Every finding on record at Mountain View Healthcare

Based on observation, interview, and record review, the facility failed to assess the use of bed and chair alarms (devices that contain sensors that trigger an alarm when they detect a change in pressure) to determine if utilized as restraints, to complete on-going evaluations for the continued need, and to identify a medical symptom that supported the use of the bed and chair alarms for one resident (Resident #45) out of one sampled resident. The facility census was 63. Review of the facility's policy titled, Safety and Supervision of Residents, revised July 2017, showed: - Our facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities; - The care team shall target interventions to reduce individual risks related to hazards in the environment, including adequate supervision and assistive devices; - Monitoring the effectiveness of interventions shall include the following: ensuring that interventions are implemented correctly and consistently, evaluating the effectiveness of interventions, modifying or replacing interventions as needed, and evaluating the effectiveness of new or revised interventions. 1. Review of Resident #45's medical record showed: - Diagnoses of senile degeneration of the brain (a decline in an individual's memory, behavior, and cognitive abilities), dementia (a disorder marked by memory loss, personality changes, and impaired reasoning that interferes with daily functioning), atrial fibrillation (an abnormal heart beat), benign prostatic hyperplasia (BPH - enlargement of the prostate causing difficulty in urination), hypertension (high blood pressure), diabetes mellitus (DM - a condition that affects the way the body processes blood sugar), pain, functional dyspepsia (a term used to describe a lingering upset stomach that has no obvious cause), muscle weakness, and need for assistance with personal care; - No documentation of a medical symptom to support the use of the bed and chair alarms; - No documentation of the bed and chair alarms assessed as a restraint or consent for use. Review of the resident's Physician Order Sheet (POS), dated 04/01/25, showed: - An order for a sensory alarm on and checked every shift. Ensure the alarm is working properly and placed under the resident, dated 01/23/25; - The order did not address the medical symptom for the use of the bed and chair alarms. Review of the resident's Progress Notes showed: - On 01/23/25 at 5:46 A.M., the resident was found on the floor; - On 01/24/25 at 12:19 A.M., the resident fell . A pressure alarm was placed on the resident's bed; - On 01/30/25 at 5:46 A.M., the resident's pressure alarm sounded. The resident found on the floor; - On 02/03/25 at 9:49 P.M., the resident had an unwitnessed fall out of the bed; - On 02/10/25 at 2:33 P.M., the resident's alarm went off. The resident was on the floor with his/her head against the nightstand; - On 02/18/25 at 12:16 A.M., the resident found on the floor; - On 02/19/25 at 10:02 P.M., the resident's pressure alarm sounded at 3:00 P.M. The resident was on the floor; - On 03/06/25 at 9:36 P.M., resident had a witnessed fall in his/her room at 9:00 P.M., - On 03/15/25 at 3:52 A.M., the resident's bed alarm sounded at 11:45 P.M., and the resident was found on the floor; - On 03/17/25 at 10:29 P.M., at 10:00 P.M., the resident's alarm sounded and the resident was found on the floor; - On 03/18/25 at 11:51 P.M., the resident had a witnessed fall in the room. The alarm sounded when the resident slipped out of the bed; - On 03/22/25 at 8:36 P.M., at 7:26 P.M., the resident's bed alarm sounded and the resident was found on the floor; - On 03/22/25 at 8:39 P.M., at 8:30 P.M., the resident's bed alarm sounded again. The resident was found on the floor. Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment instrument completed by the facility staff), dated 03/19/25, showed: - Cognition severely impaired; - Dependent for eating, lower body dressing, personal hygiene, and putting on/taking off foot ware, sit to stand, chair/bed-to-chair transfer, toilet transfer, and tub/shower transfer; - Substantial/maximal assistance for oral hygiene, toileting hygiene, shower/bathe self, upper body dressing, roll left and right, sit to lying, lying to sit on side of bed; - Dependent for use of wheelchair for mobility; - Bed, chair, and motion alarms not used. Review of the resident's comprehensive care plan, revised 01/29/25, showed: - Impaired cognitive function/dementia or impaired thought processes related to dementia; - High risk for falls related to confusion, gait/balance problems, poor communication/comprehension, unaware of safety needs; - Potential for pressure ulcer development related to incontinence and requiring assistance with transfers and ambulation; - Bladder incontinence related to dementia; - Interventions include resident uses bed electronic alarm, anticipate and meet the resident's needs, be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all request for assistance. Check as required for incontinence. Observations of the resident showed: - On 04/01/25 at 10:48 A.M., and on 04/04/24 at 1:20 P.M., the resident sat in a recliner in the room. The chair alarm lay over the left arm of the recliner, out of reach of the resident, and the pressure pad under the resident's buttocks. The resident was unable to remove the chair alarm; - On 04/01/25 at 3:43 P.M., the resident lay in bed and a bed alarm hung at the head of the bed attached to a pressure pad under resident's lower back. The resident was unable to remove the bed alarm; - On 04/02/25 at 8:33 A.M., the resident lay in bed with the bed alarm attached to the pressure pad under the resident's lower back. Incontinent care performed and staff did not check the bed alarm at any time while in the room. The resident was unable to remove the bed alarm; - On 04/02/25 at 11:46 P.M., the resident sat in a wheelchair with chair alarm attached to the back of the wheelchair on the handle and a pressure pad under the resident's thighs and buttocks. The chair alarm was out of reach of the resident. The resident was unable to remove the chair alarm. During an interview on 04/04/25 at 1:20 P.M., Resident #45 said he/she didn't know about any alarms and didn't know why he/she would have them. During an interview on 04/04/25 at 1:40 P.M., the MDS Coordinator said the bed and chair alarms the facility used were used for safety for Resident #45 due to multiple falls. During an interview on 04/04/25 at 1:52 P.M., the Director of Nursing (DON) said there was no assessments or a consent for the sensory alarms. The bed and chair alarms were used for safety, as a last resort due to Resident #45 had multiple falls.

Based on interview and record review, the facility failed to document an accurate Minimum Data Set (MDS - a federally mandated assessment completed by facility staff) for two residents (Residents #27 and #45) out of 16 sampled residents. The facility's census was 63. Review of the facility's policy titled, Resident Assessments, revised November 2019, showed: - All persons who have completed any portion of the MDS resident assessment form must sign the document attesting to the accuracy of such information. 1. Review of Resident #27's medical record showed: - An admitted [DATE]; - Diagnoses of acute kidney failure; - Hospital discharge paperwork, dated 03/15/25, a discharge exam of the resident with a right nephrostomy (a thin, flexible tube inserted into the kidney through an opening in the skin to drain urine directly from the kidney) tube and a urostomy (a surgical procedure that creates an opening in the abdomen to allow urine to exit the body) in place. Review of the resident's admission MDS, dated [DATE],showed: - The resident did not have a nephrostomy. 2. Review of Resident #45's medical record showed: - An admitted [DATE]; - Diagnosis of senile degeneration of the brain (a decline in an individual's memory, behavior, and cognitive abilities); - Nurse's Note, dated 01/22/25, the resident under hospice care; - admitted to hospice on 04/01/24; - An order for a sensory alarm (a physical device which can capture and detect the movement of resident) on and checked every shift, ensure alarm is working properly, and placed under resident, dated 01/23/25. Review of the resident's quarterly MDS, dated [DATE], showed: - The resident did not receive hospice care; - The resident did not use an alarm. During an interview on 04/04/25 at 1:30 P.M., the Administrator and the Director of Nursing (DON) said they would expect the MDS assessments to be coded accurately. During an interview on 04/04/25 at 1:40 P.M., the MDS Coordinator said the nephrostomy should be addressed on Resident #27's MDS. Hospice should be addressed on the MDS if a resident was under the care of hospice. If a sensory alarm wasn't being used as a restraint for Resident #45, then the alarm wouldn't be addressed on the MDS. During an interview on 04/04/25 at 1:52 P.M., the Director of Nursing (DON) said alarms should be addressed on the MDS and care plans.

Based on interview and record review, the facility failed to implement an accurate baseline care plan (the minimum healthcare information necessary to properly care for a resident) upon admission with specific interventions for one resident (Resident #25) out of one sampled resident. The facility's census was 63. The facility did not provide a policy regarding the baseline care plan. 1. Review of Resident #25's medical record showed: - An admitted [DATE]; - Diagnosis of acute kidney failure. Review of the resident's Hospital Discharge paperwork, dated 03/15/25, showed: - A discharge exam of the resident with a right nephrostomy (a thin, flexible tube inserted into the kidney through an opening in the skin to drain urine directly from the kidney) tube and a urostomy (a surgical procedure that creates an opening in the abdomen to allow urine to exit the body) in place upon discharge from the hospital. Review of the resident's Baseline Care Plan, dated 03/15/25, showed: - Did not address the nephrostomy. Observation on 04/01/25 at 10:30 A.M., 04/02/25 at 9:35 A.M., and 04/03/25 at 8:45 A.M., showed the resident with a nephrostomy and an urostomy. During an interview on 04/03/25 at 11:00 A.M., Licensed Practical Nurse (LPN) F said the facility changed the bags to the urostomy and nephrostomy every three days like anything else. They also emptied the bags of the urostomy and nephrostomy every shift or as needed. They monitor the sites as well. During an interview on 04/04/25 at 1:15 P.M., Registered Nurse (RN) E said the facility did have to change the dressing to the nephrostomy site but he/she had never done it. During an interview on 04/04/25 at 1:30 P.M., the Director of Nursing (DON) said the resident had both a urostomy and nephrostomy. The nephrostomy should have been included on the baseline care plan. During an interview on 04/04/25 at 1:40 P.M., the Administrator said it was expected the baseline care plan included the care required by the resident during that initial time frame.

Based on interview and record review, the facility failed to ensure two residents (Residents #45 and #57) out of three sampled residents receiving hospice (palliative care for the terminally ill with a life expectancy of six months or less) services had a complete hospice coordinated plan of care. The facility census was 63. Review of the facility's policy titled, Hospice Program, revised July 2017, showed: - Coordinated care plans for residents receiving hospice services will include the most recent hospice plan of care as well as the care and services provided by our facility (including the responsible provider and discipline assigned to specific tasks) in order to maintain the resident's highest practicable physical, mental and psychosocial well-being; - The coordinated care plan will reflect the resident's goals and wishes, as stated in his/her advanced directives and during on-going communication with the resident or representative, including palliative goals and objectives, palliative interventions, and medical treatment and diagnostic tests; - The coordinated care plan shall be revised and updated as necessary to reflect the resident's current status including, but not limited to, diagnosis; problem list; symptom management (pain, nausea, vomiting, etc.); bowel and bladder care; nutrition and hydration needs; oral health; skin integrity; spiritual, activity, and psychosocial needs; and mobility and positioning. 1. Review of Resident #45's medical record showed: - admitted to hospice on 04/01/24; - admitted to the facility on hospice on 01/22/25; - No order for hospice services. Review of the resident's Hospice and Facility Coordinated Plan of Care, dated 01/22/25, showed: - Did not address the date of admission to hospice; - Did not address the medical supplies and/or the durable medical equipment (DME - equipment that helps complete daily activities) provided by hospice; - Did not address the specific days of the hospice nurse and the hospice aide visits; - Did not address the care plan interventions or the responsible party. Review of the resident's Comprehensive Care Plan, dated 01/29/25, showed: - Did not address hospice. Review of the resident's admission Minimum Data Set (MDS), a federally mandated assessment to be filled out by the facility staff, dated 01/28/25, and the quarterly MDS, dated [DATE], showed: - The resident did not receive hospice services. 2. Review of Resident #57's medical record showed: - admitted to hospice on 10/23/24; - admitted to the facility on hospice on 11/29/24; - No order for hospice services. Review of the resident's Hospice and Facility Coordinated Plan of Care, dated 11/29/24, showed: - Did not address the medical supplies and/or the DME provided by hospice; - Did not address the specific days of the hospice nurse and the hospice aide visits; - Did not address the care plan interventions or the responsible party. Review of the resident's Comprehensive Care Plan, revised date of 03/04/25, showed: - Resident under the care of hospice due to prostate cancer; - Interventions included to notify hospice the company of any changes in condition of the resident and to work closely with hospice staff to effectively meet the needs of the resident. Review of resident #57's quarterly MDS assessment, dated 3/5/25, showed: - The resident received hospice care. During an interview on 04/01/25 at 2:56 P.M., Resident #57 said he/she was currently on hospice. The hospice staff came in to visit a few times a week. During a phone interview on 04/04/25 at 12:44 P.M., the Physician said there should always be an order for hospice. During an interview on 04/04/25 at 1:40 P.M., the MDS Coordinator said if a resident was on hospice, the care plan should address the hospice care and address the resident was under the care of hospice. During an interview on 04/04/25 at 1:52 P.M., the Director of Nursing (DON) said a resident's care plan should identify hospice with interventions. The hospice coordinated plan of care should identify the exact days the hospice nurse and aides were to be in the building, what care would be done, such as showers and cares, and equipment provided. There should be an order for hospice. During an interview on 04/04/25 at 2:15 P.M., the Administrator said hospice was to provide the facility with what they would be doing and how care the care would be provided so the facility could incorporate it into the resident's care plan. There should be an order for hospice. If the resident admitted to the facility already on hospice, it should be already documented the resident was on hospice. He wasn't if an order was required for hospice.

