look herself; -Would have another nurse look for the status code; -There should be an order for [MEDICAL RECORD OR PHYSICIAN ORDER]

Based on record review and interview, the facility failed to prevent the misappropriation of residents' medications (including narcotic medication cards (bubble packs) of Resident #1 and Resident #2) from the medication cart. The facility census was 36. The facility administrator and the Director of Nursing (DON) were notified of the Past Non-Compliance which occurred between approximately 3/3/2020 and 9/25/2020. The facility staff began an investigation on 9/26/2020 and suspended Certified Medication Technician (CMT) A. The facility began immediate in-servicing of all staff who were on-site and as they arrived for work prior to beginning their shift. The facility also notified the Department of Health and Senior Services (DHSS) and the local law enforcement agency of the event. The noncompliance was corrected on 10/1/2020. Record review of the facility's (undated) policy entitled, Narcotic and Controlled Drugs - Record and Variances showed the following information: -It is the policy of the facility to ensure the proper handling and tracking of controlled medications; -Controlled medication will be subject to special receipt, record-keeping, change of shift count verification, storage and disposal procedures; -Inventory all controlled medication upon receipt by verifying the name of the medication and the number or amount of medication received. The nurse and CMT will sign and date the narcotic sheet, place the narcotic card in the double locked container, and place the narcotic sheet in the narcotic book; -All controlled medication will have an individual resident's narcotic form. Any medication taken from the narcotic card should be documented on this sheet and count reconciled. Each control sheet will be reviewed during the change of shift verification narcotic count. At the change of shift, the on-coming and out-going staff persons jointly count all controlled medications; -All narcotics will be stored under a double lock system. The narcotic keys will be in the possession of the staff member who counted until the change of shift count is completed; -All personnel administering medication must document all medication administered on the electronic medical record (PCC). All narcotics should be signed out on the narcotic sheet at the time the medication is punched out of the card. If a dose of regularly scheduled medication is withheld or refused, the nurse is to document a reason in PCC. As needed (PRN) medications are to be documented in PCC, with a reason for use. (The policy did not direct staff to count the number of narcotic cards and boxes as part of the facility reconciliation procedure.) 1. Record review of Resident #1's face sheet (basic resident profile information) showed the following information: -admitted to the facility on [DATE]; -[DIAGNOSES REDACTED]. Record review of the resident's care plan, last revised 10/30/2020, showed the following information: -At risk for altered comfort related to chronic pain to feet and immobility; -Chronic pain related to arthritis and [MEDICAL CONDITION]; -Administer pain medication as per orders. Record review of the resident's electronic physician order [REDACTED]. -An order, dated 4/3/2020, for [MEDICATION NAME] (narcotic pain medication) 10/325 milligrams (mg), one tablet every eight hours as needed (prn) for pain; -An order, dated 4/4/2020, for [MEDICATION NAME] 10/325 mg, one tablet by mouth three times daily. Record review of the resident's September 2020 Medication Administration Record [REDACTED] -[MEDICATION NAME] was scheduled for administration at 8:00 A.M., 2:00 P.M., and 8:00 P.M.; -Staff documented administration of the [MEDICATION NAME] daily at the first and third dosing times (8:00 A.M. and 8:00 P.M.); -Staff did not document administration of the scheduled 2:00 P.M. [MEDICATION NAME] dose on 9/2/20, 9/8/20, 9/9/20, 9/15/20, 9/17/20, or 9/21/20 (six of the thirty days). Staff did not document why the medication was not administered; -Staff documented administration of prn [MEDICATION NAME] on 13 occasions (9/2/20, 9/7/20, 9/8/20, 9/10/20, 9/12/20, 9/15/20, 9/16/20, 9/18/20, 9/19/20, 9/21/20, 9/22/20, 9/25/20, and 9/27/20). Record review of the resident's nurses' notes showed staff did not document why the routine [MEDICATION NAME] doses at 2:00 P.M. were not administered on 9/2/20, 9/8/20, 9/9/20, 9/15/20, 9/17/20, or 9/21/20. Record review of the facility's investigation, dated 9/26/2020, showed the following summary: -On 9/26/2020, at 12:13 P.M., CMT D notified the DON of concerns regarding the possibility that narcotic medications had been stolen by Social Services/CMT A, and started an investigation; -Narcotic sheets were found in a shredder in the social services office. Inspection of the shredded strips included one name (Resident #1); -Facility interviews and statements showed the narcotic card for Resident #1's [MEDICATION NAME] was empty too soon. A new card of 30 tablets was received on 9/22/2020, at 4:00 P.M., and another new card of 30 tablets received on 9/25/2020, at 6:00 P.M. The maximum number of tablets that could have been administered was 18 tablets. The narcotic sheets for the two cards were missing and an approximate total of 12 tablets was unaccounted for. 2. Record review of Resident #2's face sheet showed the following information: -admitted to the facility on [DATE]; -[DIAGNOSES REDACTED]. Record review of the resident's care plan, last updated 9/17/2020, showed the following information: -At risk for altered comfort related to chronic back pain due to [MEDICAL CONDITION] and radiculopathy (history of collapsed vertebrae); -Administer pain medication as per orders. Record review of the resident's electronic POS showed an order, dated 7/25/2019, for [MEDICATION NAME]-[MEDICATION NAME] (generic for [MEDICATION NAME]) 5/325 mg; one by mouth every four hours as needed for pain. The order was discontinued on 3/3/2020. Record review of the resident's February 2020 and March 2020 MARs showed the following information: -During the month of February 2020, staff documented administration of prn [MEDICATION NAME]-[MEDICATION NAME] one time, on 2/19/2020; -On March 1-3, 2020, staff did not document administration of any prn [MEDICATION NAME]-[MEDICATION NAME]. Record review of the facility's investigation, dated 9/26/2020, showed the following summary: -On 9/26/2020, at 12:13 P.M., CMT D notified the Director of Nursing (DON) of concerns regarding the handling of medications by Social Services/CMT A, and an investigation was started; -Narcotic sheets were found in a shredder in the Social Services office. Inspection of the shredded strips included one prescription number. The pharmacy traced the prescription number to Resident #2, for a prescription filled on 10/22/2019. The medication had been discontinued for a while, and no reason was found why the narcotic sheet would have been in the shredder. 3. Record review of a statement written by CMT D on 9/26/2020, showed the following information: -On 9/22/2020, at/around 1:30 P.M., he/she double-checked the narcotic book to make sure he/she had completed all entries for the day. He/she noticed new narcotic cards and sheets had been started for two residents, but thought there should have been pills still left on the previous cards. CMT D questioned Social Service Designee (SS)/CMT A, who said he/she had finished their old cards at the lunchtime medication pass and had another available staff member sign off on the empty cards and accompanying narcotic sheets. CMT D thought it was not quite right, but the statement was believable; -On 9/26/2020, CMT D entered the office of SS/CMT A to retrieve a piece of equipment kept there. CMT D noticed a shredder under the desk, which he/she thought odd because SS/CMT A did not do his/her own shredding. CMT D opened the bin and discovered the remains of multiple control records for narcotics; -Wanting to resolve his/her suspicions, CMT D obtained permission via phone from the office manager to view video recording of the medication room on the date of 9/22/2020. The video showed SS/CMT A wrapping a narcotic sheet around a card of narcotic pills and exiting the room; -CMT D called the Director of Nursing (DON) to report his/her findings; -During a subsequent investigation, CMT D, the DON, and the office manager noted several medication cups in SS/CMT A's desk drawer. The cups were marked with resident names or initials and still contained some pills. 4. Record review of the facility's investigation showed the following information: -Multiple attempts to speak to CMT A were unsuccessful. CMT A was suspended pending completion of the investigation. A text message was sent to CMT A not to come to the building until contacting the administrator; -On 9/26/2020, at 7:50 P.M., the facility notified the local Police Department of possible missing controlled medications. 