Based on observation, interview, and record review, the facility failed to ensure a urinary indwelling catheter (a tube inserted into the bladder to drain urine) drainage bag was kept off the floor for three residents (Residents #16, #27, and #117) and to ensure proper drainage position of a urinary catheter drainage bag for one resident (Resident #117) out of three sampled residents. The facility failed to ensure a resident with a urostomy (a surgical procedure that creates an opening in the abdomen to allow urine to exit the body) and a nephrostomy (a thin, flexible tube inserted into the kidney through an opening in the skin to drain urine directly from the kidney) had physician orders for one resident (Resident #27) out of one sampled resident. The facility census was 63. Review of the facility's policy titled, Catheter Care, revised September 2014, showed: - Be sure the catheter tubing and drainage bag are kept off the floor. The facility did not provide a policy regarding catheter devices and/or care. 1. Review of Resident #16's medical record showed: - admitted on [DATE]; - Diagnosis of urinary retention (an inability to empty the bladder of urine). Review of the resident's Physician Order Sheet (POS), dated 04/01/25, showed: - An order to change the suprapubic (a tube that goes into your bladder through the abdominal wall to drain urine from the bladder) 16 French (size of the catheter) catheter monthly every day shift starting on the 28th and ending on the 28th every month and as needed (PRN) for occlusion or leakage, dated 03/03/25; - An order for urinary catheter care every shift and PRN, dated 05/02/22; - An order for an urinary drainage bag, change monthly and PRN one time a day starting on the 20th and ending on the 20th every month, dated 01/22/24. Observation on 04/01/25 at 10:46 A.M., and 1:15 P.M., of the resident showed: - The catheter drainage bag with a privacy cover in place hung from the resident's bed frame and the drainage bag touched the floor. 2. Review of Resident #27's medical record showed: - admitted on [DATE]; - Diagnosis of acute kidney failure. Review of the resident's POS, dated 04/01/25, showed: - No orders for the urostomy, the nephrostomy, and for the care of the urostomy and the nephrostomy. Review of the resident's Care Plan, dated 04/03/25, showed: - Resident had a nephrostomy and urostomy and required assistance with cleaning and changing of the bags. Review of the resident's admission Minimum Data Set (MDS - a federally mandated process for clinical assessment of all residents in certified nursing homes), dated 03/15/25, showed: - The resident had an urostomy; - The resident did not have a nephrostomy. Observations on 04/01/25 11:55 A.M., and 1:10 P.M., showed: - The resident sat in a wheelchair in his/her room with the urostomy and nephrostomy bags touching the floor hanging from under the middle of the wheelchair and without privacy bags. Observation on 04/02/25 at 12:15 P.M., showed: - The resident sat in a wheelchair in his/her room and six inches of the urostomy tubing lay on the floor. During an interview on 04/03/25 at 11:00 A.M., Licensed Practical Nurse (LPN) F said the facility changed the resident's urostomy and nephrostomy bags every three days like anything else. They also emptied the urostomy and nephrostomy bags every shift or as needed. They monitor the sites as well. During an interview on 04/04/25 at 1:15 P.M., Registered Nurse (RN) E said the facility did have to change the dressing to the nephrostomy site but he/she had never done it. 3. Review of Resident #117's medical record showed: - Date of admission 02/06/25; - Diagnosis of obstructive and reflux uropathy (a condition where urine flows backward from the bladder into the ureters (the ducts between the kidneys and the bladder) and sometimes the kidneys). Review of the resident's POS, dated April 2025, showed: - An order for a Foley (a flexible tube inserted into the bladder to drain urine) catheter 16 French with a 10 milliliter (ml) balloon, dated 03/28/25; - An order to change the catheter ever 30 days and PRN every day shift starting on the 27th every month related to obstructive and reflux uropathy, dated 03/28/25; - An order to change the urinary catheter drainage bag PRN for bag leaks, dated 02/06/25; - An order to irrigate the urinary catheter with 60 ml of normal saline (salt water) PRN for occlusion or obstruction, dated 02/06/25. Observation on 04/01/25 at 11:20 A.M., and at 1:20 P.M., showed: - The resident lay in bed and the catheter bag and tubing lay on the floor; - The catheter bag not in a privacy cover. Observation on 04/02/25 at 9:37 A.M., of the resident's catheter and incontinent care showed: - Certified Nurse Assistant (CNA) C placed the resident's urinary catheter drainage bag on the foot of the bed; - The drainage bag was not positioned below the resident's bladder to drain. During an interview on 04/02/25 at 12:30 P.M., CNA C said catheter drainage bags should be below the bladder, off the floor, and have a privacy cover. During an interview on 04/03/25 at 2:43 P.M., CNA A said catheter drainage bags should be kept below the bladder, off the floor, and have a privacy cover. During an interview on 04/04/25 at 1:52 P.M., the Director of Nursing (DON) said catheter drainage bags should be placed hanging below the bladder, not touch the floor, and with a privacy cover in place. There should be orders for any catheter devices and/or care that was provided by the facility. 47445

Based on observation, interview, and record review, the facility failed to maintain proper infection control practices during catheter (a tube inserted into the bladder to drain urine) care for one resident (Resident #117) out of two sampled residents, wound care for one resident (Resident #13) outside the sample of two sampled residents, and incontinent care for one resident (Resident #45) out of three sampled residents. The facility failed to utilize proper sterile technique for accessing a venous port (a medical device surgically placed under the skin in the chest area, providing access to a large vein for administering medications, fluids, or drawing blood) for one resident (Resident #27) out of one sampled resident. The facility census was 63. Review of the facility's policy titled, Catheter Care, Urinary, revised September 2014, showed: - The urinary drainage bag must be held or positioned lower than the bladder at all times to prevent the urine in the tubing and drainage bag from flowing back into the urinary bladder; - Maintain clean technique when handling or manipulating the catheter, tubing, or drainage bag; - Wash and dry your hands thoroughly; - Put on gloves; - Use a clean washcloth with warm water and soap to cleanse and rinse the catheter from the insertion site to approximately four inches outward; - Discard the disposable items into designated containers. Remove gloves and discard into designated container; - Wash and dry your hands thoroughly. Review of the facility's policy titled, Perineal Care, revised February 2018, showed: - Wash and dry your hands thoroughly; - Put on gloves; - Obtain pre-moistened washcloths or wet washcloth and apply soap or skin cleansing agent; - Wash perineal (the thin layer of skin between the genitals and anus) area starting with the urethra and working outward; - If the resident has an indwelling catheter, gently wash the juncture of the tubing from the urethra down the catheter about 3 inches; - Wash and rinse the rectal area thoroughly; - Discard disposable items into designated containers; - Remove gloves and discard into designated container; - Wash and dry your hands thoroughly. Review of the facility's policy titled, Handwashing/Hand Hygiene, revised August 2019, showed: - This facility considers hand hygiene the primary means to prevent the spread of infections; - Wash hands with soap (antimicrobial or non-antimicrobial) and water when hands are visibly soiled; - Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: before and after coming on duty; before and after direct contact with residents; before performing any non-surgical invasive procedures; before and after handling an invasive device (e.g., urinary catheters, IV access sites); before putting on sterile gloves; before handling clean or soiled dressings, gauze pads, etc.; before moving from a contaminated body site to a clean body site during resident care; after contact with a resident's intact skin; after contact with blood or bodily fluids; after handling used dressings, contaminated equipment, etc.; after contact with objects (e.g., medical equipment) in the immediate vicinity of the resident; after removing gloves; before and after entering isolation precaution settings; - Hand hygiene is the final step after removing and disposing of personal protective equipment (PPE); - The use of gloves does not replace hand washing/hand hygiene. Integration of glove use along with routine hand hygiene is recognized as the best practice for preventing healthcare-associated infections. Review of the facility's policy titled, Implanted Venous Port- Accessing, dated April 2016, showed: - Wash hands and assemble equipment on a clean surface near the resident; - Place a mask on yourself and on the resident; - Apply non-sterile gloves; - Palpate (examine by touch) the port, remove the gloves, wash hands, and open the dressing kit to prepare a sterile field; - Apply sterile gloves; - Flush air out of the non-coring needle and prime the tubing; - Clean the port area with antiseptic cleaning solution and air dry; - With the non-dominant hand palpate the port, hold the port steady, and insert the needle into the center of the port; - Check for blood return, flush, clamp tubing, and cover with sterile dressing. 1. Observation on 04/02/25 at 9:37 A.M., of Resident #117's catheter and incontinent care showed: - Enhanced Barrier Precautions (EBP) signage on the door frame; - Certified Nursing Assistant (CNA) C and CNA D put on gowns, did not perform hand hygiene, put on gloves, and entered the resident's room; - CNA C cleaned the catheter from the insertion site down the tubing with a wipe, moved back to the insertion site, did not use a clean area of the wipe, and wiped down the catheter again; - CNA C wiped from the insertion site down the catheter with a clean wipe, did not change gloves, did not perform hand hygiene, touched the catheter tubing and the catheter drainage bag to remove the resident's pants, assisted CNA D to put the resident's legs through a clean brief, touched the catheter tubing, and placed the catheter drainage bag on the foot of the bed; - CNA D tucked the brief soiled with fecal material between the resident's legs; did not change gloves; did not perform hand hygiene; assisted CNA C with the removal of the resident's pants and placed the resident's legs through a clean brief; removed the gloves; did not perform hand hygiene; touched the resident's cell phone, the bed side table, and the call light; removed the gown; and performed hand hygiene; - CNA C did not change gloves, did not perform hand hygiene, touched the perineal cleanser bottle, touched the wipe package, removed a wipe from the package, cleaned the fecal material from the resident's buttocks, did not change gloves, did not perform hand hygiene, touched the resident's shirt and bare leg to turn the resident, touched the wipe package, touched the trash bag, moved the catheter drainage bag from the foot of the bed to the bed frame, and touched the perineal cleanser bottle; - CNA C removed the gloves and gown and performed hand hygiene. During an interview on 04/02/25 at 12:30 P.M., CNA C said for catheter care should only wipe one time per wipe. For catheter or incontinent care, should perform hand hygiene, put gloves on, clean the resident, perform hand hygiene and change gloves, put on a clean brief, and wash hands when done. The catheter drainage bag should be below the bladder and off the floor with a privacy cover. 2. Observation on 04/02/25 at 8:33 A.M., of Resident #45's incontinent care showed: - CNA A and CNA B entered the room, performed hand hygiene, and put on gloves; - CNA A cleaned the resident's perineal area and did not use a clean area of the wipe for each swipe; - CNA A did not change gloves, did not perform hand hygiene, touched the resident's drawer handle, retrieved a clean brief, and touched the resident's bare right thigh; - CNA B touched the resident's perineal area, did not change gloves, did not perform hand hygiene, touched the resident's shirt, and assisted CNA A to turn the resident to the left side; - CNA A did not change gloves, did not perform hand hygiene, picked up the perineal cleanser bottle, retrieved a wipe from the package, wiped the resident's buttocks, did not change gloves, did not perform hand hygiene, closed the wipe package, picked up the perineal cleanser bottle, and sat it on the side table; - CNA A did not change gloves; did not perform hand hygiene; touched the resident's pillow and bed covers; removed a trash bag from his/her pocket and put it in the trash can; touched the resident's wheelchair handles, fall mat, call light, light switch by the sink, light switch by the door, and the door handle; exited the resident's room and walked down the hall to the common area; touched another resident's wheelchair handles; and pushed another resident in the wheelchair to their room, touched the light switch in the other resident's room, and performed hand hygiene; - CNA B removed the gloves, removed the trash bag from the trash can, walked the trash bag to the soiled utility, touched the doorknob, and performed hand hygiene. During an interview on 04/03/25 at 2:43 P.M., CNA A said for incontinent care, should wash hands and put on gloves, change gloves and do hand hygiene when moving from dirty to clean care, and perform hand hygiene after care was done before leaving the room. Should wipe front to back and use a new wipe with each swipe. If the foreskin was pulled back, it should be put back in place. Should sanitize hands between residents. When performing catheter care, should wear a gown and gloves, and clean away from insertion site using one wipe with each swipe, and the catheter should stay below the bladder and off the floor with a privacy cover. 3. Observation on 04/03/25 at 9:23 A.M., of Resident #117's wound care treatment showed: - EBP signage on the door frame; - The Minimum Data Set (MDS - a federally mandated assessment completed by facility staff) Registered nurse (RN) put on a gown, performed hand hygiene, and put on gloves; - The MDS RN entered the room, sat the supplies on a clean towel on the bedside table, and placed a clean cloth under the resident's left heel; - The MDS RN removed the dressing from the left heel, did not change gloves, did not perform hand hygiene, cleaned the heel wound with the wound cleanser soaked gauze; - The MDS RN didn't change gloves, didn't perform hand hygiene, removed the dressing from the nipple area wound, did not change gloves, did not perform hand hygiene, and removed the dressing from the wound under the breast area; - The MDS RN removed the gloves, performed hand hygiene, and put on new gloves; - The MDS RN applied calcium alginate (a natural, highly absorbent wound dressing derived from brown seaweed) with silver, and covered with a bordered gauze adhesive island dressing to the left heel; - The MDS RN did not change gloves, did not perform hand hygiene, opened the packaging for the breast dressings, applied Xeroform gauze (type of wound dressing used to cover and protect wounds), and covered with a bordered gauze adhesive island dressing to the nipple area wound; - The MDS RN removed the gown and gloves, did not perform hand hygiene, exited the room, obtained gauze from the treatment cart, entered the room, performed hand hygiene, and put on a gown and gloves; - The MDS RN cleaned the blood that oozed from the nipple area wound; - The MDS RN did not change gloves, did not perform hand hygiene, applied calcium alginate with silver, and covered with a bordered gauze adhesive island dressing to the under the breast wound; - The MDS RN did not change gloves, did not perform hand hygiene, put on the resident's left sock and shoe, removed the gloves, did not perform hand hygiene, removed the right sock, performed hand hygiene, and put on gloves; - The MDS RN applied skin prep (barrier film that protects the skin) to the resident's right heel, did not change gloves, did not perform hand hygiene, and put on the resident's right sock and shoe; - The MDS RN removed the gown and gloves, and performed hand hygiene. 4. Observation on 04/02/25 at 9:55 A.M., of Resident #27's venous port access procedure showed: - EBP signage on the door frame; - The Director of Nursing (DON) put on a gown, performed hand hygiene, and put on gloves; - The DON entered the room and sat the supplies on a clean towel on the bedside table, - The DON opened the packages and left the contents inside the packages; - The DON and the resident did not wear face masks; - The DON did not put on sterile gloves; - The DON performed the venous port access procedure. During an interview on 04/04/25 at 1:40 P.M., the DON said accessing the port should be a sterile procedure and with a mask worn by the staff. If the resident could tolerate wearing a mask, the resident should wear one also. During an interview on 04/04/25 at 1:52 P.M., the DON said the catheter drainage bag should be placed hanging below the bladder, not touching the floor, with a privacy bag in place, it should not be placed on top of the bed. Should perform hand hygiene and change gloves when going from dirty to clean care, and when moving between different wound sites. For catheter care, a gown and gloves should be worn; wash hands going in; put on gloves; perform the peri care; pull back the foreskin if needed and clean the penile head; discard the wipe; clean the shaft, groin and scrotum using a clean wipe to clean each area; use a clean wipe to clean the catheter from the insertion site; wipe downward, and discard the wipe after each wipe. 47445

Based on observation, interview and record review, the facility failed to provide a safe, clean and comfortable homelike environment. This deficient practice had the potential to affect all residents in the facility. The facility census was 66. Review of the facility's policy titled, Homelike Environment, revised February 2021, showed: - Residents are provided with a safe, comfortable and homelike environment and encouraged to use their personal belongings to the extent possible; - Staff provides person-centered care that emphasizes the residents' comfort, independence, and personal needs and preferences; - The facility staff and management maximizes, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting which includes a clean, sanitary and orderly environment. Observations made on 1/10/24 at 8:40 A.M. of the 100 hall showed: - One, two foot (ft.) by two ft. ceiling tile missing near the nurses' station; - One, ten inch (in.) x four ft. ceiling tile near room [ROOM NUMBER] with a linear brown stain approximately two in. x two ft.; - One, ten in. x four ft. ceiling tile near room [ROOM NUMBER] with a small brown circle; - One, two ft. x four ft. ceiling tile with small area of discoloration next to the metal tract near the hall light near room [ROOM NUMBER]. Observation made on 01/10/24 at 9:00 A.M. of room [ROOM NUMBER] showed several areas of exposed sheetrock and peeled paint on the wall, near the bed on the left side of the room. Observations made on 01/10/24 at 9:16 A.M. of the [NAME] Hall shower room, next to soiled utility room, showed: - Dust and debris on the ceiling vent in front of shower; - Three black tape-like strips peeling on the floor in front of shower; - Five black tape-like strips peeling on the floor in front of the toilet; - A 36 in. x 36 in. area of peeling tile on the floor next to a locked cabinet; - Several areas with exposed sheetrock and peeled paint on the left-side divider wall above the ceramic tile next to shower. During an interview on 01/10/24 at 9:36 A.M., Housekeeper A said there is a maintenance request form staff fill out to address areas of concerns. He/she had not seen any areas of exposed sheetrock, peeled paint, peeled floor tape or any other environmental concerns. He/she does not really pay attention to things while doing routine cleaning and sometimes will verbally tell maintenance of any issues. During an interview on 01/10/24 at 10:03 A.M., Shower Aid B said he/she had not reported anything to maintenance, but notified the charge nurse of environmental concerns. He/she is aware of the issues in the shower room, but had not notified anyone yet. During an interview on 01/10/24 at 10:16 A.M., Housekeeper C said he/she had not reported anything to maintenance recently. If he/she does have an environmental concerns a maintenance request form should be filled out and placed in the maintenance file to be addressed. During an interview on 01/10/24 at 10:34 A.M., the Maintenance Supervisor (MS) said staff verbally tell him of any needed repairs. It does make it hard to keep up because some things he/she can't remember. Once an area of concern is completed, the request form is signed and thrown away. MS does not keep copies of the maintenance request forms. During an interview on 01/11/24 at 10:23 A.M., the Administrator said he would expect staff to write down any environmental concerns on a maintenance request form to be addressed in a timely manner instead of verbally informing the maintenance department. This would allow the maintenance department to stay on top of environmental issues.