5. During an interview on 3/17/2021, at 10:17 A.M., CMT B said prior to the incident regarding missing medications, the outgoing and oncoming CMT or nurse counted all narcotics together at the shift change, but did not count the total number of narcotic cards and boxes of liquid narcotics. 6. During an interview on 3/17/2021, at 10:21 A.M., CMT C said they count all narcotics at each shift change; one CMT/nurse looks at the narcotic sheets and the other CMT/nurse verifies the number of pills or amount of liquid. CMT C said that after the incident regarding missing medications, the procedures changed to include the verification of the actual number of narcotic pill cards compared to a log; both staff must sign the log with the shift change count. CMT C said staff should not give the medication room and cart keys to anyone until they have signed the shift change count verification. 7. During interviews on 3/16/2021, at 3:05 P.M., and 3/17/2021, at 1:56 P.M., the DON said on 9/26/2020, CMT D reported concerns regarding recent actions by Social Services designee A (SS; who was also a CMT) and the finding by CMT D of shredded narcotic sheets in the shredder bin in the office of SS A. Subsequent to the report and finding of shredded narcotic sheets, review was made of the videos from cameras in the medication room and hallways recorded on 9/22/2020 and 9/25/2020. The DON said a full audit of all residents' narcotics showed possible variances for fifteen residents, for a worst case total of up to 419 pills unaccounted for. No residents went without medications. The DON said at the time of the medication misappropriation, the CMT's were most likely sharing their keys with CMT A, who would assist with medication pass during the day. CMT A had worked for the facility for quite a few years and everyone trusted him/her. The DON said prior to the incident staff were not directed to count the actual number of narcotic cards and boxes/bottles of liquid narcotics during the shift change narcotic count done by the outgoing and oncoming staff. The in-servicing after the incident included a procedural update for the staff to verify the card/box count during the shift change narcotic count and sign a log. MO 004 and MO 502

Based on interview and record review, the facility failed to notify and coordinate with the State-designated authority following newly evident or possible serious mental illness for six residents (Resident #23, #34, #42, #11, #35, and #37) who had a negative level one Preadmission Screening and Resident Review (PASARR-a federal requirement to help ensure that individuals who have a mental disorder or intellectual disability are not inappropriately placed in nursing homes for long-term care. The PASARR requires that all applicants to a Medicaid-certified nursing facility be evaluated for a serious mental disorder and/or intellectual disability and be offered the most appropriate integrated setting for their needs (in the community, a nursing facility, or acute care setting) and receive the services they need in those settings). A sample of 14 residents were selected for review out of a facility census of 56. Record review of the facility's (undated) policy and procedure titled, Resident Assessment-483.20 showed the following information: -Coordination: the facility follows the RAI (Resident Assessment Instrument-is used in conducting comprehensive assessments as part of an ongoing process through which the facility identifies each resident's preferences and goals of care, functional and health status, strengths and needs, as well as offering guidance for further assessment once problems have been identified) assessment schedule and coordinates assessments with the PASARR program in an effort to avoid duplicate testing; -Coordination includes: 1. Recommendations obtained from the PASARR level II screening and including this information in the RAI, care plan and transitions of care; 2. Refers all level II residents and all residents with newly evident or possible serious mental disorders, intellectual disability, or related condition for level II residents upon significant change in status assessment. 1. Record review of Resident #23's Level I Nursing Facility Pre-Admission Screening for Mental Illness/Mental [MEDICAL CONDITION] or related condition, dated 10/21/14, showed the following information: -Does not show any signs or symptoms of major mental disorder; -Had not been diagnosed as having a major mental disorder; -Primary reason for nursing facility placement not due to dementia; -Had never had serious problems in levels of functioning in the last six months; -Not known or suspected to have mental [MEDICAL CONDITION] that originated prior to age 18; -Not known or suspected to have a related condition; -Did not qualify for a special admission category. Record review of a physician progress notes [REDACTED]. The resident had a history of [REDACTED]. Record review of the resident's medical record showed the following information: -Date of admission 6/13/16; -[DIAGNOSES REDACTED]. -Major [MEDICAL CONDITION] (a mental disorder characterized by a feeling of loss of interest in things that were once pleasurable); -Anxiety disorder (a psychiatric disorder causing feelings of persistent anxiety); -Hallucinations (a sensory experience of something that does not exist outside the mind, caused by various physical and mental disorders, or by reaction to a certain toxic substance, and usually manifested as visual or auditory images). Record review of the resident's medical record showed no Level II screening had been completed. 2. Record review of Resident #34's medical record showed the following information: -Date of admission 7/01/15; -[DIAGNOSES REDACTED]. Record review of a physician progress notes [REDACTED]. Record review of the Level I Nursing Facility Pre-Admission Screening for Mental Illness/Mental [MEDICAL CONDITION] or related condition, dated 12/15/15, showed the following information: -Does not show any signs or symptoms of major mental disorder; -Had not been diagnosed as having a major mental disorder; -Primary reason for nursing facility placement not due to dementia; -Had never had serious problems in levels of functioning in the last six months; -Not known or suspected to have mental [MEDICAL CONDITION] that originated prior to age 18; -Not known or suspected to have a related condition; -Did not qualify for a special admission category. Record review of the resident's medical record showed no Level II screening had been completed. 3. Record review of Resident #42's Level I Nursing Facility Pre-Admission Screening for Mental Illness/Mental [MEDICAL CONDITION] or related condition, dated 8/12/14, showed the following information: -Does not show any signs or symptoms of major mental disorder; -Had not been diagnosed as having a major mental disorder; -Primary reason for nursing facility placement not due to dementia; -Had never had serious problems in levels of functioning in the last six months; -Not known or suspected to have mental [MEDICAL CONDITION] that originated prior to age 18; -Not known or suspected to have a related condition. Record review of a physician's progress note dated 3/29/16, showed the resident had acute [MEDICAL CONDITION] with exacerbation of late-onset [MEDICAL CONDITION] secondary to [MEDICAL CONDITION]. Record review of the resident's medical record showed the following information: -Date of admission 10/10/16; -[DIAGNOSES REDACTED]. Record review of the resident's medical record showed no Level II screening had been completed. During an interview on 10/04/18, at 2:18 P.M., Administrative Assistant A said if the PASARR had not been completed at the hospital prior to the resident's admission; then, he/she would complete the Level I screening. If the resident received a [DIAGNOSES REDACTED]. The primary reason for the resident's admission to the facility was not related to his/her mental disorders so he/she did not realize a Level II screening should be completed. 4. Record review of Resident #11's Level I Nursing Facility Pre-Admission Screening for Mental Illness/Mental [MEDICAL CONDITION] or related condition, dated 2/5/16, showed the following information: -Did not show any signs or symptoms of major mental disorder; -Had not been diagnosed as having a major mental disorder; -Primary reason for nursing facility placement not due to dementia; -Had never had serious problems in levels of functioning in the last six months; -Not known or suspected to have mental [MEDICAL CONDITION] that originated prior to age 18; -Not known or suspected to have a related condition; -Did not qualify for a special admission category. Record review of the resident's medical record showed the following information: -Date of admission 2/5/16; -[DIAGNOSES REDACTED]. -Anxiety disorder. Record review of a physician progress notes [REDACTED]. Record review of the resident's medical record showed no Level II screening completed. 