Based on observation, interview, and record review, the facility failed to ensure appropriate incontinent care was provided to prevent possible infection when staff failed to provide peri-care for two residents (Resident #1 and Resident #2) who were incontinent of urine and failed to completely clean one resident (Resident #3) who was incontinent of urine and bowel. The facility census was 65. Review of the facility's policy titled Perineal Care, dated February 2018, showed the purpose of perineal care was to provide cleanliness and comfort to the resident, to prevent infections and skin irritation, and to observe the resident's skin condition. 1. Review of Resident #1's face sheet (brief resident profile sheet) showed the following: -admitted [DATE]; -Diagnoses included nontraumatic subarachnoid hemorrhage (stroke), muscle weakness, hypertension (high blood pressure), anxiety, and depression. Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff), dated 08/29/23, showed the following: -Severe cognitive impairment; -Required extensive assistance for bed mobility, transfer, dressing, toilet use, and personal hygiene; -Always incontinent of bowel and bladder. Review of the resident's care plan, revised 09/04/23, showed the following: -Provide resident with supportive care and services; -Keep skin clean and dry to prevent skin breakdown. Observation on 09/08/23, at 5:45 A.M., showed the following: -CNA A entered the resident's room and donned gloves without performing hand hygiene; -CNA A removed the resident's wet brief; -CNA A placed a new brief on resident. The CNA did not perform perineal care or cleaning the resident's body contaminated with urine. 2. Review of Resident #2's face sheet showed the following: -admitted [DATE]; -Diagnoses included cerebral infarction (stroke), Type 2 diabetes mellitus (chronic condition that affects the way the body processes blood sugar), atrial fibrillation (irregular, often rapid heart rate), anemia (lack of blood), and hypokalemia (low potassium). Review of the resident's care plan, revised on 02/03/23, showed the following: -Provide resident with supportive care and services; -Keep skin clean and dry to prevent skin breakdown. Review of the resident's quarterly MDS, dated [DATE], showed the following: -Moderate cognitive impairment; -Required extensive assistance for bed mobility, transfer, dressing, toilet use, and personal hygiene; -Frequently incontinent of bowel and bladder. Observation on 09/08/23, at 5:50 A.M., showed the following information: -CNA A entered the resident's room and donned gloves without performing hand hygiene; -CNA A removed wet brief from the resident and dropped it on a mat on the floor; -CNA A placed a new brief on resident. The CNA did not perform perineal care or cleanse the resident's body contaminated with urine. 3. Review of Resident #3's face sheet (a brief resident profile sheet) showed the following: -admitted [DATE]; -Diagnoses included hypertensive heart disease (high blood pressure) with heart failure (heart cannot pump blood adequately), peripheral vascular disease (narrowed blood vessels reduce blood flow to arms and legs), unsteadiness on feet, and dysphagia (difficulty swallowing). Review of the resident's annual MDS, dated [DATE], showed the following: -Cognitively intact; -Required extensive assistance for bed mobility, transfer, dressing, toilet use, and personal hygiene; -Frequently incontinent of bowel and bladder. Review of the resident's care plan, revised on 06/23/23, showed the following: -Staff to wear personal protective equipment when providing cares. Observation on 09/08/23, at 5:52 A.M., showed the following: -CNA A entered the resident's room; -CNA A donned gloves; -CNA A pulled back the resident's blanket and a wet and brown ring colored area from the right side of his/her lower back to across the left side of his/her lower back and down to the thigh area was visible; -CNA A removed a wet and soiled brief from the resident, cleaned his/her buttocks with one swipe of a wet wipe and placed the soiled brief and wipe in the trash; -CNA A left the room without performing perineal care or cleaning the resident's body contaminated with urine. 4. During an interview on 09/08/23, at 6:40 A.M., CNA A said staff should check residents for incontinence every two hours. Staff should clean all parts of the body that had contact with urine and or feces. 5. During an interview on 09/08/23, at 9:30 A.M., CNA B said staff should provide peri-care to residents that have been incontinent. 6. During an interview on 09/08/23, at 9:32 A.M., CNA C said staff should provide peri-care to residents that have been incontinent. Staff should use wet wipes and wipe from front to back. 7. During an interview on 09/08/23, at 10:20 A.M., Licensed Practical Nurse (LPN) D said that staff should provide peri-care to residents that have been incontinent of urine and or stool. Staff should clean from front to back with a warm wet washcloth or use the perineal spray to clean the resident. 8. During an interview on 09/08/23, at 10:28 A.M., the Registered Nurse (RN) E said staff should provide peri-care to residents that have been incontinent of urine and or stool. Staff should clean from front to back with a wet wipe and then allow time to dry before replacing brief. 9. During an interview on 09/08/23, at 10:38 A.M., the Director of Nursing (DON) said he/she expects staff to perform peri-care on residents that have been incontinent of urine or stool. Staff should clean the resident from front to back and allow time to dry before replacing brief. 10. During an interview on 09/08/23, at 11:55 A.M., the Administrator said he/she expects staff to clean the resident during incontinent cares if the resident is wet or soiled. MO00220362

Based on observation, interview, and record review, the facility failed to maintain an effective infection control program when staff failed to complete appropriate hand hygiene while assisting three residents (Resident #1, Resident #2 and Resident #3) with cares. The facility census was 65. Review of the facility policy titled Handwashing/Hand Hygiene, undated, showed the following: -This facility considers hand hygiene the primary means to prevent the spread of infections; -Wash hands with soap and water when hands are visibly soiled and after contact with a resident with infectious diarrhea; -Use an alcohol-based hand rub before and after direct contact with residents; -Use an alcohol-based hand rub before donning gloves; -Use an alcohol-based hand rub before moving from a contaminated body site to a clean body site during resident care; -Use an alcohol-based hand rub after contact with bodily fluids; -Use an alcohol-based hand rub after removing gloves; -Hand hygiene is the final step after removing and disposing of personal protective equipment. 1. Review of Resident #1's face sheet (brief resident profile sheet) showed the following: -admitted [DATE]; -Diagnoses included nontraumatic subarachnoid hemorrhage (stroke), muscle weakness, hypertension (high blood pressure), anxiety, and depression. Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff), dated 08/29/23, showed the following: -Severe cognitive impairment; -Required extensive assistance for bed mobility, transfer, dressing, toilet use, and personal hygiene; -Always incontinent of bowel and bladder. Review of the resident's care plan, revised 09/04/23, showed the following information: -Provide resident with supportive care and services; -Keep skin clean and dry to prevent skin breakdown. Observations on 09/08/23, at 5:45 A.M., showed the following information: -Certified Nursing Assistant (CNA) A entered the resident's room, donned gloves, removed the resident's wet brief, and placed a new brief on the resident without completing hand hygiene; -With the same contaminated gloves, the CNA then placed the call light, that was attached to a small stuffed animal, back in the resident's hands; -With the same contaminated gloves the CNA patted the resident on the head with his/her gloved hand; -The CNA then removed his/her gloves, gathered trash, and left the room without completing hand hygiene. 2. Review of Resident #2's face sheet showed the following: -admitted [DATE]; -Diagnoses included cerebral infarction (stroke), Type 2 diabetes mellitus (chronic condition that affects the way the body processes blood sugar), atrial fibrillation (irregular, often rapid heart rate), anemia (lack of blood), and hypokalemia (low potassium). Review of the resident's care plan, revised on 02/03/23, showed the following: -Provide resident with supportive care and services; -Keep skin clean and dry to prevent skin breakdown. Review of the resident's quarterly MDS, dated [DATE], showed the following: -Moderate cognitive impairment; -Required extensive assistance for bed mobility, transfer, dressing, toilet use, and personal hygiene; -Frequently incontinent of bowel and bladder. Observations on 09/08/23, at 5:50 A.M., showed the following: -CNA A entered the resident's room, donned gloves, removed the resident's wet brief, and placed a new brief on the resident without completing hand hygiene; -The CNA dropped the wet brief on a mat on the floor; -With the same contaminated gloves, the CNA off the call light; -The CNA removed his/her gloves, did not perform hand hygiene, and assisted the resident with a drink of water by holding the cup to the resident's mouth; -The CNA gathered the wet brief from the floor, along with the resident's trash, and left the room without completing hand hygiene. 3. Review of Resident #3's face sheet (a brief resident profile sheet) showed the following information: -admitted [DATE]; -Diagnoses included hypertensive heart disease (high blood pressure) with heart failure (heart cannot pump blood adequately), peripheral vascular disease (narrowed blood vessels reduce blood flow to arms and legs), unsteadiness on feet, and dysphagia (difficulty swallowing). Review of the resident's annual MDS, dated [DATE], showed the following information: -Cognitively intact; -Required extensive assistance for bed mobility, transfer, dressing, toilet use, and personal hygiene; -Frequently incontinent of bowel and bladder. Review of the resident's care plan, revised on 06/23/23, showed the following information: -Staff to wear personal protective equipment when providing cares. Observations on 09/08/23, at 5:52 A.M., showed the following: -CNA A entered the resident's room; -CNA A entered the resident's room, donned gloves, removed the resident's wet/soiled brief, provided peri-care, and placed the soiled brief and wipe in the trash without completing hand hygiene; -With the same contaminated gloves, the CNA removed a clean gown from the resident's closet and assisted the resident with removing his/her soiled gown and replaced it with a clean gown; -With the same contaminated gloves, the CNA A applied deodorant to the resident's armpits; -The CNA removed his/her gloves, did not perform hand hygiene, and assisted the resident with a drink of water by holding the cup to the resident's mouth; -CNA A left the room to gather bed linens. 3. During an interview on 09/08/23, at 6:40 A.M., CNA A said staff should perform hand hygiene after every resident. Staff should perform hand hygiene before donning gloves. Gloves should be changed between dirty and clean process only if gloves become soiled. 4. During an interview on 09/08/23, at 9:30 A.M., CNA B said staff should perform hand hygiene when entering and exiting a resident room. 5. During an interview on 09/08/23, at 9:32 A.M., CNA C said staff should perform hand hygiene when entering and exiting a resident room. Gloves should be changed while performing incontinent cares if gloves become visibly dirty. 6. During an interview on 09/08/23, at 10:20 A.M., Licensed Practical Nurse (LPN) D said staff should perform hand hygiene before putting on gloves and after removing gloves. Gloves should be removed and hand hygiene performed after incontinence cares is given and brief is removed. Staff should wash hands and put on clean gloves prior to cleaning resident. Staff should remove gloves and wash hands again prior to placing clean brief on resident. Staff should remove gloves and wash hands prior to leaving resident's room. 7. During an interview on 09/08/23, at 10:28 A.M., Registered Nurse (RN) E said staff should wash hands and put on gloves, provide incontinent cares including cleaning the resident. Staff should remove gloves and wash hands, place brief, remove gloves and wash hands again before leaving the resident's room. 8. During an interview on 09/08/23, at 10:38 A.M., the Director of Nursing (DON) said he/she expects staff to wash their hands before putting on gloves and after taking off gloves. Gloves should be changed after incontinent cares are performed. It is never acceptable to provide incontinent cares to a resident and then touch things in the room such as call light or pat resident on the head with dirty gloved hand. 9. During an interview on 09/08/23, at 11:55 A.M., the Administrator said he/she expects staff to do good infection control. Staff should wash hands when entering a resident's room, put on gloves, perform incontinent cares, remove gloves then use hand hygiene. MO00220362

Based on record review, observation, and interview, the facility failed to store and prepare food in accordance with professional standards of practice and protect food from possible contamination when staff did not maintain clean surfaces, stored a scoop in the dry food storage bin, and staff did not wear proper facial hair or hair coverings. The facility census was 67. 1. Record review of the 2013 Missouri Food Code showed the following information: -Chapter 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils showed; (A) Equipment food-contact surfaces and utensils shall be clean to sight and touch; (B) The food-contact surfaces of cooking equipment and pans shall be kept free of encrusted grease deposits and other soil accumulations; (C) Nonfood-contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris; -Chapter 4-101.19 Nonfood-Contact Surfaces. Nonfood-contact surfaces of equipment that are exposed to splash, spillage, or other food soiling or that require frequent cleaning shall be constructed of a corrosion-resistant, nonabsorbent, and smooth material; -Chapter 4-602.13 Nonfood-Contact Surfaces. Nonfood-contact surfaces of equipment shall be cleaned at a frequency necessary to preclude accumulation of soil residues; -Chapter 6-501.12, Paragraph A, The physical facilities shall be cleaned as often as necessary to keep them clean. Record review of the facility policy, dated 2020, on cleaning rotation showed the following information: -Equipment and utensils will be cleaned and sanitized according to the following guidelines, or manufacturer's instructions; -Items cleaned daily; stove top, grill, steam table, exterior of large appliances; -Items cleaned monthly; walls; -Items cleaned annually; ceilings. Observation of the kitchen on 4/18/2022, beginning at 10:35 A.M., showed the following: -Pot rack that held tongs, pans and cutting boards, had a thick layer of fuzzy lint around the top; -Kitchen wall as you enter from the dining area had dried splatters from liquid and/or food; -Fuzzy lint on the vent in the dishwasher room; -Fuzzy lint on the fan, located on the wall in the dishwasher room; -Fuzzy lint on the vents over the counter and sink area; -Dry food container that contained oatmeal with a plastic spoon, down in the oatmeal, with approximately 3 inches of the handle visible; -The outside of the oven had a brown liquid substance on the front, and clear liquid substances on the sides and back of the oven. The outside front of the oven, located under the oven doors had black/brown burnt, food particles. Observations of the kitchen on 4/20/2022, beginning at 11:30 A.M., showed the following: -Scoop down in the dried oatmeal, with approximately three inches of the handle visible; -Two of the steamtable compartments had three spots of mostly burnt food, covering about 1/4 of the compartment. Record review of the cleaning schedules for the week of April 17th through April 23rd, 2022 showed the following information: -Staff checkmarked that the walls in the dish room had been cleaned on Monday, Tuesday, Wednesday, Thursday and Sunday; -Staff checkmarked that oven 1 and 2 had been cleaned Tuesday, Wednesday and Thursday; -Staff checkmarked that the steamer had been deep cleaned on Monday, Tuesday, Wednesday, Thursday and Sunday; -Staff checkmarked that the steam table had been cleaned on Tuesday, Wednesday and Thursday. During an interview on 4/21/2022, at 1:15 P.M., Dietary aide A said the following: -Kitchen staff have a cleaning schedule and they are assigned certain duties; -Scoops should not be left in dry food containers; -Kitchen staff are required to clean the hanging pot rack holder; -Maintenance is responsible for cleaning the ceiling vents and fans in the kitchen During an interview on 4/21/2022, at 1:21 P.M., Dietary Aide B said the following: -Kitchen staff have a cleaning schedule. Dietary Aide A cleans one half of the kitchen and Dietary Aide B cleans the other half of the kitchen; -Kitchen staff are responsible for cleaning the hanging pan holders and the appliances; -He/she did not know if scoops should be left in dry food containers; -Maintenance is responsible for cleaning the ceiling vents and fans. During an interview on 4/21/2022, at 1:30 P.M., the dietary manager said the following: -The kitchen has different cleaning schedules for each area, they're visible on the walls/windows in each section; -Scoops should be removed after using them and not left in the dry food containers; -The hanging pan holder should be cleaned by kitchen staff; -Staff are required to clean the oven weekly; -Staff are required to clean the walls in the dish room daily; -Staff are required to clean the steamtable weekly. 2. Record review of the 2013 Food Code, issued by the Food and Drug Administration, showed the following: -Food employees shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed food; clean equipment, utensils, and linens; and unwrapped single-service and single-use articles. Record review of the facility policy, dated 2020, on hair restraints showed the following information: -Hair restraints shall be worn by all dining services staff when in food production areas, dishwashing areas, or when serving food; -Staff shall wear hair restraints in all food production, dishwashing and serving areas; -Hair restraints, hats, and/or beard guards shall be used to prevent hair from contacting exposed food. Facial hair is discouraged. Any facial hair that is longer than the eyebrow shall require coverage with a beard guard in the production and dishwashing areas. During an observation and interview on 4/21/2022, at 1:15 P.M., in the kitchen showed the following: -Dietary Aide A transferred pudding from a can into small cups; -He/she did not wear a facial hair cover or hair covering; -He/she said kitchen staff are required to wear hair nets, he/she forgot; -He/she had asked about beard nets, but didn't know for sure where they were located; -The kitchen staff are required to wear hair nets when in the kitchen. During an interview on 4/22/2022, at 9:59 A.M., the administrator said the following; -Staff should be wearing hairnets in the kitchen; -Maintenance is supposed to be cleaning the vents in the ceiling.

Based on observation, interview, and record review, the facility failed to complete a risk/versus benefit review for one resident's side rails (Resident #51), and failed to document alternatives attempted prior to bed rail use for two residents (Resident #51 and #17); failed to complete bed rail safety check to include measurements of the bed frame and bed rails for risk of entrapment for four residents (Residents #51, #17, #15, #46); failed to obtain physician order for [MEDICAL RECORD OR PHYSICIAN ORDER] #17), and failed to address the use of bed rails in the residents' care plans for one resident (Resident #46). The facility census was 67. Record review of the facility's policy for the use of bed rails, from Med-Pass, 2001 and last revised 2017, showed the following information: -The resident's sleeping environment shall be assessed by the interdisciplinary team, considering the resident's safety, medical condition, comfort, and freedom of movement, as well as input from the resident and family regarding previous sleeping habits and bed environment; -To try to prevent deaths/injuries from the beds and related equipment (including the frame, mattress, side rails, headboard, footboard, and bed accessories), the facility shall promote the following approaches: -Inspection by maintenance staff of all beds and related equipment as part of our regular bed safety program to identify risk and problems including potential entrapment risk: -Review that gaps within the bed system are within dimensions established within the Food and Drug Administration (FDA-note the review shall consider situations that could be caused by the resident's weight, movement, or bed position); -Ensure that the bed system components are worn and need to be replaced, components meet manufacturer specifications; -Ensure the bed rails are properly installed using the manufacturer's instructions and other pertinent safety guidance to ensure proper fit (e.g., altered mental status, restlessness, etc.); -Identify additional safety measures for residents who have been identified as having a higher than usual risk for injury including entrapment (e.g., altered mental status, restlessness, etc.); -The maintenance department shall provide a copy of inspections to the administrator and report results to the Quality Assurance (QA) committee for appropriate action. Copies of the inspection results and QA committee recommendations shall be maintained by the administrator and/or safety committee; -The facility's education and training activities will include instruction about risk factors for resident injury due to beds, and strategies for reducing risk factors for injury, including entrapment; -If side rails are used, there shall be an interdisciplinary assessment of the resident, consultation with the attending physician, and input from the resident and/or legal representative; -The staff shall obtain consent for the use of side rails from the resident or resident's legal representative prior to their use; -After appropriate review and consent as specified above, side rails may be used at the resident's request to increase the resident's sense of security (e.g., if he/she has a fear of falling, his/her movement is compromised, or he/she is used to sleeping in a larger bed); -Side rails may be used if assessment and consultation with the attending physician has determined that they are needed to help manage a medical symptom or condition, or to help the resident reposition or move in bed and transfer, and no other reasonable alternatives can be identified; -Before using side rails for any reason, the staff shall inform the resident and family about the benefits and potential hazards associated with side rails; -When using side rails for any reason, the staff shall take measurements to reduce the related risk; -Side rails shall not be used as protective restraints. Should a protective restraint be used, our facility's protocol for the use of restraints shall be followed; -The use of physical restraints on individuals in bed shall be limited to situations where they are needed to treat a resident's medical symptoms, and only after being reviewed by authorized individuals; -The staff shall report to the director of nursing (DON) and administrator any deaths, serious illnesses and/or injuries resulting from a problem associated with a bed and related equipment including the bed frame, bed side rails, and mattresses. The administrator shall ensure that reports are made to the FDA or other appropriate agencies, in accordance with pertinent laws and regulations including the Safe Medical Devices Act. Record review of the guidance for industry and Food and Drug Administration (FDA) staff, Hospital Bed System Dimensional And Assessment Guidance To Reduce Entrapment, issued on 3/10/2006, from the FDA, Center for Devices and Radiological Health, showed the following information: -The term medical bed and hospital bed are used interchangeably and include adult medical beds with side rails; -Evaluating the dimensional limits of the gaps in hospital beds may be one component of a bed safety program which includes a comprehensive plan for patient and bed assessment; -Bed safety programs may also include plans for reassessment of hospital bed systems; -Reassessment may be appropriate when there is reason to believe that some components are worn, such as rails wobble, rails have been damaged, mattresses are softer and could cause increased spaces within the bed system; when accessories such as mattress overlays or positioning poles are added or removed; when components in the bed system are changed or replaced, such as new bed rails or mattresses; -Bed rails are rigid bars that are attached to the bed and are available in a variety of sizes and configurations from full length to half, one-quarter, and one-eighth length and are used as restraints, reminders, or as assistive devices; -Zone 1 is the measurement within the rail, any open space within the perimeter of the rail, a loosened bar or rail can change the size of the space; -Zone 2 is the gap under the rail between a mattress compressed by the weight of a patient's head and the bottom edge of the rail at a location between the rail supports or next to a side rail support. Factors to consider are the mattress compressibility which may change over time due to wear, the lateral shift of the mattress or rail, and any degree of play from loosened rails or rail supports. A restless patient may enlarge the space by compressing the mattress beyond the specified dimensional limit. This space may also change with different rail height positions and as the head or foot sections are raised or lowered; -Zone 3 is the space between the inside surface of the rail and the mattress compressed by the weight of a patient's head; -Zone 4 is the gap that forms between the mattresses compressed by the patient and the lowermost portion of the rail, at the end of the rail. Factors that may increase the gap size are mattress compressibility, lateral shift of the mattress or rail, and degree of play from loosened rails; -General testing considerations include for ease of mattress movement and measurement, and general safety, the patient should not be in the bed during the measurement procedures. 1. Record review of Resident #51's current physician order sheet (POS) showed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the resident's annual Minimum Data Set (MDS), a federally mandated comprehensive assessment instrument, completed by facility staff, dated 4/4/2022, showed the following information: -admitted to the facility on [DATE]; -Cognitively intact; -diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] -Required extensive assistance of two staff for bed mobility, transfers, dressing, and toileting; -No history of falls; -Bed rails not used. Record review of the resident's care plan, last updated 3/18/2022, showed the resident used half side rails to assist with bed mobility and positioning and the resident requested to continue the use of the half side rails when in bed for positioning and bed mobility. The bed rails were not a restraint per the care plan team. Observation on 4/19/2022, at 9:25 A.M., showed half side rails on both sides of the bed in the raised position. During an interview, on 4/19/2022, at 11:33 A.M., the resident said he/she used the side rails to assist him/her with repositioning in bed. Record review of the resident's electronic medical record showed the following information: -No paper or electronic record of when the resident signed a consent for the use of side rails for positioning; -No risk versus benefits assessment for the use of the side rails; -No alternatives documented prior to the use of the side rails; -Bed gap measurements completed on 3/1/2019. There was no documentation of annual side rail measurements for 2020 or 2021. 2. Record review of Resident #17's current POS showed a physician's order, dated 7/22/2018, for bilateral half side rails when in bed per resident request to assist with bed positioning and a feeling of security. The half side rails were not a restraint. Record review of the resident's annual MDS, dated [DATE], showed the following information: -admitted to the facility on [DATE]; -Cognitively intact; -diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] -No history of falls since prior assessment; -Bed rails not used. Record review of the resident's care plan, annual review (date of annual review not listed), initial date of 5/10/2018 to present), showed the following information: -The resident's preferred use of side rails. Up on both/one side for safety and assistance with repositioning. -The resident and family have been educated on the risk of side rails and communicated understanding. -Followed Primaris Device Decision Guide and considered not a restraint. Record review of the resident's electronic health record showed the following information: -A side rail assessment, dated 2/22/2022 for the use of bilateral side rails for positioning; -No signed consent for the use of bed rails; -Resident and family educated on the risk versus benefits of the use of side rails on 2/22/2022; -No alternatives documented prior to the use of side rails. -No documentation of side rail gap measurements since side rails installed on 2/22/2022. Observations on 4/19/2022, at 9:25 A.M., showed half side rails on the bed in the raised position. The resident was not in his/her bed. During an interview on 4/19/2022, at 1:52 P.M., the resident said he/she used the bed rails for positioning in bed. 3. Record review of Resident #15's face sheet (a brief resident profile sheet) showed the following information: -The resident admitted to the facility on [DATE]; -His/her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #15's annual Minimum Data Set (MDS), a federally mandated assessment instrument, completed by facility staff, dated 1/31/2022, showed the following information: -The resident was cognitively intact; -He/she was totally dependent on staff for transfers and bed mobility; -He/she had upper extremity impairment on both sides. Record review of Resident #15's current POS, showed no physician order for [MEDICAL RECORD OR PHYSICIAN ORDER] Record review of Resident #15's medical record showed facility staff did not obtain gap measurements for the side rails for 2020 or 2021. Observation on 4/20/2022, at 8:47 A.M., showed Resident #15 rested in bed. The bed had a quarter rail on the left side of the bed in the raised position. 4. Record review of Resident #46's face sheet showed the following information: -The resident admitted to the facility on [DATE]; -His/her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #46's admission MDS, dated [DATE], showed the following information: -The resident was moderately cognitively impaired; -He/she needed setup help with eating. Record review of Resident #46's care plan, dated 3/11/2022, showed the facility staff did not address the resident's side rails on the care plan. Record review of Resident #46's current POS showed the facility staff did not obtain a physician order for [MEDICAL RECORD OR PHYSICIAN ORDER] Record review of Resident #46's medical record showed facility staff did not obtain gap measurements for the side rails. Observation on 4/19/2022, at 2:00 P.M., showed the resident rested in bed. The bed had a quarter rail in the raised position on the left side of the resident's bed. The rail was positioned in middle of the bed. 5. During an interview on 4/22/2022, at 10:50 A.M., the MDS/Care Plan coordinator said side rails should be on a resident's care plan if the resident has them. 6. During an interview on 4/22/2022, 10:11 A.M., the administrator and DON said maintenance had been completing side rail assessments and the former DON took control of the process. Maintenance completed the measurements. Now, anyone who has side rails gets assessments and therapy is completing the measurements. That new process started about 3 weeks ago. They are completing them with their quarterly assessments.

Based on observation, interview, and record review, the facility failed to ensure staff treated all residents with dignity and respect when they did not provide a dignity bag for one resident's (Resident #23) catheter (sterile tube inserted into the bladder to drain urine) bag. The facility census was 67. Record review of the facility's policy titled' Dignity, dated February 2021, showed the following: -Residents are treated with dignity and respect at all times; -Demeaning practices and standards of care that compromise dignity are prohibited; -Staff are expected to promote dignity and assist residents to keep urinary catheters (a sterile tube inserted in the bladder to drain urine) bags covered. 1. Record review of Resident #23's face sheet (a document that gives a resident's information at a quick glance) showed the following: -admitted d 11/20/18; -diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the resident's quarterly Minimum Date Set (MDS - a federally mandated assessment instrument completed by facility staff, dated 02/07/22, showed the following: -Cognitively intact; -Extensive staff assistance required for dressing, toileting, and hygiene; -Indwelling catheter. Record review of the resident's care plan dated 2/19/20 did not give direction to staff for interventions related to the catheter bag. Observations on 04/19/22 at 9:15 A.M., showed the resident in his/her wheelchair at the nurse's station. The residents' pants leg raised to the mid-calf area. A catheter leg bag, laid on the resident's right ankle, showing amber colored urine. Observations on 04/20/22 at 8:32 A.M., showed the resident in his/her wheelchair at the nurse's station. A nurse passed the resident pushing a medication cart. The resident's catheter leg bag was fully visible laying near his/her right ankle. The catheter bag was approximately half full of amber-colored urine. Observations on 04/20/22 at 12:25 P.M., showed the resident in his/her wheelchair at the nurse's station eating lunch. The residents catheter leg bag laid fully visible on the resident's right ankle area. The catheter bag was approximately half full of amber-colored urine. A Certified Nurse Assistant (CNA) stood along side of the resident and spoke to him/her about lunch. The CNA did not adjust the resident's clothing to cover the bag. Observations on 04/20/22 at 2:34 P.M., showed the resident in his/her wheelchair at the nurse's station. The resident's catheter leg bag was fully visible on the resident's right ankle area with dark amber-colored urine. Observations on 04/21/22 at 8:00 A.M., showed the resident in his/her wheelchair at the nurse's station. The resident's catheter leg bag laid atop his/her right shoe. The leg bag was approximately one-fourth full of cloudy amber-colored urine. Observations on 04/21/22 at 1:07 P.M., showed the resident in his/her wheelchair at the nurse's station. The resident's catheter leg bag, fully visible, hanging between the wheelchair foot pedals. The catheter tubing was stretched taunt (tight). The leg bag straps laid on the floor. During an interview on 04/21/22 at 1:12 P.M., CNA F said catheter care is provided anytime care is provided to the resident. Catheter leg bags should be secured to the resident's lower leg and should be covered by the resident's clothing. During an interview on 04/02/22 at 1:17 P.M., Licensed Practical Nurse (LPN) G said the following: -Catheter leg bags should be secured to the resident's leg; -Staff should monitor for correct placement and adjust as necessary; -Catheter leg bags should be covered. Observations and interview on 04/21/22 at 1:25 P.M., showed LPN G checked the resident's catheter leg bag placement. The leg bag was fully visible hanging between the resident's wheelchair pedals. The LPN said the leg bag should be secured to the resident's leg and the bag should be covered with the resident's clothing. During an interview on 04/21/22 at 1:36 P.M., the MDS Coordinator said catheter care and monitoring of the catheter should be addressed in the resident's care plan. During an interview on 04/22/22 at 8:35 A.M., the Director of Nursing (DON) and Administrator said they expected staff to ensure catheter bags were secured and covered. The staff should monitor the catheter bags and adjust as needed.