5. Record review of Resident #35's Level I Nursing Facility Pre-Admission Screening for Mental Illness/Mental [MEDICAL CONDITION] or related condition, dated 6/2/16, showed the following information: -Did not show any signs or symptoms of major mental disorder; -Had not been diagnosed as having a major mental disorder; -Primary reason for nursing facility placement not due to dementia; -Had never had serious problems in levels of functioning in the last six months; -Not known or suspected to have mental [MEDICAL CONDITION] that originated prior to age 18; -Not known or suspected to have a related condition; -Did not qualify for a special admission category. Record review of the resident's medical record showed the following information: -Date of admission 6/3/16; -[DIAGNOSES REDACTED].>-Major [MEDICAL CONDITION]. Record review of a physician progress notes [REDACTED]. Record review of the resident's medical record showed no Level II screening completed. 6. Record review of Resident #37's Level I Nursing Facility Pre-Admission Screening for Mental Illness/Mental [MEDICAL CONDITION] or related condition, dated 7/26/16, showed the following information: -Did not show any signs or symptoms of major mental disorder; -Had not been diagnosed as having a major mental disorder; -Primary reason for nursing facility placement not due to dementia; -Had never had serious problems in levels of functioning in the last six months; -Not known or suspected to have mental [MEDICAL CONDITION] that originated prior to age 18; -Not known or suspected to have a related condition; -Did not qualify for a special admission category. Record review of the resident's medical record showed the following information: -Date of admission 7/28/16; -[DIAGNOSES REDACTED].>-Depression; -Anxiety disorder; -Delusions. Record review of a physician progress notes [REDACTED]. Record review of the resident's medical record showed no Level II screening completed. During an interview on 10/05/18, at 11:30 A.M., the administrator said the facility staff did not realize a new Level I was required if a resident received a new [DIAGNOSES REDACTED]. The facility will complete an audit of all the residents to ensure no residents who required a new Level I PASARR screening had been missed. The facility would speak to the physician to ensure a system was in place to know if a resident received a new [DIAGNOSES REDACTED].

Based on observation, interview, and record review, the facility failed to maintain a medication error rate of less than 5%. During 31 randomly observed medication administrations, staff made three errors, resulting in an error rate of 9.68%. Facility staff attempted to administer the wrong dosage of medication to one resident (Resident #10) and failed to administer eye medication drops appropriately for two residents (Residents #10 and #17). The facility had a census of 56. 1. Record review of the Certified Medication Technician Student Manual, revised date 2008, showed the following information: -Review and verify medication administration records/cards with physician's orders [REDACTED]. -Check medication record/card and remove that container of medication from bin. Verify medication strength, dose and labeled direction on the medication administration record (MAR) against the label on the card or bottle. -Prepare medication; -Check medication record/card with the label again; -Check the label against the MAR a third time and return the medication container to appropriate storage; -To administer ophthalmic medications: Review and verify medication administration records/medication cards with physician's orders [REDACTED]. Wash hands and put on gloves. Cleanse the eye with a tissue, wiping from the inner corner outward. Ask the resident to look upward. Hold the lower eyelid away from the eye to form a pouch. -For eye drops: Instill drop into the pouch, never directly onto the center of the eyeball. With a finger, apply pressure to the inside corner of the eye (inner canthus) for one (1) minute. Remove gloves and wash hands. 2. Record review of the facility's policy titled, Specific Medication Administration Procedures revised date of January, (YEAR) showed the following information: -Purpose, to administer ophthalmic solution/suspension into the eye in a safe, accurate, and effective manner; -Apply gloves, remove eye drop cap, taking care to avoid touching the dropper tip. Tilt resident's head slightly back. With a gloved finger, gently pull down lower eyelid to form pouch, while instructing resident to look up. Instill prescribed number of drops into pouch near outer corner of eye. Instruct resident to close eyes slowly to allow for even distribution over surface of the eye. While the eye is closed, use one finger to compress the tear duct in the inner corner (inner canthus) of the eye for one (1) to two (2) minutes. This reduces systemic absorption of the medication. Alternatively, the resident may keep his/her eyes closed for approximately three minutes. -If administering medications to both eyes, use a different gloved finger to apply pressure to the inner tear duct. 3. Record review of Resident #10's admission Minimum Data Set (MDS), a federally mandated assessment instrument, completed by facility staff, dated 7/16/18, showed the following information: -An admission date of [DATE]; -Severe cognitive impairment; -[DIAGNOSES REDACTED]. Record review of the resident's MAR, dated October, (YEAR) showed the resident's physician directed staff to administer the following: -A physician order, dated 9/19/18 for [MEDICATION NAME] (an [MEDICATION NAME]) 5 milligrams (mg) once a day for allergic rhinitis (also known as hay fever, is an allergic response to specific allergens). Record review of the resident's physician order, dated 9/26/2018, showed the resident's physician directed staff to administer [MEDICATION NAME] Solution 0.1 % (an [MEDICATION NAME] used as eye drops), instill one drop in both eyes two times a day related to allergic rhinitis. Observation on 10/04/18, at approximately 9:33 A.M., showed Certified Medication Technician (CMT) D prepared to administer the resident's [MEDICATION NAME] 5 mg, according to the electronic MAR. The CMT retrieved a stock bottle from the medication cart which showed [MEDICATION NAME] 10 mg. The CMT did not identify the discrepancy in the dosage amount. The CMT said he/she was ready to give the resident his/her medications. Only after the surveyor pointed out the discrepancy in the medication's dosage, the CMT stopped dispensing the medication. The CMT proceeded to administer the resident's [MEDICATION NAME] eye drops. The CMT pulled down the lower eyelid and dispensed the eye drop. The CMT did not apply pressure to the inner eye duct area. 4. Record review of Resident #17's quarterly MDS, dated [DATE], showed the following information: -admission date of [DATE]; -Cognitively intact; -[DIAGNOSES REDACTED]. Observation on 10/04/18, at approximately 9:54 A.M., CMT D administered the resident's [MEDICATION NAME] (prescription eye drops - for increasing tear production). The CMT pulled the resident's lower eyelid to form a pouch and administered the medication. The CMT did not hold the inner eye area (tear duct). During an interview on 10/05/18, at 9:44 A.M., Licensed Practical Nurse (LPN) C said staff should check to ensure they have the correct medication and the correct dosage when administering medications. If it does not match, staff needs to double check the orders, call the pharmacy, and get a label correction. When staff administer an eye drop medication, staff should hold the resident's lower lid down and hold pressure for a second or two so not to drain to the inner eye area. During an interview on 10/05/18, at 9:58 A.M., CMT B said when giving the residents' medications, staff should to ensure they have the right medication and the right dosage of the medication. Staff should notify the charge nurse and/or pharmacy whenever the medication or dosage do not match the physician's orders [REDACTED]. During an interview on 10/05/18, at 10:05 A.M., the Director of Nursing (DON) said the following: -She expects staff to check the resident's MAR and follow the physicians' orders; -Staff should check the medication container against the resident's MAR, to check for the correct dosage of the medication; -When the physician order [REDACTED]. -Staff should contact the pharmacy with questions related to medication discrepancies; -She expects staff to hold pressure at the inner corner of the eye for one minute when administering the residents' eye medications.