Based on observation, interview, and record review, the facility failed to ensure staff developed, reviewed, and revised one resident's (Resident #11) comprehensive care plan to include wandering and elopement behaviors. The facility census was 67. Record review of the facility's policy titled care plan, dated 2001, revised 2006, showed the following information: -The care plan shall be used in developing the resident's daily care routines and will be available to staff personnel who have responsibility for providing care or services to the resident; -Completed care plans are placed in the resident's chart; -Certified Nurse's Aides/CNA's, are responsible for reporting to the nurse supervisor any change in the resident's condition and care plan goals and objectives that have not been met or expected outcomes that have not been achieved; -Other facility staff noting a change in the resident's condition must also report those changes to the nurse supervisor and/or the MDS assessment coordinator; -Changes in the resident's condition must be reported to the MDS assessment coordinator so that a review of the resident's assessment and care plan can be made; -Documentation must be consistent with the resident's care plan. Record review of the facility's policy titled, wandering and elopements, dated 2001, and revised March 2019, showed the following information: -The facility will identify residents who are at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for residents; -If identified as at risk for wandering, elopement, or other safety issues, the resident's care plan will include strategies and interventions to maintain the resident's safety. 1. Record review of Resident #11's face sheet (a document that provides resident information at a quick glance) showed the following information: -admitted to the facility on [DATE]; -diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #11's care plan, dated 11/02/2021, showed the following information; -Exhibited periods of disorganized thinking: disorganized speech. -Allow him/her adequate time to express self; complete word or sentence if he/she is unable to do so. -Assess potential cause (s) for deterioration (lack of sleep, medication change, illness, and change in routine/activities); -diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . -Assess and record behaviors. -Determine pattern of behavior (time of day, precipitating factors/situations), -Discuss with physician and team a trial period of antianxiety medication therapy. -Assess changes in mental status. -Staff did not address the resident's wandering or elopement behaviors in the care plan. Record review of the resident's re-hospitalization risk assessment, dated 11/2/2021, showed the following information: -The resident exhibited early evening confusion (sundowning); -The resident had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] -The resident's risk assessment score was 25; -If the score is 5 or greater, refer to elopement precautions and initiate elopement precautions, when appropriate. Record review of the resident's significant change Minimum Data Set (MDS), a federally mandated comprehensive assessment instrument, completed by facility staff, dated 11/5/2021, showed the following information: -Severely impaired cognition; -No wandering behaviors; -Required extensive assistance for transfers and locomotion; -The resident used a wheelchair mobility device. Record review of Resident #11's progress notes showed the following information: - On 12/29/2021, resident not found in the facility, staff received a call stating the resident was at a house across the street from the facility. Staff notified the nurse the resident was at the brick apartments across the road. When the nurse ran over to the apartments, he/she found the resident standing and about to fall; Staff escorted the resident back to the facility in a wheelchair. Resident had gone looking for his/her car. When staff asked him/her where he/she was going, he/she said to hell. Unclear which door he/she went out. Staff notified the resident's guardian of the elopement and staff placed the resident on 15 minute checks; -After the incident on 12/29/2021, the resident was at the nurse's station and said he/she would not go outside again, but the next minute, the resident said he/she wanted to go home; -On 12/30/2021, the resident had increased anxiety. The resident wandered and talked about leaving. The resident put on his/her coat and said he/she had to leave. Staff will continue 15 minute checks; -On 1/4/2022, the resident cursed at staff when attempting to go into other residents' rooms; -On 1/7/2022, the resident wandered into female rooms. Resident up and down the halls, wandering. -On 1/9/2022, the resident wandered during first shift, walking around the nurse's station and day room; -On 1/10/2022, the resident wandered during first shift, walking around the nurse's station and day room. Resident up with occasional roaming. The resident would go to court yard door, look out, and come up to the nurse's station and ask about leaving. Will continue to monitor closely; Record review of the resident's care plan showed staff did not update the care plan to reflect the wandering behaviors and elopement incident on 12/29/2021. Record review of the resident's restorative quarterly assessment, 1/27/2022, showed staff assessed the resident as not at risk for elopement. Record review of the elopement risk assessment, dated 1/27/2022, showed the following information: -diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] -The resident is cognitively impaired with poor decision-making skills; -The resident did not have a history of elopement; -The resident had verbalized the intent to leave the facility; -The resident wandered and was seeking to find spouse or family; -The resident wandered aimlessly. - The resident's elopement risk score was 4, due to four yes responses; - If the assessment indicated yes to any question, consider initiating a care plan or service plan for elopement risk. Record review of the resident's care plan showed staff did not update the care plan or service plan to address the resident's wandering behaviors or elopement risk. Record review of Resident #11's progress notes showed the following information: -On 3/14/2022, the resident had been angry with staff. The resident told staff they can't tell him/her what to do. He/she wandered and staff tried to toilet him/her. The resident pulled down his/her pants, tore his/her incontinent brief apart, and had a bowel movement in the recliner in the common TV area; -On 3/29/2022, the resident gathered some of his/her clothes and walked the hallway with them. The resident said he/she was leaving. The resident had been wandering since he/she got back up. Record review of Resident #11's quarterly MDS, dated [DATE], showed the following information: -Severely impaired cognition; -Disorganized thinking occurred in two of the seven days of the lookback period; -Wandering behavior of this type occurred one to three days of the seven day lookback period; -Required extensive assistance for dressing, toilet use, and personal hygiene; -Locomotion on unit, supervision only; -No mobility device; -Dementia; -The resident had a legal guardian. Record review of the resident's care plan showed staff did not update the resident's care plan to reflect the wandering behaviors or elopement risk. During an interview and observation on 4/18/2022, at 11:11 A.M., Resident #11 showed the following: -Resident sat in the dining area at the end of the hall; -Resident verbalized, but difficult to understand the resident's words; -Resident unable to answer some questions appropriately. During an interview on 4/22/2022, at 8:52 A.M., Certified Nursing Assistant (CNA) J said the following: -Not aware of any residents at risk for elopement; -Staff look at care plans to know which residents are at risk for elopement; -Resident #11 does wander to the door in the courtyard; -Resident #11 has not eloped on his/her shift; -If residents attempt to open the doors, there are door alarms that sound; -If residents are elopement risk, they keep the residents in sight more and redirect the resident with activities. During an interview on 4/22/2022, at 9:03 A.M., CNA K said the following: -No residents have eloped on his/her side of the building; -If residents are wandering or exit seeking, staff should redirect them; -He/she has worked with Resident #11 in the past, he/she did not wander; -Staff look at charting to see which residents are elopement risks, or other staff make him/her aware of residents at risk for elopement. During an interview on 4/22/2022, at 8:45 A.M., CNA I said staff look at care plans to know which residents may be an elopement risk. He/she did not work with Resident #11. During an interview on 4/22/2022, at 9:32 A.M., Licensed Practical Nurse (LPN) G said the following: -Resident #11 is not as bad about wandering since he/she got sick and went to the hospital; -Resident #11 will ask where his/her truck is at; -Resident #11 doesn't usually show behaviors during the day, but more so in the evening. -Staff will document if residents are wandering and this will be shared at shift change. -The careplan would also have a resident's elopement status. During an interview on 4/22/2022, at 9:08 A.M., LPN C said the following: -Not aware of any residents at risk for elopement; -If a resident is at risk for elopement, it would be on the resident's care plan and would pop up in their system; -Residents at risk for elopement may have chair alarms, or one on one; -He/she does not work with Resident #11. During an interview on 4/22/2022, at 9:17 A.M., the MDS/care plan coordinator said the following: -If a resident is an elopement risk, they would be on 15 minutes checks; -Staff know which residents are elopement risk as there's a book at the nurse's station; -If a resident is an elopement risk, this would be on his/her care plan; -Resident #11 did not score high enough on the elopement assessment; -Resident #11 is not considered an elopement risk; -Resident #11 is confused and walks a lot, also has sundowners; -He/she did not know if Resident #11 had eloped in the past. During an interview on 4/22/2022, at 9:35 A.M., the Director of Nursing (DON) said the following: -If an elopement has occurred more than one time, it would be in the resident's care plan; -When residents are admitted , they will have an elopement risk assessment completed by the DON; -If residents tend to wander, staff will watch to figure out these behaviors; -If a resident has cognitive decline, they may need to be put on 15 minute checks; -Resident 11 is not an elopement risk, he wanders and pilfers. During an interview on 4/22/2022, at 9:27 A.M., the administrator said the following: -MDS assessment process drives the care plan; -Elopement risks are also completed on residents, if it's determined the resident is at risk, this would be in the care plan; -If eloped in the past, but doesn't get off the facility property, or stays in sight of facility staff, this would not be considered an elopement; -In his/her recollection, Resident #11 went out the end door, and across the street, but he/she was in sight at all times.

Based on interviews and record review, the facility failed to implement physician orders of Two-Cal (a liquid dietary supplement) and calcium for one resident (Resident #46), who had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the facility's policy, titled nutrition (impaired)/unplanned weight loss-clinical protocol, dated September 2017, showed the following information: -The nursing staff will monitor and document the weight and dietary intake of residents in a format which permits comparisons over time; -The staff and physician will define the individual's current nutritional status and identify individuals with anorexia (lack or loss of appetite for food), weight loss or gain, and significant risk for impaired nutrition; for example, high risk residents with acute symptoms such as vomiting, diarrhea, fever and infection, or those taking medications that may be causing weight gain or increasing the risk of anorexia or weight loss; -The staff will report to the physician significant weight gains or losses or any abrupt or persistent change from baseline appetite or food intake; -The physician will authorize appropriate interventions as indicated. Record review of the facility policy, titled administering medications, dated April 2019, showed the following information: -Medications are to be administered in a safe and timely manner, and as prescribed. 1. Record review of Resident #46's face sheet (a brief resident profile sheet) showed the following information: -The resident admitted to the facility on [DATE]; -His/her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #46's Weight Report showed the following information: -On 3/3/2022, Resident #46 weighed 140 pounds; -On 3/5/2022, Resident #46 weighed 140.8 pounds. Record review of Resident #46's admission Minimum Data Set (MDS), a federally mandated assessment instrument, completed by facility staff, dated 3/9/2022, showed the following information: -The resident was moderately cognitively impaired; -He/she needed setup help with eating. Record review of Resident #46's care plan, dated 3/11/2022, showed the facility did not address the resident's weight loss on the care plan. Record review of Resident #46's Registered Dietitian Nutritional Assessment showed the following information: -On 3/11/2022, the Registered Dietitian documented the resident was newly admitted and had two fractures with an open area on the coccyx (tailbone). Nutritional needs were elevated and the hospital records referred to his/her appetite and intake as not being very good, despite encouragement. Recommend continuing regular diet, adding fortified foods at all meals, Two-Cal with medication passes, and continue efforts to learn and honor his/her food preferences. Due to his/her arm fracture, he/she will need assist with set up, and may need assist with feeding. Suggest we add calcium + vitamin D in view of his/her fractures. Record review of Resident #46's clinical notes report showed the following information: -On 3/11/2022, at 9:32 A.M., the Registered Dietitian documented she recommended the facility staff add fortified foods, Two-Cal with medication passes, and Calcium+ Vitamin D for healing. -On 3/25/2022, at 10:41 A.M., facility staff documented the physician reviewed the Registered Dietitian recommendations with agreement to the following changes: 1. Add fortified foods to current regular diet, 2. Add Two-Cal with medication passes, 3. Learn and honor food preferences to help with eating, 4.Add calcium plus vitamin D related to fractures. Facility staff documented the orders were updated. Record review of Resident #46's physician order sheet (POS), dated March 2022, showed facility staff failed to document the order for Two-Cal and Calcium. Record review of Resident #46's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #46's weight report showed the following information: -On 4/1/2022, Resident #46 weighted 127 pounds; which is a loss of 9.29 % in one month. Record review of Resident #46's care plan showed the facility did not update the care plan to address the resident's weight loss on 4/1/2022. Record review of Resident #46's POS, dated April, 2022 showed facility staff failed to document the order for Two-Cal and Calcium. Record review of Resident #46's MAR, dated April, 2022 showed facility staff failed to document the order for Two-Cal or Calcium. During an interview on 4/21/2022, at 8:45 A.M., Resident #46 said he/she eats until he/she is full, but a couple hours later he/she is hungry. He/she is not getting any shakes between meals. During an interview on 4/21/2022, at 12:45 P.M., Licensed Practical Nurse (LPN) C said when a resident has weight loss, they usually get reweighed, and added to the physician's list. The physician will add interventions and they usually include things like Two-Cal. He/she is not aware of Resident #46 having weight loss or getting Two-Cal. The Director of Nursing (DON) is responsible for adding orders to the resident's chart after the physicians' complete their rounds. During an interview on 4/21/2022, at 1:00 P.M., Certified Medication Technician (CMT) D, said when a resident has weight loss, staff should start encouraging the resident to eat, and offering alternatives to the resident. The dietary department is notified, the family is notified, and the physician is notified, and many times, Two-Cal and Mighty shakes are added. Fortified foods are often added as well. The DON or medical records person is responsible for adding new orders to the resident's chart. If the orders aren't added, the staff is not aware to do the medication pass. Orders should always be added if they are given. During interview on 4/21/2022, at 1:10 P.M., and 4/22/2022, at 9:18 A.M., Registered Nurse (RN) E/MDS/Care Plan Coordinator, said several residents receive Two-Cal, but Resident #46 does not. Staff should implement dining assist if needed, offer snacks, fortified foods, etc. Staff involves the physician, the Registered Dietician, and the Dietary director to keep the residents from having weight loss. The DON is responsible for entering in new medication orders after completing rounds with the physician. He/she did not see where the order had been entered after it was suggested by the Dietitian and approved by the physician. Medication orders should be entered after approved by the physician. If a resident has weight loss, it should be documented on the care plan. If the weight loss does not get addressed in Quality Measure meetings, it may not be addressed until quarterly meetings. During an interview on 4/21/2022, at 2:30 P.M., the DON said she or the medical records staff is responsible for putting in new physician orders. The shower aide is responsible for weighing the residents and if a resident displays a weight loss, the aide will reweigh them in a couple days, and if the loss is still present, the provider is notified. Interventions are put in place to prevent weight loss, such as snacks, Two-Cal, encouraging eating, and Registered Dietitian (RD) consults. The physician did order vitamins, Two-Cal, and a fortified diet for Resident #46 and it just got missed. She got part of it put in but the Two-Cal and calcium just got missed. During an interview on 4/22/2022, at 9:29 A.M., the administrator said he expects staff to enter physician orders when written if they are reasonable orders. If the orders need clarification, they may need to call the physician back. If a resident has weight loss, staff should encourage the resident to eat, offer snacks, Two-Cal, Mighty Shakes (a high calorie, high protein nutritional shake), get with the physician and RD for evaluation, and go from there. When Resident #46 came from the apartments, he/she did not want to eat, then his/her family came and stayed with the resident for several days, and the resident's eating improved greatly. The resident always tells him he is feeding him/her too much.