Based on observation and interview the facility failed to follow accepted infection control measures when the staff handled food items with bare hands and failed to appropriately cleanse their hands when indicated to minimize the transmission of infectious agents/ organisms. The deficient practice affected two residents (Resident #5 and # 16) of 13 sampled residents and four additionally selected residents (Resident #17, #18, #20, and #21) added for dining observation. The facility census was 67. 1. Observation on 8/30/11, at 12:20 P.M., showed Certified Nurse Aide (CNA) Z delivered a meal tray to Resident #5. The CNA set up the meal tray on an over the bed table (a small moveable table), and started to feed the resident. CNA Z stopped feeding the resident to adjust the blinds of the window by turning the hanging rod of the blinds. The CNA did not wash his/her hands, but started feeding the resident. The resident took a few bites, and then CNA Z flipped on the light switch to turn on the lights. Again, the CNA did not clean his/her hands before feeding the resident. 2. Observation on 8/31/11, at 4:55 P.M., showed CNA BB feeding Resident #16 in the main dining room. CNA BB walked around the table, picked up a dirty towel from the floor, disposed of the towel in a barrel, and rubbed his/her nose. The CNA walked back to the table and fed the resident without cleaning his/her hands. During an interview on 8/31/11, at 5:26 P.M., CNA BB said staff can clean hands with hand sanitizer on the medication cart parked in the dining room. 3. Observation on 8/29/11, showed at 12:50 P.M., Certified Nurse Aide (CNA) H sat behind a half-circle shaped table. Resident #21 and Resident #22 sat in wheelchairs on the other side of the table; -With bare hands, the CNA picked up a piece of buttered bread off of Resident #22's plate, gave the resident a bite then laid the bread back onto the plate;-The aide did not use hand sanitizer or wash his/her hands to reduce the spread of infection and/or possible cross contamination. With bare hands, the aide picked up a piece of buttered bread off of Resident #21's plate, gave the resident a bite then laid the bread back onto the plate. 4. Observation on 8/29/11, between 5:15 P.M., to 5:46 P.M., showed CNA I sat behind a half-circle shaped table. Resident #17 and Resident #18 sat in wheelchairs on the other side of the table. The CNA used a spoon and gave Resident #17 a bite of food. Resident #17 coughed. Food particles and saliva came out of the resident's mouth. The aide wiped Resident #17's mouth and face with a cloth napkin. The aide did not use hand sanitizer or wash his/her hands;-With the same hand, the CNA picked up the fork off Resident #18's plate, gave the resident a bite of food, then laid the fork back onto Resident #18's plate;-Resident #17 coughed and sneezed. The aide wiped Resident #17's mouth and face with the resident's cloth clothing protector, then picked up Resident #17's spoon and gave the resident a bite of food. The CNA did not use hand sanitizer or wash his/her hands;-With the same hand the CNA picked up the fork off Resident #18's plate, gave the resident a bite of food, then laid the fork back onto Resident #18's plate.-The above observations occurred multiple times during the meal service. The aide did not use hand sanitizer or wash his/her hands between residents to reduce the spread of infection and/or possible cross contamination.5. During an interview on 09/01/11, at 1:20 P.M., License Practical Nurse (LPN) L said the following: -Staff should never touch the resident's food with bare hands; -He/she was unaware where the hand sanitizers were located in the dining room except in the restroom; -Staff should wash hands their after touching the resident's wheel chair, coughing, or touching anything that caused hands to be contaminated. During an interview on 09/01/11, at 1:35 P.M., registered nurse (RN) N said the following: -While feeding the resident, staff should never touch the resident food with bare hands; -The facility's policy said staff can use hand sanitizer three times, then they must use soap and water. During an interview on 09/1/11 at 1:35 P.M., the Director of Nursing (DON) said: -There was hand sanitizer and sanitizing wipes all over the building; -Staff should use sanitizer when going from resident to resident;-She expected staff not to handle a resident's food bare-handed.

Based on observation, record review and interview the facility failed to ensure staff appropriately assessed, documented & treated a symptomatic urinary tract infection [MEDICAL CONDITION] in a timely manner as ordered by the physician for one resident (Resident #3) who had a history of [REDACTED].#1) who had a history of [REDACTED]. The facility had a census of 67. 1. Record review of Resident #3's 60-day minimum data set (MDS) a federally mandated assessment completed by facility staff dated 5/31/11, showed the resident was cognitively intact, and required extensive staff assistance for transfers, mobility, toileting and personal hygiene. Record review of the nurse's notes showed, in part, the following information: -On 6/13/11, new orders received for body alarm for resident getting up on his/her own;-On 6/14/11 at 6:00 P.M., staff added a condition change form with the following: physician notified of blood in the resident's urine. New order for urinalysis (UA) and culture to lab. Staff did not document they had obtained the UA;-Staff did not docuement regarding the above on 6/14/11 at 6:50 P.M., and 6/15/11 at 3:45 A.M. Staff did not document they had obtained the UA;-On 6/15/11 at 11:00 A.M., the resident complained of urinary frequency. Staff did not document they had obtained the UA;-Staff did not docuement regarding the above on 6/15/11 at 4:20 P.M., and 6/16/11 at 3:00 A.M. Staff did not document they had obtained the UA;-On 6/16/11 at 8:00 A.M., resident voids small frequent amounts. Staff did not document they had obtained the UA;-Between 6/16/11 at 8:00 A.M., to 6/19/11 at 11:20 A.M., staff did not document regarding the resident's above noted complaints of blood in urine and urinary frequency. Staff did not document they had obtained the UA and/or followed up on the UA lab results;-On 6/19/11 at 11:20 A.M.,(six days) physician notified of UTI. New orders for Bactrim (antibiotic) one tablet twice a day times 10 days. Record review of the lab urinalysis showed the following information: -Date collected:6/16/11 (orders received 6/14/11);-Dated received at lab: 6/17/11;-Date reported: 6/19/11;-Appearance: cloudy (normal range-clear);-Blood: 1+ (normal range-negative);-Leukocyte esterase: 1+ (normal range-negative);-Bacteria: 3+ (normal range-none seen);-White blood cell: 75-100 (normal range-none seen). During the initial tour of the facility on 8/29/11, at 9:30 A.M., the assistant director of nursing (ADON) said the resident was alert with confusion at times. The resident had a history of [REDACTED]. The staff helped the resident with transfers and toileting. The ADON said the resident did have a recent infection. Observation showed the resident sat in the recliner in his/her room. The walker sat next to the recliner and the resident had the television playing. The resident was alert with conversation but showed signs of confusion with slowed responses to questions asked. During an interview on 9/1/11 at 1:35 P.M., the Director of Nursing (DON) said when staff notice a resident may need a UA, they should notify the physician, and then notify the aides of the need to get the UA;-The nurse's should document on a resident's status when a resident had blood in their urine;-She would hope the nurses would document a resident's condition while waiting to get a UA or waiting for results to come back from the lab. 2. Record review of Resident #1's face sheet (admission data) showed the resident was originally admitted to the facility on [DATE], and readmitted to the facility on [DATE], after being discharged to the hospital. Record review of the resident discharge (MDS), a federally mandated comprehensive assessment tool required to be completed by facility staff, dated 08/08/11, showed the following information: -Short and long term memory problems; -Severely impaired decision-making skills; -Extensive assist required from two staff for bed mobility, transfers, dressing, and personal hygiene; -Extensive assist required from two staff for locomotion on and off unit; -Extensive assist required from two staff for ambulation in room and corridors; Record review of the hospital history and physicial dated 08/08/11, showed the resident had an indwelling urinary catheter (A sterile tube inserted into the bladder to drain urine) due to chronic kidney stage III failure. Record review of the resident's care plan dated 08/22/11, showed the following: -Indwelling urinary catheter due to [MEDICAL CONDITION] with potential for urinary tract infections; -Maintain closed drainage system, use aseptic