Based on interview and record review, the facility failed to ensure all allegation of alleged abuse were reported timely when one facility staff (Nurse Aide (NA) A) failed to immediately report an allegation of employee-to-resident verbal abuse involving one resident (Resident #1) to a charge nurse or administrative staff and when the facility staff failed to report the allegations of abuse to the State Survey Agency (Department of Health and Senior Services - DHSS) within two hours of staff becoming aware of the allegation of abuse. The facility's census was 69. Record review of the facility's Reporting Patient Abuse Policy, undated, showed the following: -All personnel are responsible to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source are reported immediately to the facility Administrator or Director of Nursing (DON) in order to meet reporting requirements to any Agency, which has responsibility and oversight. Record review of the facility's Abuse Prevention, Reporting, and Investigation Policy, revised February 2017, showed the following: -Should an allegation be made of an incident of resident abuse, mistreatment, neglect, exploitation, mistreatment, including injuries of unknown source and/or misappropriation of resident's property, or the events that cause the allegation to occur involve abuse or result in serious bodily injury; the incident will be immediately, but no later than 2 hours after allegation is made, reported to the Administrator, or his/her designee, and other officials (including the State Survey Agency) in accordance with Federal and State law. If not done so by the Administrator themselves, the Administrator will appoint a member of management to investigate the alleged incident and make an immediate (as defined above) report to DHSS. -If the events that cause the allegations to be made do not involve abuse and do not result in serious bodily injury (as determined within 2 hours of the allegation being made) the incident must be reported no later than 24 hours to the Administrator, or his/her designee and other officials (including the State Survey Agency) in accordance with Federal and State law. If not done so by the administrator themselves the Administrator will appoint a member of management to investigate the alleged incident and make an immediate (as defined above) report to DHSS. 1. Record review of Resident #1's face sheet (a document that gives a resident's information at a quick glance) showed the following: -admitted [DATE]; -diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the resident's Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff), dated 08/06/2021, showed the following: -Cognitively intact; -Mobile and independent of all activities of daily living (ADL - bathing, eating, and toileting). Record review of staff's statements included in an elopement investigation showed the following: -An undated and untimed written statement by Nurse Assistant (NA) A. The nurse wrote that on on 10/16/2021, around 10:30 P.M. or 11:00 P.M., the resident said he/she had been told to just kill himself/herself and get it over with. During an interview on 11/4/21, at 3:49 P.M., NA A said the following: -If any resident reported any type of abuse, he/she would report it to his/her charge nurse; -The resident reported that someone had told him/her to go kill himself/herself and get it over with; -He/she did not report this to anyone and went back to work; -On 10/18/21, the DON asked the night shift staff who worked during an elopement to each write a statement of what he/she observed; -He/he submitted to the DON a written statement that showed between 10:30 P.M. and 11:00 P.M. the resident approached him/her and reported someone told the resident to just go kill himself/herself and get it over with; -The DON did not follow up with him/her regarding the written statement; -He/she should have told his/her nurse. Record review of facility's elopement Investigation Summary, dated 10/21/21, showed the following: -NA A reported on 10/18/21, time unknown, the alleged abuse to the DON in a written statement (two days after the allegation occurred); -The DON faxed the facility investigation to DHSS on 10/21/21, that included NA A's written statement (five days after the allegation occurred and three days after management staff were made aware of the allegation); -The alleged verbal abuse statement was not reported. During an interview on 10/22/2021, at 1:00 P.M., the resident said on 10/16/21, the resident was told by a nurse to go kill himself/herself. The resident said he/she had not told anyone of the verbal abuse and then said he/she had told several people, but was unable to recall who. During an interview on 10/22/2021, at 3:25 P.M., Certified Medication Technician (CMT) I said if a resident reported any type of abuse, he/she would report it to the charge nurse. During an interview on 10/22/21, at 3:48 P.M., Certified Nurse Aide (CNA) H said the following: -If any resident reported verbal abuse, he/she would report it to his/her charge nurse; -Those allegations had to be reported to DHSS within two hours. During an interview on 10/22/21, at 3:50 P.M., CNA B said if any resident reported verbal abuse, he/she would report it to his/her charge nurse. During an interview on 10/22/21, at 4:25 P.M., Licensed Practical Nurse (LPN) E said the following: -The resident told LPN E the day following the elopement that a nurse told him/her to kill himself/herself; -The resident would not give the staff's name; -He/she reported this to the DON at shift report. During an interview on 10/22/21, at 4:59 P.M., the Administrator said the following: -The resident told the DON that a staff person had told him/her to hurt himself/herself; -The DON spoke with the resident about this statement and then told the Administrator; -The Administrator told the Psychiatric Nurse Practitioner who said it was delusions; -He/she expected any staff to report to the charge nurse if a resident reported they were told to self-harm. During an interview on 11/4/21, at 8:49 A.M., Registered Nurse (RN) G said if any resident reported verbal abuse, he/she would report it to his/her nurse supervisor, the DON and the Administrator. During an interview on 11/4/21, at 1:12 P.M., LPN D said if any resident reported verbal abuse, he/she would report it to his/her charge nurse. During an interview on 11/5/21, at 11:11 A.M., the Social Service Director (SSD) said the following: -He/she attempted to talk with the resident on 10/18/21, but the resident refused; -He/she attempted to reapproach the resident later in the day on 10/18/21, but the resident again refused; -He/she heard staff rumors that someone, possibly a nurse, told the resident to kill himself/herself; -The resident never told SSD that directly and refused to discuss the statement; -He/she did not report the abuse allegation to the State within two hours. During an interview on 11/5/21, at 1:16 P.M., CNA C said the following: -Emotional abuse included demeaning a resident or telling them they're no good; -He/she would consider it mental abuse if a resident had been told to self-harm or kill themselves, and reported it. During an interview on 11/15/21, at 3:28 P.M., and 11/16/21, at 11:12 A.M., the DON said the following: -He/she expected staff to report all incidents of abuse to their supervisor, up the chain of command all the way to the Administrator; -If a resident believes something (abuse) happened, it's reportable; -He/she or the Assistant Director of Nursing (ADON) would report the allegation of abuse to the State agency within two hours of the allegation; -He/she became aware of the resident's report of alleged abuse upon returning to work 10/18/21; -He/she requested written statements from each staff who worked during the shift of an elopement; -NA A's statement showed around 10:30 P.M. that the resident reported he/she was told to go kill himself/herself; -NA A should have reported the allegation to the nurse as soon as he/she was told the resident; -He/she interviewed the resident who said no staff had directly said the comment to him/her, but that it was said in general. The resident said he/she never told anyone that someone directed the statement toward him/her, rather he/she just heard it; -He/she did not believe the abuse allegation needed to be self-reported since it had been immediately addressed and was able to verify the named alleged perpetrator did not work the night of the allegation. During an interview on 11/15/21, at 6:58 P.M., LPN F said the following: -Verbal abuse included threatening or hurting the self-esteem of a resident; -If any resident reported any type of abuse, he/she would report it to the DON; -Abuse allegations had to be reported to DHSS within 2 hours; -The resident's allegation was verbal abuse and reportable to the State. During an interview on 11/16/21, at 12:08 P.M., the Administrator said the following: -Verbal abuse included speaking inappropriately to a person and being demeaning; -He would expect staff to report any abuse to the charge nurse, and then up the chain of command; -Abuse allegations had to be reported to DHSS within 2 hours; -The resident's verbal abuse allegation was discovered during the elopement investigation and included within the five day timeline to report their investigation to the State; -The resident's psychologist said the resident had persecutory delusions; -The resident's statement would have been reportable if it was a stand-alone event. Since it was part of the elopement investigation, it did not get reported; -The NA should have known to report and did not. MO 300

Based on record review and interview, the facility failed to protect residents from misappropriation when five tablets of one resident's (Resident #1) [MEDICATION(S)]/acetaminophen (a narcotic pain medication for the treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility census was 68. The Administrator and Director of Nursing (DON) were notified on 4/26/21 of the Past Non-Compliance which occurred on 04/26/21 at approximately 10:00 P.M. Facility staff notified Department of Health and Senior Services (DHSS) of the noncompliance, started an investigation, began in-servicing licensed staff who were involved in medication pass and medication storage, and implemented a new policy regarding the usage of home medications. In-services were finished on May 4, 2021. The noncompliance was corrected on May 4, 2021. Record review of the facility's policy, titled Abuse Prevention, Reporting and Investigating, dated 2/2017, showed the following: -Should an allegation be made of an incident, or suspected incident of misappropriation of a resident's property, the incident will be immediately, but no later than two hours after the allegation is made, reported to the Administrator, or his/her designee, and other officials (including the State Agency), in accordance with federal and state law; -The policy did not define misappropriation. Record review of the facility's policy, titled Controlled Substances, dated April 2007, showed the following: -Controlled substances must be counted upon delivery; -Nursing staff must count controlled drugs at the end of each shift. The nurse coming on duty and the nurse going off duty must make the count together. They must document and report any discrepancies to the Director of Nursing Services. 1. Record review of Resident #1's face sheet (brief resident profile sheet) showed the following: -The resident was admitted on [DATE]; -diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the resident's admission Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff), dated 4/19/21, showed the following: -Cognitively intact; -Receives scheduled and as needed pain medications. Record review of the resident's care plan, updated 4/28/21, showed the following: -Required extensive assistance for transfers, turning, and positioning; -Resident has acute (having a short course) and chronic (having a long course) pain; -Interventions included review pain assessment and pain medication effectiveness and notify physician of any abnormal findings. Record review of the resident's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] -An order, dated 4/12/21, for [MEDICATION(S)]/acetaminophen 10-325 milligram (mg), one tablet every six hours as needed for pain. Record review of the resident's Individual Resident's Controlled Substance Record, undated, showed the following: -[MEDICATION(S)]/acetaminophen 10-325 mg, one tablet every six hours as needed; -Amount ordered 120; -Amount received 35; -On 4/13/21, at 4:00 P.M., staff documented administering one tablet. The beginning amount was 35, and the end total was 34; -On 4/14/21, at 4:00 P.M., staff documented administering one tablet. The beginning amount was 34, and the end total was 33; -On 4/18/21, at 3:39 P.M., staff documented administering one tablet. The beginning amount was 33, and the end total was 32. -On 4/19/21, at 4:44 P.M., staff documented administering one tablet. The beginning amount was 32, and the end total was 31; -On 4/20/21, at 3:00 P.M., staff documented administering one tablet. The beginning amount was 31, and the end total was 30; -On 4/21/21, at 4:00 P.M., staff documented administering one tablet. The beginning amount was 30, and the end total was 29; -On 4/22/21, at 3:58 P.M., staff documented administering one tablet. The beginning amount was 29, and the end total was 28; -On 4/23/21, at 4:30 P.M., staff documented administering one tablet. The beginning amount was 28, and the end total was 27. Record review of the facility's investigation, dated 4/30/21, showed the following: -On 4/26/21, at approximately 10:00 P.M., the facility staff called the DON and told her the resident had five [MEDICATION(S)]/acetaminophen unaccounted for when the medication count was completed; -Statements from the staff were taken at that time; -The medication in the bottle was pulled from use and stored during the investigation. Any doses administered were pulled from the facilty's emergency kit. Record review of Licensed Practical Nurse (LPN) H's investigation statement, dated 4/27/21, showed the following: -On 4/23/21, before starting the night shift, the LPN counted the resident's narcotics with Certified Medication Technician (CMT) J. The count was correct; -On 4/24/21, in the morning, the LPN counted medications with CMT I. The count was correct. Record review of CMT I's investigation statement, dated 4/27/21, showed the following: -On 4/24/21, before starting the morning shift, CMT I counted the resident's narcotics with LPN H and the count was correct; -On 4/25/21, before starting the morning shift, CMT I counted the resident's narcotics with Registered Nurse (RN) E and the count was correct. The last known correct count to his/her knowledge was the evening of 4/25/21. Record review of RN E's investigation statement, undated, showed that following: -RN E counted the resident's narcotics with CMT A and CMT I on night shift from 4/24/21 through 4/26/21. The counts were correct each time; -The last time the count was correct was the morning of 4/26/21. Record review of LPN F's investigation statement, dated 4/26/21, showed the following: -On 4/26/21, during the 3 to 11 shift, the LPN counted the resident's medications with the CMT (unnamed) and the count was off by 5 tablets; -The DON was notified. Record review of CMT G's investigation statement, dated 4/26/21, showed the following: -On 4/26/21, nearing the end of the 3 to 11 shift, the employee and nurse counted the resident's narcotics. In one bottle, there were 5 pills missing. Record review of CMT A's employee statement, undated, showed the following: -On 4/26/21, CMT A was told the resident was being moved from one wing of the building to another; -CMT A took the resident's medications and belongings to the new wing and they were put in the narcotics drawer of the cart. During an interview on 6/3/21, at 11:30 A.M., CMT A said staff is to do a count of the medications carts before and after each shift. If the count is not correct, staff is to call the DON immediately. The DON will come and attempt to reconcile the cart. If the cart cannot be reconciled, everyone who has had access to the medications will be drug screened. The day the resident was transferred to the other wing, CMT A took his/her medications over to that wing, and counted them with the receiving nurse before placing them in the locked narcotics box. The count was correct at that time. He/she always counts with receiving staff. It would never be acceptable to take medications from a resident. It would be considered misappropriation to take medications from the resident. Record review of LPN D's investigation statement, dated 4/27/21, showed the following: -The resident's medications were brought to his/her wing and placed in the narcotic drawer. During an interview on 6/3/21, at 12:20 P.M., LPN D said on 4/26/21, CMT A brought the resident's medications and belongings over to his/her wing. Both staff counted the medications and the count was correct. Staff are to count narcotics at the beginning and end of each shift. If the count is not correct, management is notified immediately. No staff involved with that cart leaves until the count is reconciled. If the count cannot be reconciled, all staff involved with the cart are subject to a drug screen. It would never be appropriate to take a resident's medication. It would be considered misappropriation to take the resident's medications. It would be considered misappropriation to take any resident's medications. During an interview on 6/3/21, at 11:55 A.M., LPN B said staff are to do medication counts before and after each shift. If the count was incorrect, the DON should be notified immediately. It would never be appropriate to take medications from a resident. It would be considered misappropriation to take the resident's medications. During an interview on 6/3/21, at 12:10 P.M., LPN C said medications are counted between each shift. If the counts did not match, the DON would be notified. No staff would leave if the counts did not match. If the counts could not be reconciled, all the staff involved with the med pass on that cart would be subject to a drug screen. He/she would consider taking the resident's medications misappropriation. It would never be acceptable to take a resident's medications or belongings. During an interview on 6/3/21, at 2:25 P.M., the Administrator and Director of Nursing said medications carts should be counted before and after each shift. If the counts are not correct, they expect staff to contact management immediately. An investigation would be started immediately and no staff would leave until the medications were reconciled. All staff involved with the medication pass on that cart would be subject to a drug screen. When the resident was admitted , the narcotics were brought from home and counted. When the resident transferred halls, the narcotics were counted. Staff is not sure what happened to the missing pills. If someone took the medications, it would be considered misappropriation. It would never be acceptable to take a resident's medications or property. MO 583