technique emptying bag; -Indwelling urinary catheter care; -Encourage fluid intake; -Monitor for signs and symptoms for urinary tract infection, foul/cloudy urine or elevated temperature and notify the physician; Observation on 8/29/11, at 12:20 P.M., showed the resident seated in his/her wheelchair in the dining room. Observation showed the resident's catheter bag in a dignity bag rested on the floor. Observation on 8/29/11, at 12:50 P.M., showed family was feeding resident in dining room. The resident's catheter bag in a dignity bag positioned under the resident's wheel chair. The dignity bag rested on the floor while resident was being fed by family. The catheter tubing lay next to the dignity bag on the floor. Observation on 8/29/11, at 2:20 P.M., showed the resident in his/her wheelchair in the activity room. The resident's catheter bag in a dignity bag positioned under the resident's wheel chair. The dignity bag rested on the floor. The catheter tubing lay next to the dignity bag on the floor. Observation on 8/29/11, at 5:00 P.M., showed the resident in his/her wheelchair at the dining room table. The resident's catheter bag in a dignity bag positioned under the resident's wheel chair. The dignity bag rested on the floor. The catheter tubing lay next to the dignity bag on the floor. Observation on 8/29/11, at 5:30 P.M., showed the resident in his/her wheelchair in the dining room. Observation showed the resident's catheter bag in a dignity bag positioned under the resident's wheel chair. The dignity bag rested on the floor. The catheter tubing lay next to the dignity bag on the floor. Observation on 8/30/11, at 5:15 A.M., showed the resident lay in bed with the catheter bag on the siderail. Observation showed the resident's catheter bag in a dignity bag that rested on the floor. Observation on 8/30/11, at 12:05 P.M., showed the resident seated in his/her wheelchair in the dining room. Observation showed the resident's catheter bag in a dignity bag positioned under the resident's wheel chair. The dignity bag rested on the floor. The catheter tubing lay next to the dignity bag on the floor. Observation on 8/31/11, at 1:30 P.M., showed the resident seated in his/her wheelchair across from the nurse's station. Observation showed the resident's catheter draining tubing lay directly touching the floor. Therapy staff wheeled the resident up the hall corridor with the tubing dragging on the floor. During an interview on 09/01/11, at approximately 2:20 P.M., the DON said staff were instructed to place the catheter bag in a dignity bag. The catheter bag and tubing should not touch the floor.

Based on observation, interview, and record review, the facility failed to assist one resident (Resident #5) with feeding from a sample selection of 13 residents. The resident was unable to eat without assistance. The facility census was 67. 1. Record review of Resident #5's 60 day Minimum Data Set ((MDS) dated [DATE], showed the following information: - A decline in eating ability; staff provided guided maneuvering of limbs; - Cognitive problems; - Mood problems; - Frequent moderate pain which had limited daily activity; - Therapeutic diet; - The use of psychiatric medication for depression and anxiety. Record review of the physician's orders [REDACTED]. - Regular diet, super cereal with breakfast; - House supplement with meals; - Weekly weights. Record review of the plan of care dated 6/21/11, showed the following information: - Potential for impaired nutritional status/weight loss due to consuming an average of 60 percent of meals; - Potential for dehydration and fluid/electrolyte imbalance due to poor intake; - Encourage resident to eat meals; - Assist resident to eat and drink if unable to complete task per self. Record review of the weight variance record showed the following information: - 8/4/11, 110.2 pounds (lbs); - 8/11/11, 109.1 lbs; - 8/18/11, 101.8 lbs, staff notified the physician and started the resident on a nutritional supplement; - 8/25/11, 99.8, resident started on hospice services. Record review of the [MEDICAL CONDITION] risk assessment dated [DATE], showed the following information: - Self feeding ability declined; - Fed by staff; - Weight loss; - Food intake 40%; - Fluid intake 84%; - Laboratory values abnormal. Record review of a nurse summary dated 8/27/11, showed the staff should provide extensive assistance to the resident during meals. During observation on 8/29/11, at 12:10 P.M., the resident sat in the living room area in a wheelchair. During interview Registered Nurse (RN) J said staff placed the resident in the living room area to wait before taken to the dining room to be fed by staff. During observation on 8/29/11, 12:40 P.M., staff wheeled the resident to a table (horseshoe shaped utilized to assist residents to eat meals). Certified Nurse Aide (CNA) W assisted the resident to drink a glass of milk. The CNA turned to assist other residents, and the resident picked up a spoon. The resident tried to eat a spoonful of chicken and dumplings but his/her hand shook violently. The food flew out of the spoon. The resident put the empty spoon in his/her mouth. The resident made several attempts to eat, with no success, and stopped. After several minutes, a family member arrived and assisted the resident. The resident ate vigorously when fed by the family member. During an interview on 8/29/11, at 4:30 A.M., a family member of the resident said the staff told them the resident had not eaten very well, recently. The staff told the family if the resident did not want to eat he/she did not have to eat. Staff have given a supplement to the resident for weight loss. During observation on 8/29/11, at 5:25 P.M., the resident lay in bed with family members present. As the family watched, Certified Medication Technician (CMT) X fed the resident. CMT X said the resident had preferred to eat alone in his/her room while fed by family members. But, today the resident and the family did not seem to mind if the CMT fed the resident. During interview on 8/29/11, at 5:40 P.M., the Social Services Director (SSD) Y said the resident had lost weight due to not eating. The resident's weight loss was one aspect of used by the staff to determine if the resident met the criteria to receive hospice services. During observation on 8/30/11, at 7:00 A.M., the resident sat at a table that had a slide out tray. The resident drank from a cup with a lid to prevent spills. The resident held the cup with both hands to keep the cup steady. The resident tried to fill out a menu for breakfast, but his/her hands shook, and the resident could not write out the order. CNA O commented on the resident's hand shake, and assisted the resident to write out the breakfast order. The resident attempted to eat with a fork, independently. The resident's hand shook back and forth violently, and shook the food off the fork. Most of the food fell on to the resident's clothes. The resident consumed a small amount of food. The resident made several attempts to use the fork. The resident picked food off his/her clothes with his/her hands, and ate the food. The resident's tablemate told staff the resident needed help to eat. Staff asked the resident if he/she needed help, and the resident said he/she did not need help. The tablemate started crying, and raised his/her voice. He/she said again the resident needed help. The staff told the tablemate the resident ate just fine. The resident did not eat anymore. The resident consumed approximately 10% of the food served. During observation on 8/30/11, at 12:20 P.M., CNA Z fed the resident in the resident's room. The resident's family member came into the room, and watched while the CNA fed the resident without intervention. During interview CNA Z said the resident had preferred to eat alone in his/her room. During interview on 9/1/11, at 9:35 A.M., the Assistant Director of Nursing (ADON) said he/she planned to do a significant change of condition assessment for the resident due to the resident's decline in overall function. During interview 9/1/11, at 11:20 A.M., the Director of Nursing (DON) said the family would not let staff feed the resident, and the resident should eat in his/her room. The family would not let the staff take the resident to the dining room last week. The family said they would feed the resident. During interview on 9/1/11, at 1:20 P.M., the SSD Y said the family had insisted they did not want a stranger to feed the resident, and they would feed the resident at all meals. The staff and family recognized the resident's hands shook all the food off the spoon when he/she tried to feed him/herself. The family said staff should feed the resident if no family came to the facility to feed the resident. During interview on 9/1/11, at 1:30 P.M., RNA R, and RNA Q said staff should feed the resident if no family are present. They said the resident's hand shook more when he/she seemed more anxious and nervous.

Based on observation, interview and record review, the facility staff failed to ensure staff followed physician's orders for one resident (Resident #2) out of 13 sampled residents when staff did not apply anti-embolitic hose (Juzo-support stockings) and heel protectors as ordered. The facility census was 67. 1. Record review of the Resident #2's face sheet (admission data) showed the resident was originally admitted to the facility on [DATE], and re-admitted on [DATE]. The resident had [DIAGNOSES REDACTED]. Record review of a physician's order dated 03/17/11, showed the physician directed the staff to apply heel protectors to the resident's heels while in bed. (A foam padding applied to the resident's heels). Record review of a physician order dated 06/02/10, showed the physician directed the staff to apply Juzo compression stockings off in P.M. and on in A.M., to the resident's lower extremities to help reduce swelling in the resident legs. Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 06/11/11, showed the following: -Moderately impairment with cognitive skills of daily decision making; -Extensive assistance needed by staff for transfers ambulation dressing, bathing; -Frequently incontinent of bowel and bladder; -Pressure relieving devices. Record review of the resident's care plan dated 06/15/11, showed the following information: -Turn every two hours and position with pillows; -Juzo compression stockings on in A.M.; -Monitor for redness, blisters, open areas and notify nurse if any signs of breakdown. -Heel protectors while in bed. Record review of the resident's treatment administration record (TAR) dated 08/01/11, to 08/31/11,showed staff initialed the TAR which indicated the staff followed physician's order for the application of the resident's compression stockings and heel protectors everyday. Observation on 08/29/11 at 12:15 P.M., 1:00 P.M., 2:15 P.M., 3:00 P.M., and 5:15 P.M., showed the resident wore only ankle socks and showed no Juzo compression stockings to his/her lower extremities as ordered. During an interview on 08/29/11, at 1:00 P.M., the resident said staff last applied the stockings approximately one month ago. The resident said he/she was unaware where the stockings were. The resident said not all staff would place his/her heels in the heel protectors. Observation on 08/29/11, at 3:00 P.M., showed the resident in bed on his/her back with no heel protectors on his/her heels. Observation on 08/30/11, at 5:10 A.M., showed the resident in bed on his/her back with no heel protectors on his/her heels. Observation on 08/30/11, at 6:15 A.M., showed certified nurse aide (CNA) D provided personal care for the resident. CNA D dressed the resident and transferred the resident to his/her wheel chair. CNA D did not apply the Juzo compression stockings as ordered. The resident lower extremities had minimal swelling. During an interview on 08/30/11, at 12:00 P.M., registered nurse (RN) J said staff members were aware the resident had sores on his/her lower extremities last month and were told not to use the Juzo compression stockings. Staff should have documented and notified the physician. During an interview on 08/30/11, at 12:10 P.M., RN K said staff should have circled the Juzo compression stocking in the resident's TAR to indicate the resident did not received the stockings on days they were not applied. Observation on 08/30/11, at 12:15 P.M., showed RN K found the resident's Juzo compression stockings in the top shelf of the resident's closet. Observation on 08/30/11, at 1:10 P.M., the resident was seated in a wheel chair with no Juzo compression stockings to his/her lower extremity as ordered. Observation on 08/30/11 at 1:25 P.M., showed the resident in bed on his/her back with no heel protectors on his/her heels and no Juzo compression stockings to his/her lower extremities as ordered. During an interview on 09/01/11, at approximately 1:40 P.M., the Assistant Director of Nurses (ADON) said she thought the resident's compression stocking were discontinued. The resident had a large amount swelling to his/her lower extremities but the swelling was better now. During an interview on 09/01/11, at approximately 1:45 P.M., the Director of Nurses (DON) said nursing staff should have notified the resident's physician if the compression stocking were not needed. Staff should apply the compression stocking and heel protectors as ordered.

Based on observation, interview and record review the facility staff failed to develop a comprehensive individualized care plan that identified the specific assessed needs and precautions for one resident (Resident #9) with a arteriovenous (AV) fistula (the surgical joining of an artery to a vein) used for renal (kidney) [MEDICAL TREATMENT]. The facility staff failed to develop a comprehensive individualized care plan that identified the care needs of one resident (Resident #7) who displayed behaviors and resistance to care out of 13 sampled residents. The facility census was 67. 1. Review of Brunner and Suddarth's Textbook of Medical-Surgical Nursing, 10th edition, 2004, showed the following information regarding [MEDICAL CONDITION] (ERSD), [MEDICAL TREATMENT], and AV fistula precautions: -"[MEDICAL CONDITION], or [MEDICAL CONDITION], is a progressive, irreversible deterioration in renal function in which the body's ability to maintain metabolic and fluid and electrolyte balance fails....[MEDICAL TREATMENT] or kidney transplantation eventually becomes necessary for patient survival"; -"In [MEDICAL TREATMENT], the blood...is diverted from the patient to a machine, a dialyzer, in which the blood is cleansed and then returned to the patient"; -An AV fistula is created by surgically joining an artery to a vein. "Needles are inserted into the vessel to obtain blood flow adequate to pass through the dialyzer"; -Nursing management includes protection of the AV fistula from damage. Protective measures include: -Ensuring the extremity with the AV fistula is not used for taking blood pressures or for obtaining blood specimens; -Avoidance of tight dressings, restraints, or jewelry on the affected extremity; -Regular assessment of the AV fistula for signs and symptoms of blockage and/or infection. Record review of Resident #9's Medicare 60-day Minimum Data Set (MDS), a federally mandated comprehensive assessment tool required to be completed by the facility staff, dated 8/2/11, showed the following information: -The facility admitted the resident on 6/3/11; -Independent with cognitive skills for daily decision-making; -Required minimal assistance with most activities of daily living (ADLs); -Received [MEDICAL TREATMENT] while a resident of the facility. Record review of the resident's August 2011, physician order [REDACTED]. -Medical [DIAGNOSES REDACTED]. -No orders for [MEDICAL TREATMENT] or for pre- or post-[MEDICAL TREATMENT] care. Record review of a physician's progress note, dated 8/29/11, showed the resident had [MEDICAL CONDITION] and received [MEDICAL TREATMENT] three times per week. Record review of a nursing admission note, dated 6/3/11, showed the resident had an AV fistula present on his/her right arm. Record review of the resident's care plan, updated on 8/30/11, showed the following information: -Problems and goals for care related to [MEDICAL CONDITION], [MEDICAL TREATMENT], and AV fistula care included: -Problem: Potential for signs of [MEDICAL CONDITION] due to [MEDICAL CONDITION] and [MEDICAL TREATMENT]. Goal: Will reduce incidences of disordered thinking within one month; -Problem: Impaired physical mobility related to gait disturbance and balance problems due to weakness secondary to [MEDICAL CONDITION]. Goal: Will ambulate independently using a walker and one staff (member assistance); -Problem: At risk for constipation related to [MEDICAL CONDITION] and medications that can cause constipation. Goal: Will have soft, formed stool every three days or as regular for the resident; -Problem: Requires a therapeutic diet related to [MEDICAL CONDITION]. Recent (weight) loss before admission. Consumes an average of 65 percent of meals. Goes to [MEDICAL TREATMENT] three times weekly. Goal: Will consume 75 to 100 percent of meals served. Will maintain ideal body weight. Will have no skin breakdown. Will be able to eat with no complications related to diet; -Problem: Potential