Based on interview and record review, the facility failed to report two allegations of misappropriation of resident's property involving two residents (Resident #1 and Resident #2) to the Department of Health and Senior Services (DHSS) within twenty-four hours as required. The facility census was 60. Record review of the facility's Abuse Prevention Program, revised January 2017, showed the following: -Our residents have the right to be free from mistreatment, abuse, neglect, misappropriation of resident property, corporal punishment and involuntary seclusion; -Misappropriation of resident's property is defined as the deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a resident's belongings or money without the residents consent. Record review of an untitled facility policy, revised February 2017 and reviewed December 2020, showed the following: -Residents of Mtn. View Healthcare Care facilities have the right to be free from verbal, sexual, physical and mental abuse, corporal punishment, involuntary seclusion, exploitation, and misappropriation of property; -All personnel are responsible to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately to the facility Administrator in order to meet reporting requirements to any Agency, which has responsibility and oversight. Record review of Willow Healthcare Abuse Prevention, Reporting and Investigation Policy, revised February 2017, showed the following: -Should an allegation be made of an incident of resident abuse, mistreatment, neglect, exploitation, mistreatment, including injuries of unknown source and/or misappropriation of resident's property, or the events that cause the allegation to occur involve abuse or result in serious bodily injury; the incident will be immediately, but no later than 2 hours after allegation is made, reported to the Administrator, or his/her designee, and other officials (including the State Survey Agency) in accordance with Federal and State law. If not done so by the Administrator themselves, the Administrator will appoint a member of management to investigate the alleged incident and make an immediate (as defined above) report to DHSS. -If the events that cause the allegations to be made do not involve abuse and do not result in serious bodily injury (as determined within 2 hours of the allegation being made) the incident must be reported no later than 24 hours to the Administrator, or his/her designee and other officials (including the State Survey Agency) in accordance with Federal and State law. If not done so by the administrator themselves the Administrator will appoint a member of management to investigate the alleged incident and make an immediate (as defined above) report to DHSS. 1. Record review of Resident #1's face sheet (a document that gives a resident's information at a quick glance) showed staff admitted the resident to the facility on [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the resident's quarterly Minimum Data Set (MDS - federally mandated assessment instrument completed by facility staff), dated 1/07/21, showed the resident's cognition was intact. Record review of the resident's nurse note dated 9/8/20, at 9:54 P.M., showed Registered Nurse (RN) A documented the resident called the police department and reported he/she had $250 missing from his/her room. The Director of Nursing (DON) was notified and statements were received from all aides working on the floor at the time of the report. (Staff did not document notifying DHSS of the allegation within the required 24-hour period.) Record review of staff's statements included with the facility's investigation showed: -On 9/8/20 (no time documented), the resident reported to Licensed Practical Nurse (LPN) B that he/she had $240.00 stolen and he/she reported it to the sheriff. LPN B reported to RN supervisor. -On 9/9/20 (no time documented), the resident reported to the Social Services Director (SSD) that he/she had $350.00 missing from his/her room. The SSD called the resident's his/her spouse who confirmed giving the resident $220.00 when he/she visited on 9/3/20. SSD completed a grievance form. -On 9/9/20 (no time documented), Director of Nursing (DON) documented the SSD had confirmed with the resident's spouse he/she had given the resident money. The SSD asked the spouse to bring the resident items he/she requested instead of money. (Staff did not document notifying DHSS of the possible misappropriation of the resident's money). During an interview on 1/28/2021, at 1:09 P.M., Resident #1 said the following: -On 9/7/20, he/she had $279 stolen. It was in his/her wallet on the bedside table; -He/she called the sheriff and reported it to the charge nurse. He/she wrote a statement to give to the sheriff; -He/she stated it made him/her feel sad that someone would take his/her money. 2. Record review of Resident #2's face sheet showed staff admitted the resident to the facility on [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the resident's Quarterly MDS dated [DATE], showed the resident's cognition was intact. Record review of staff's statements included with the facility's investigation showed: -Resident Grievance/Complaint Form, dated 8/13/20 (no time documented), showed the resident reported to the SSD that he/she placed his/her wallet on the bedside table before he/she went to bed and when he/she woke up the wallet was gone. -On 8/17/20 (no time documented) the DON documented RN A and SSD knew the resident had a wallet but could not confirm if he/she had any money in the wallet and that the SSD assisted the resident with replacing the insurance cards, banking information and other reported items. (Staff did not document notifying DHSS of the possible misappropriation of the resident's items.) During an interview on 1/28/21, at 2:03 P.M., the resident said the following: -He/she had two wallets stolen. One wallet contained his/her ATM card, social security card, Medicare card and $251; the other wallet did not contain any money. The first wallet was stolen a couple of months ago, and the second wallet was stolen a month ago. -He/she reported both stolen wallets to the DON and SSD. They searched his/her room for the first wallet but did not search for the second wallet. Nothing was done about the stolen wallets. The DON and SSD just asked what was in the wallet. -He/she said it made him/her angry and upset and it was wrong to steal. -He/she did not know he/she could lock up valuables in the SSD's office until after his/her items were stolen. 3. During an interview on 1/28/21, at 1:28 P.M., CNA G said the following: -If any resident reported a stolen item to him/her, he/she would report it to his/her charge nurse. -Those allegations had to be reported to DHSS within 2 hours. 4. During an interview on 1/28/21, at 2:37 P.M., LPN H said if a resident reported an item stolen, he/she immediately notified the DON, RN Supervisor, or Administrator. 5. During an interview on 1/28/2021, at 2:42 P.M., Certified Medication Technician (CMT) I said the following: -If a resident reported a stolen item, he/she reported it to the charge nurse. -Those allegations have to be reported to DHSS within 24 hours. 6. During an interview on 1/28/2021, at 3:17 P.M., DON stated the following: -If the residents did not want to lock up their personal items, the facility had no obligation for those items. -If staff or a resident reported missing or stolen items, she obtained statements from the staff and family members. -He/she did not know if misappropriation was reportable, but if items were stolen, it was reportable to DHSS. If a resident or family reported a substantial amount of money was stolen, she reported it to DHSS, but would want to prove the resident actually had the money at the facility. -He/she did not know if the allegations made by Resident #1 and Resident #2 were reported to DHSS. 7. During an interview on 1/28/2021, at 3:43 P.M., SSD stated the following: -If a resident reported items missing or stolen, she searched for the reported item first then assisted with the investigation. -The DON was responsible for notifying DHSS. -Allegations of misappropriation have to be reported to DHSS within 24 hours. -The allegations made by Resident #1 and Resident #2 should have been reported to DHSS. 8. During an interview on 1/29/21, at 4:28 P.M., the Administrator said the following: -The facility staff were trained to notify the DON and the Administrator of any allegations of misappropriation; -The facility was responsible for reporting allegations of misappropriation to the DHSS within two hours; -The facility staff tried to assist the resident in finding the item and determining if the resident had the item or money to begin with; -He/she thought the Director of Nursing was given bad advice and that was why the allegations made by Resident #1, of money being stolen, did not get reported to DHSS; -He/she thought all true allegations of misappropriation will be reported to DHSS in the future. MO 560 and MO 435

Based on observation, interview, and record review, the facility failed to ensure one resident (Resident # 1), who required assistance with all activities of daily living (ADLs - dressing, grooming, bathing, eating, and toileting), received appropriate nail care and was dressed in clean clothes. The facility census was 79. Record review of the facility's policy titled Care of Fingernails and Toenails, last revised on October 2010, showed the following: -Nail care includes daily cleaning and regular trimming; -Proper nail care can aid the prevention of skin problems around the nail bed; -Trimmed and smooth nails prevent the resident from accidentally scratching and injuring his/her skin. 1. Record review of Resident #1's face sheet (admission information) showed the following information: -An admission date of [DATE]; -[DIAGNOSES REDACTED]. Record review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment tool completed by facility staff), dated 8/26/20, and showed the following information: -Extensive assistance of two or more in bed mobility and transfer; -Total dependence with transfers; -Locomotion total dependence with staff; -Extensive assistance with toileting and bathing. Record review of the resident's care plan, dated 1/11/19 and last updated 9/30/20, showed the following information: -Resident requires extensive assistance; -Resident is at risk of infection; -Staff to pay attention to skin care, washing and drying. Observation and interview of on 9/30/2020, at 12:50 P.M., showed the following: -The resident wore a white sweater with dark brown bloodstains around the right sleeve; -Four staples in the resident's head; -Blood stained nails approximately an inch long in both hands. During an interview on 9/30/20, at 1:05 P.M., Certified Nursing Assistant (CNA) A said the following: -The resident's sweater is stained with blood and need to be washed; -Requires total assistance; -There is dry blood on the resident's nails; -Does not know why staff have not cleaned and cut the resident's nails. During an interview on 9/30/20, at 1:05 P.M., CNA B said the following: -Resident does not resist showers; -The resident's toenails need to be cut; -The resident's long nails can potentially spread disease; -Staff are required to cut the resident's toenails and finger nails routinely; -If a resident is a diabetic, a nurse is required to cut a resident's nails. During an interview on 9/30/20, at 1:40 P.M., Licensed Practical Nurse (LPN) C said the following: -The resident's toe and fingernails are long and stained with blood; -Dry blood under the resident's nails can potentially pass infection. During an interview on 9/30/20, at 2:15 P.M., CNA D said the following: -Does not know why staff have not been providing nail care for the resident; -The dark and dry substance under the nails look like dry blood and needs to be cleaned. During an interview on 9/30/20, at 3:00 P.M., Assistant Director of Nursing (ADON) said the following: -Nail care should be done every shift; -The blood-stained sweater should have been changed. MO 096

Based on observation, interview, and record review, the facility failed to ensure staff provided adequate supervision and monitoring to prevent falls for one resident (Resident #1), with a history of repeated falls, when staff did not provide care planned direct supervision while the resident was out of bed resulting in a fall. The facility census was 79. Record review of the facility's policy titled Fall Risk Assessment, last revised December 2010, showed the following: -The nursing staff and the physician will review a resident's record for a history of falls, especially falls in the last 90 days and recurrent or periodic bouts of falling over time; -The stuff, with the input of the attending physician, will identify appropriate interventions to reduce the risk of falls; -Staff will seek to identify environmental factors that may contribute to falling, such as lighting and room layout; -The staff and the attending physician will collaborate to identify and address modifiable fall risk factors and interventions to try to minimize the consequences of risk factors that are not modifiable; -For individuals who have fallen, staff will attempt to define possible causes within 24 hours of the fall. 1. Record review of Resident #1's face sheet (admission information) showed the following information: -An admission date of [DATE]; -[DIAGNOSES REDACTED]. Record review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment tool completed by facility staff), dated 8/26/20, and showed the following information: -Moderately Impaired vision; -Long-term memory problems; -Severely impaired decision-making; -Extensive assistance of two or more in bed mobility and transfer; -Total dependence with transfers; -Restraints in chair or bed not used; -Chair alarm not used. Record review of the resident's care plan, dated 1/11/19 and last updated 9/30/20, showed the following information: -Resident is at risk for falls related to inability to ambulate and dependence on others for transfers/mobility; -Keep a low bed with enabler rails, resident does not recognize safety limitations; -Resident has high back tilt wheelchair for positioning; -Poor to no weight bearing bilateral extremities/mechanical lift for transfers two assist; -Resident has long term and short-term memory problems; -Staff to provide direct supervision. (Staff did not care plan regarding the resident rocking in his/her wheelchair.) Record review of the facility's Incident/Accident/Fall questionnaire form, dated 1/24/19, showed the following: -Resident slid out of chair in front of the nurses' station and landed on the foot rests of the chair; -Intervention was to keep the resident close to the charge nurse. Record review of the resident's clinical notes showed the following: -On 8/13/2020, resident observed attempting to transfer himself/herself out of wheelchair and staff helped him/her back into the chair. Record review of the resident's clinical notes showed the following: -On 8/17/2020, observed resident attempting to self-transfer out of wheelchair, staff assisted resident back into the chair. Record review of the facility's Incident/Accident/Fall questionnaire form, dated 9/29/20, showed the following: -Resident scooted and rocked his/her wheel chair forward and fell out striking his/her head on a wooden post in the television room area; -Staff did not document new interventions, or a reason for no new interventions, as guided on the form. Record review of the facility's Incident/Accident/Fall investigations, for fall on 9/29/20, showed the following: -Resident on hypoglycemic agents (medication that lowers levels in the blood), narcotics (medication that relieves pain), and antihypertensives (medication that treats blood pressure); -One fall in the last 30 days; -Resident was sitting -Resident was attempting to move forward in his/her wheel chair; -No pressure alarm chair; -Staff were not assisting the resident at the time of the fall; -Fall was a witnessed fall; -Resident suffered a laceration to forehead; -Staff wrote, Resident may require a new wheelchair, as a new intervention. During an interview on 9/30/20, at 1:05 P.M., Certified Nursing Assistant (CNA) A said the following: -The resident's wheelchair is supposed to be tilted backward when seated to prevent falls. During an interview on 9/30/20, at 1:05 P.M., CNA B said the following: -Resident is a fall risk and requires constant supervision when out of the bed; -The resident should have been supervised by staff. During an interview on 9/30/20, at 1:40 P.M., Licensed Practical Nurse (LPN) C said the following: -The resident is always calm and quiet; -Requires supervision, staff are required to watch the resident when he/she is in a chair; -Staff should have intervened when the resident started rocking the chair; -Facility policy requires staff to intervene and prevent falls; -Staff left the resident unsupervised; -LPN E was supposed to be watching the resident. During an interview on 9/30/20, at 3:00 P.M., Assistant Director of Nursing (ADON) said the following: -Staff did not tilt the resident's chair backwards to prevent the resident from falling out of the chair; -Staff have been instructed to intervene when the resident starts rocking in the chair; -All staff have been instructed to tilt the resident chair backwards to prevent the resident from falling out of the chair; -Staff should have laid the resident down immediately when the resident started getting anxious and rocking the chair; -He/she has reminded LPN E to tilt the resident's chair backwards, when the resident starts rocking. During an interview on 9/30/20, at 3:15 P.M., LPN E said the following: -The resident fell around the television room in the common area; -The resident should have been supervised by staff. During an interview on 9/30/20, at 3:45 P.M., the administrator said the following: -There were three CNA's, one certified medication technician (CMT), and a charge nurse around the television room area when the resident fell from the chair; -There should have been some protective oversight. MO 096