for dehydration and fluid and electrolyte imbalance due to [MEDICAL CONDITION] and [MEDICAL TREATMENT]. Prone to nausea and vomiting secondary to [MEDICAL TREATMENT]. Goal: Will have no signs or symptoms of fluid and electrolyte imbalance or dehydration; -Problem: Potential for skin breakdown due to immobility, incontinence, and [MEDICAL CONDITION] requiring [MEDICAL TREATMENT]. Goal: Will have no skin breakdown; -Skin integrity impairment related to itching and scratching secondary to [MEDICAL CONDITION]. Comfort with no evidence of serious skin disorder. Open scratches will heal without difficulty; -Problem: At risk for infection related to right AV shunt (fistula) with [MEDICAL TREATMENT] on Monday, Wednesday and Friday secondary to [MEDICAL CONDITION]. Goal: No infections will be noted; -The care plan failed to directly address pre-[MEDICAL TREATMENT] care, pre- and post-[MEDICAL TREATMENT] care/ monitoring of the resident's AV fistula, AV fistula precautions, signs and symptoms of AV fistula dysfunction, or emergency procedures and contact telephone numbers to use in the event of complications related to the resident's AV fistula. During an interview on 9/1/11, at 8:25 A.M., LPN L said the following: -The resident receives [MEDICAL TREATMENT] on Monday, Wednesday, and Friday and usually leaves the facility for the [MEDICAL TREATMENT] center at 7:00 A.M.; -The resident is up and dressed and eats breakfast before leaving for the [MEDICAL TREATMENT] center; -If able, the staff obtains the resident's vital signs prior to departure; -The staff administers the resident's morning medications at 6:00 A.M.; -The resident usually returns to the facility before the noon meal; -The nurse assesses the resident immediately upon his/her return to the facility; -The nursing assessment consists of a blood sugar test and a head-to-toe physical assessment which includes an assessment of the pressure dressing that covers the resident's AV fistula site; -The nurse reassesses the AV fistula site again in one to one and a half hours; -The certified nurse aides (CNAs) obtain information on each resident's care needs and precautions from a resident information sheet (cheat sheet) kept in a book at the nurses' desk; -The resident information sheet is updated at least once per week. During an interview on 9/1/11, at 8:40 A.M., RN V said the following: -The resident eats his/her A.M. meal early then leaves for [MEDICAL TREATMENT]; -The resident returns to the facility before the noon meal; -The resident tolerates the [MEDICAL TREATMENT] process well on some days but other days complains of nausea or heart palpitations; -The nurse usually assesses the resident before he/she leaves for [MEDICAL TREATMENT]. However, if the nurse is unable to assess the resident before [MEDICAL TREATMENT], the nurse will assess the resident upon his/her return to the facility; -The nurse obtains a blood sugar test upon the resident's return but a full assessment is performed later in the shift; -There were no specific physician's orders [REDACTED]. -The resident usually has a pressure dressing on (covering the AV fistula site) when he/she returns from [MEDICAL TREATMENT]; -The resident usually takes the pressure dressing off his/herself; -The CNAs obtain information on the care needs and precautions for each resident from a basic care plan kept at the nurses' desk, from a resident information sheet that highlights important measures and precautions, and from change of shift reports; -Most of the CNAs are good to ask for information regarding resident care needs and precautions. Record review of a patient information sheet, dated 8/27/11, showed the following information for Resident #9: -Interventions and precautions for the staff to observe and provide included: -One person assist with transfers; -Full weight bearing; -Alert and oriented with some forgetfulness; -Scheduled toileting; -Feeds self; -Assist with all ADLs; -Heel protectors on while in bed; -[MEDICAL TREATMENT] on Monday, Wednesday, and Friday; -Needs to be up and have breakfast before 6:00 A.M. on [MEDICAL TREATMENT] days: -Send snack with him/her to [MEDICAL TREATMENT]; -The resident information sheet failed to provide the staff with directives or precautionary measures regarding the resident's AV fistula. 2. Record review of Resident #7's admission face sheet showed the resident had [DIAGNOSES REDACTED]. Record review of the nurses' notes between 7/22/11 to 8/3/11, the staff noted in the part the following information:-The resident was alert with periods of confusion;-The resident had a personal body alarm in place for safety;-The resident can be non-compliant with cares, very [MEDICATION NAME] with others;-The resident was irritable and verbally aggressive; -The resident wanted a laxative, reminded he/she received a laxative. The resident cussed and yelled angrily;-The resident takes alarm off frequently and does not remember instructions;-The resident was not always cooperative with staff and can be rude to others;-The resident was non-compliant with waiting for assistance with toileting and transfers. He/she removed his/her body alarm and transfers;-The resident talks gruff to others, not cooperative with cares;-The resident was not getting along with his/her roommate, very agitated;-The resident cussed at staff when they applied the body alarm;-The resident ran into people with his/her wheelchair;-The resident takes off the alarm and transfers self;-During rounds an aide realized the resident had removed his/her body alarm. As the aide tried to place it (the alarm) back on him/her, the resident slapped the aide's hand and cussed at him/her. The nurse spoke with the resident and told him/her the alarm was for safety, and was ordered by the physician. The resident said, "that doctor can kiss my ass";-Change in condition: continually taking off personal alarm, fighting with staff to not put it on;-The resident was refusing to let staff change his/her clothes or to allow staff to assist with needs and care. Record review of the care plan dated 8/8/11, showed in part the following information: -Disturbed thought process related to dementia;-Regularly assess behavior and social interactions for appropriateness;-Physical mobility impaired actual related to unable to transfer self safely or to ambulate independently;-Body alarm on at all times, check resident when alarm goes off;-Altered mood state related to anxiety;-Floor pad alarm on while in bed for increased risk for falls;-Staff did not develop individualized problems, goals and approaches as documented by staff regarding the resident's specific behaviors and being resistive to care. Observation on 8/30/11, showed the following information:-At 6:00 A.M., the resident sat in the wheelchair in his/her room with the alarm clipped to the back of the resident's shirt. The resident pulled off the personal alarm and the alarm sounded. An aide entered the room and the resident began cussing at the aide about clipping the alarm on his/her shirt. The aide wheeled the resident to the nurse's station and reported to the ADON.-At 6:05 A.M., the ADON wheeled the resident into the shower room. The resident continued to cuss at the ADON and that he/she wanted the alarm removed. During an interview on 9/1/11, at 9:50 A.M., the Assistant Director of Nurses (ADON) said the following information:-The care plan staff were responsible for gathering information through resident, family and staff interviews, by reviewing the record, through observations and through various assessments when completing the MDS assessments; -Resident #7 had a [DIAGNOSES REDACTED]. The resident had confusion and it had gradually improved;-The ADON said the resident's behavior (8/30/11) was the first she had seen it but that the resident "acted" that way over the weekend.-The MDS assessment generated the Care Assessment Areas (CAAs- the section of the MDS that identifies potential problem areas according to the data entered into the MDS. Staff review triggered CAA areas to determine care planning needs); -The staff used the CAAs to develop the care plan;-The care plan software allowed staff to input specific information;-Staff can add any new problems/goals not triggered in the CAAs; -Staff can choose, modify or add a problem;-Staff can make the care plan individualized for each resident.

Based on interview and record review, the facility failed to complete a comprehensive assessment that accurately reflected the status of one resident (Residents #7) of 13 selected for review. The facility had a census of 67. 1. Record review of Resident #7's admission face sheet showed the resident had [DIAGNOSES REDACTED]. Record review of the nurses' notes between 7/22/11 to 7/28/11 (seven day look back period used to complete the 7/28/11, MDS assessment), the staff noted, in part, the following information:-The resident was alert with periods of confusion;-The resident had a personal body alarm in place for safety;-The resident can be non-compliant with cares, very [MEDICATION NAME] with others;-The resident was irritable and verbally aggressive; -The resident wanted a laxative, reminded he/she received a laxative. The resident cussed and yelled angrily;-The resident takes alarm off frequently and does not remember instructions;-The resident was not always cooperative with staff and can be rude to others;-The resident was non-compliant with waiting for assistance with toileting and transfers. He/she removed his/her body alarm and transfers. Record review of the resident's admission five-day MDS assessment dated [DATE], showed the following information: -Verbal behavioral symptoms directed toward others (e.g., threatening others, screaming at others, cursing at others): staff noted the behavior was not exhibited;-Rejection of care (e.g., bloodwork, taking medications, care assistance) that was necessary to achieve the resident's goals for health and well-being: staff noted the behavior was not exhibited. Record review of the nurses' notes between 7/28/11 to 8/3/11 (seven day look back period used to complete the 8/3/11, MDS assessment), the staff noted, in part, the following information:-The resident talks gruff to others, not cooperative with cares;-The resident was not getting along with his/her roommate, very agitated;-The resident cussed at staff when they applied the body alarm;-The resident ran into people with his/her wheelchair;-The resident takes off the alarm and transfers self;-During rounds an aide realized the resident had removed his/her body alarm. As the aide tried to place it (the alarm) back on him/her, the resident slapped the aide's hand and cussed at him/her. The nurse spoke with the resident and told him/her the alarm was for safety, and was ordered by the physician. The resident said,"that doctor can kiss my ass";-Change in condition: continually taking off personal alarm, fighting with staff to not put it on;-The resident was refusing to let staff change his/her clothes or to allow staff to assist with needs and care. Record review of the 14-day MDS assessment dated [DATE], showed the following information:-Verbal behavioral symptoms directed toward others (e.g., threatening others, screaming at others, cursing at others): staff noted the behavior was not exhibited;-Physical behavioral symptoms directed toward others (e.g., hitting, kicking, pushing, grabbing): staff noted the behavior was not exhibited;-Rejection of care (e.g., bloodwork, taking medications, care assistance) that was necessary to achieve the resident's goals for health and well-being: staff noted the behavior was not exhibited. During an interview on 9/1/11 at 9:50 A.M., the Assistant Director of Nurses (ADON) said the care plan staff members were responsible for gathering information through resident, family and staff interviews, by reviewing the record, through observations and through various assessments when completing the MDS assessments.

Based on observation, interview, and record review the facility failed to reasonably accommodate the individual needs of one resident (Resident #10) with the appropriate positioning and table height to accommodate the resident's small stature to provide an effective and pleasant dining experience. A sample of 13 residents was chosen for review in this facility with a census of 67 residents. 1. A record review of Resident #10's significant change Minimum Data Set ((MDS) dated [DATE], a federally required assessment instrument, showed the following information: - Minimal hearing difficulty in noisy settings; - Total dependence for eating with full staff assistance by one staff member; - The use of a wheelchair for mobility; - [DIAGNOSES REDACTED]. - Severe pain which may limit daily activity; - A swallowing disorder which included the loss of liquids when eating or drinking, the holding of food in the mouth after meals, and coughing and choking during meals; - A therapeutic diet; - Insulin injections. A record review of the plan of care dated 8/2/11, showed the following information: - Required therapeutic diet related to diabetes; - A mechanical soft diet related to dysphagia (swallowing difficulties); - Consumption of 50% average of meals; - [DIAGNOSES REDACTED]. - Pureed diet; - Assist resident to eat and drink if unable to complete task per self. Observation on 8/31/11, at 4:56 P.M., showed staff wheeled Resident #10 to an assisted eating table (horseshoe shaped) in a small (child size) wheelchair. The staff positioned the resident with the top of his/her shoulders even with the top of the table, and slightly away from the table. Certified Nurse Aide (CNA) S sat on a stool positioned above the resident. CNA S reached over the top of the table and down to give the resident a drink of milk by lowering the glass below the top of the table, with the CNA's right wrist bent downward. As CNA S reached down and over to the resident with a spoonful of soup, he/she spilled the soup on the front of the resident's clothing protector. The resident became concerned about his/her stuffed animal, referred to as his/her baby. The resident refused to eat anymore. During observation on 9/1/11, at 8:00 A.M., the resident sat in the small wheelchair at the assisted eating table positioned away from the table. CNA T reached over the top of the table, and down to feed the resident. During interview the CNA said the "U" shaped table did not have slide out trays like some of the other tables. Staff used this table to feed residents who needed assistance. During interview on 9/1/11, at 1:20 P.M., Licensed Practical Nurse (LPN) L said the staff should feed the residents at eye level. During interview on 9/1/11, at 1:30 P.M., Restorative Nurse Aide (RNA) M said the facility's policy showed the following: - Staff should sit next to the resident while assisting with eating in the dining room; - Staff should not stand next to a resident or be above the resident; - Staff should assist the resident to eat at eye level to encourage [MEDICATION NAME]. During interview on 9/1/11, at 1:35 P.M., Registered Nurse N said staff needed to sit next to the resident at eye level while assisting with eating. During an interview on 09/1/11 at 1:35 P.M., the Director of Nursing (DON) said staff should sit to feed residents. Staff should take a stool around and sit beside a resident and should not lean over the table to feed residents. During interview on 9/1/11, at 2:00 P.M., LPN O said staff needed to sit at the resident's level to feed them. During interview on 9/1/11, at 2:30 P.M., RNAs Q and R said feeding assistance has been awkward when staff sit on the inside of the horseshoe shaped table without the slide outs. When staff feed residents positioned below and away from the staff member, the pressure of the spoon on the resident's mouth is wrong for the resident. Staff should follow facility policy to sit outside the table next to the resident when feeding small residents.