Based on observation, interview, and record review, the facility failed to protect food from possible contamination when food was stored undated and unsealed and staff failed to dispose of expired food items; when staff failed to ensure refrigerator and freezer units had accurate thermometers present to monitor the temperatures; and when staff failed to hold and serve foods at a safe temperature. The facility had a census of 83. 1. Record review of the Missouri Food Code, published 2013, regarding refrigerator food storage, showed the following information: -Refrigerated, ready-to-eat, potentially hazardous food, prepared and held in a food establishment for more than twenty-four (24) hours shall be clearly marked to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded when held at a temperature of forty-one degrees Fahrenheit (41°F) or less for a maximum of seven (7) days or when held at a temperature of forty-five degrees Fahrenheit (45 °F) or less for a maximum of four (4) days. -Refrigerated, ready-to-eat, potentially hazardous food, prepared and packaged by a food processing plant shall be clearly marked, at the time the original container is opened in a food establishment and if the food is held for more than twenty four (24) hours, to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded, based on the temperature and time combinations specified: -The day the original container is opened in the food establishment shall be counted as Day 1; -The day or date marked by the food establishment may not exceed a manufacturer's use-by-date if the manufacturer determined the use-by date based on food safety. Record review of the facility's undated policy, titled Sanitation and Infection Control/Dry Goods Storage and Refrigerated Storage, showed the following information: -Plastic containers with tight-fitting lids or re-sealable plastic bags should be used to store dry items previously opened, such as pastas, rice, and dry cereals. All products that have been opened previously should be labeled and dated. Reusable containers should be thoroughly washed and sanitized before refilling; -All refrigerated foods should be covered properly. All cooked food must be labeled and dated; -The opened, unused portions of packaged foods should be dated to assure that they will be used first. Observation of the kitchen on [DATE], at 10:30 A.M., and [DATE] at 10:08 A.M., showed the following: -Undated oatmeal and sugar in bins in dry storage area; -Undated bins and containers in baking area of flour, shortening, corn starch, honey dip glaze, pecans, walnuts, baking soda, baking powder, brown sugar, salt, cocoa, raisins, graham cracker crumbs, and coconut; -Undated and unrefrigerated container of cherry topping in the baking area that had mold-like substance present, and a manufacturer's label to refrigerate after opening; -Undated and unlabeled container of white powder and four undated cereal bins in food preparation area; -Expired container of fruit salad, dated [DATE], with a manufacturer's use by date of [DATE] in walk-in refrigerator; -Expired container of milk with best by date of [DATE]; undated, unlabeled, and unsealed bag of cooked chicken chunks in reach-in refrigerator. Observation of Special Care Unit (SCU) refrigerator on [DATE], at 11:30 A.M., showed undated, unlabeled, separated container of coleslaw. Observation of main dining room refrigerator on [DATE], at 9:00 A.M., showed open carton of grape juice dated [DATE] with manufacturer's best by date of [DATE]. During an interview on [DATE], at 11:00 A.M., Dietary Aide (DA) F said he/she forgot to refrigerate the left over cherry topping. During an interview on [DATE], at 10:23 A.M., the Dietary Manager (DM) said the following: -Staff should date food when opened; -Staff should dispose of leftovers, such as cooked meats, after three days; -Staff use manufacturer's best by date on items such as barbecue sauce; -Staff date milk and juices when open and remove items that go beyond manufacturer's best by date; -Staff do not date items, such as cereals, as they are non-perishable; -She expects staff to label, date and seal a container used for food storage; -Staff should refrigerate food items when the manufacturer instructs to refrigerate after opening. 2. Record review of the Missouri Food Code, published 2013, showed the following information: -In a mechanically refrigerated or hot food storage unit, the sensor of a temperature measuring device shall be located to measure the air temperature or a simulated product temperature in the warmest part of a mechanically refrigerated unit and in the coolest part of a hot food storage unit. Record review of the facility's undated policy, titled Sanitation and Infection Control/Dry Goods Storage and Refrigerated Storage, showed the following information: -Each refrigerator must have a thermometer that is easily visible; -Refrigerator temperatures must be recorded daily for each refrigerator in the facility. Observation of SCU refrigerator on [DATE], at 11:30 A.M., showed the following: -No thermometer; -No temperature log. Observation of main dining room refrigerator on [DATE], at 9:00 A.M., showed no temperature log. Observation on [DATE], at 12:15 P.M., showed the refrigerator in the deli/kitchenette area had no thermometer. During an interview on [DATE], at 10:56 A.M., DA E, said the following: -Residents can choose the alternate meal served from the deli kitchenette; -He/she prepares some food in the deli kitchenette, such as omelets. Some food is prepared in the main kitchen and kept warm in the deli kitchenette; -Omelet ingredients and salad bar items are kept in the deli kitchenette refrigerator. During an interview on [DATE], at 9:50 A.M., Certified Medication Technician (CMT) G, said SCU staff do not monitor or log SCU refrigerator temperatures. During an interview on [DATE], at 10:23 A.M., the DM said the following: -Dietary staff should log refrigerator temperatures and check for expired foods in the kitchen, dining room and deli/kitchenette; -Nursing staff should log refrigerator temperatures and check for expired food in SCU, rehabilitation unit, East hall and West hall; -Thermometers should be in every refrigerator. 3. Record review of the 2013 Food Code, published by the Food and Drug Administration, showed that except for during preparation, cooking, or cooling, control of food temperature shall be maintained at or above 135 degrees Fahrenheit (F) for hot foods, and at or below 41 degrees F for cold foods. Record review of the facility's policy dated (YEAR), titled Monitoring Food Temperatures for Meal Service, showed the following information: -Food temperatures will be monitored daily to prevent food borne illness and ensure foods are served at palatable temperatures; -If the serving/holding temperature of a hot food item is not at 135 degree F or higher when checked prior to meal service, the item will be reheated to at least 165 degrees F for a minimum of 15 seconds; -If the serving/holding temperature of a cold food item or beverage is not at 41 degrees F or below, for less than four hours in duration, when checked prior to meal service, the item will be chilled on ice or in the freezer until it reaches 41 degrees F or less before service; -Food temperatures of hot food on room trays at the point of service are preferred to be at 120 degrees F or greater to promote palatability for the resident. Observation of test tray from hall cart on [DATE], at 12:16 P.M., showed the following temperatures: -Chicken fried steak 111 degrees F; -Ham salad 52 degrees F; -Cream puff cake (made with milk) 57 degrees F; -Milk 49 degrees F. During an interview on [DATE], at 10:23 A.M., the DM said the following: -Staff should hold and serve cold food below 41 degrees F, including milk and foods that contain milk; -Staff should hold and serve hot food above 135 degrees F.

Based on interview and record review the facility failed to follow a physician's order to obtain a [MEDICATION NAME] Time/International Normalized Ratio (PT/INR- a lab test to determine the clotting tendency of blood) lab for one resident (Resident #1) receiving [MEDICATION NAME] (anticoagulant medication - a blood thinner used to prevent blood clots). The facility failed to develop and implement a policy and procedure to ensure staff entered all lab tests into the lab computer system as ordered. The facility failed to address the resident's anticoagulation therapy in the care plan to direct the staff to monitor the resident for signs and symptoms of bleeding. The staff failed to identify the resident did not have his/her PT/INR test performed as ordered. These deficient practices resulted in the development of a critically high level of anticoagulation of the resident's blood and the formation of a hematoma (a localized swelling filled with blood) to the back of the resident's left lower leg. The resident required emergency transfer to the emergency room and admission to the hospital with [DIAGNOSES REDACTED]. The deficient practice affected one of four residents selected for review from a facility census of 79 residents. 1. Record review of Mosby's Manual of Diagnostic and Laboratory Tests, 1998; Mosby's Nursing Drug Reference, 22nd edition, 2009; and Mosby's Diagnostic and Laboratory Test References, 7th edition, 2005, showed the following information: -[MEDICATION NAME] (brand name for [MEDICATION NAME]) is an anticoagulant (blood-thinning) medication used to help minimize the risk of blood clot formation in individuals with, or at risk for, blood clots;-[MEDICATION NAME] inhibits the clotting ability of the blood and can lead to prolonged bleeding time and/or hemorrhage (bleeding) if the blood is allowed to become too thin;-[MEDICATION NAME] ([MEDICATION NAME] sodium) therapy can be monitored by following the patient's PT/INR; -The degree of anticoagulation can be monitored through the performance of a PT/INR test on the individual's blood; -The dosage of anticoagulant medication is adjusted based on the results of the PT/INR test to keep the blood-clotting time within therapeutic range; -A therapeutic PT range is usually 1.5 to 2.0 times the normal value of 11.0 to 12.5 seconds; -A therapeutic INR value is usually considered to be within the range of 2.0 to 3.5 depending on the clinical situation;-The preferred INR range for the prevention of [MEDICAL CONDITION] (blood clots) is 1.5 to 2.0;-The preferred INR range for the treatment of [REDACTED]. -[MEDICATION NAME] is slow acting, but the action may persist for 7 to 14 days after discontinuation of the drug. Record review of Resident #1's face sheet showed the following information: -The facility admitted the resident on 10/2/14; -[DIAGNOSES REDACTED]. Record review of the resident's October 2014 physician order sheets (POS) showed the following information: -Lab orders to be performed "One time daily for one day starting on 10/2/14" included the following tests: -PT/INR; -CBC (complete blood cell count); -CMP (complete metabolic panel- a test of the electrolyte levels in the blood); -Lipid profile (a test for cholesterol levels and liver function); -TSH and a T4 ([MEDICAL CONDITION] tests) one time daily for one day starting on 10/2/14; -Medication orders included: -[MEDICATION NAME] sodium three milligrams (mg), one tablet by mouth at 5:00 P.M., six days a week (Sunday, Monday, Tuesday, Wednesday, Thursday and Saturday), for A-fib starting 10/3/14; -[MEDICATION NAME] sodium one and a half mg, half of a (three mg) tablet by mouth at 5:00 P.M., one day a week starting the week of 10/3/14 on Friday. Record review of a nurse's note dated 10/2/14, at 1:38 P.M., showed Registered Nurse (RN) A documented he/she entered the resident's admitting and standing labs in the lab computer program to be drawn the next day (10/3/14). Record review of the resident's care plan, dated 10/14/14, showed the following information: -The staff did not address the resident's anticoagulation therapy; -The care plan did not direct the staff to monitor the resident for signs and symptoms of bleeding, or provide interventions for the staff to implement related to the anticoagulant therapy. Record review of the nurses' notes dated 10/4/14 through 10/10/14 showed the following information: -On 10/4/14, at 11:11 A.M., Physician K saw the resident at the facility for an admission visit. The physician ordered [MEDICATION NAME] powder for the redness in the perineal, groin and gluteal areas, also clarification order for left forearm skin tear. Staff faxed the pharmacy and discussed the orders with LPN P; -On 10/6/14, at 9:23 A.M., Physician L assessed the resident at the facility and did a chart review with orders to continue the current orders; -On 10/8/14, at 10:19 A.M.Physician L reviewed a radiological test of the bilateral lower extremities with no new orders noted at that time; -On 10/8/14, at 12:04 P.M., the Physician Assistant (PA) evaluated the resident's CBC, CMP, lipid profile, TSH and T-4 results from the blood draw performed by the lab on 10/3/14 (no PT/INR lab results were available for review) and documented he/she would review the chart on Friday (there were no new orders); -On 10/10/14, at 10:02 A.M., the PA reviewed the resident's chart (no PT/INR lab results were available for review) and staff notified the PA of the resident's request for a stool softener related to painful bowel movements. The PA ordered [MEDICATION NAME] 100 mg twice a day; -The nursing staff failed to identify the resident received [MEDICATION NAME] daily and had not had a PT/INR test performed since admission eight days prior. Record review of the nurses' notes for 10/11/14 through 10/14/14 showed the following information: -On 10/10/14, all three shifts documented the resident received Medicare Part A services for a fractured right arm and the resident required extensive assist with transfers and toileting. At 2:10 P.M., staff documented the resident's Foley catheter (a flexible tube inserted into the bladder to drain urine) was patent and draining dark yellow urine; -On 10/11/14, at 3:07 P.M. nursing documented the resident rested in bed and received Medicare Part A services for a fractured right arm; -On 10/12/14, at 3:05 A.M., nursing documented the resident's Foley catheter appeared patent and exhibited brown drainage with a strong odor; -On 10/13/14, at 3:48 A.M., nursing documented the resident had a Foley catheter that appeared patent and drained cloudy amber urine with a strong odor. At 3:22 P.M. nursing documented the resident had a Foley catheter that was patent and drained dark yellow urine; -On 10/14/13, at 4:55 P.M., RN A documented staff obtained a urinalysis via the Foley catheter. -The nursing staff failed to identify the resident received [MEDICATION NAME] daily and had not had a PT/INR test performed since admission twelve days prior. Record review of the nurses' notes on 10/15/14 showed the following information: -On 10/15/14, at 2:43 P.M., RN B documented the resident was in bed, complained of feeling hot and requested the staff to turn on the air conditioner. After a few minutes the resident said he/she felt better. The resident requested a Kleenex and when he/she blew his/her nose bright red blood was visible on the Kleenex, but the resident had no active bleeding from his/her nose. RN B reported this information to Licensed Practical Nurse (LPN) C. -On 10/15/14, at 5:31 P.M., Physician M saw and assessed the resident at the facility. New orders were received from the physician for a Nephrology consult (a physician who studies and treats kidney disease), a Venous Doppler test (an ultrasound study of the veins) on the lower extremities, an echocardiogram (ultrasound of the heart), a medication order for [MEDICATION NAME] (medication to treat fluid retention) 2.5 mg one time a day for two days, and to change [MEDICATION NAME] to two tablets a day. RN I noted the orders in the electronic medical chart and in the mobile x-ray company computer program; -RN B did not document that he/she notified the physician of the visible blood on the Kleenex; -LPN C did not document that he/she notified the resident's physician of the blood in the Kleenex; -The nursing staff failed to identify the resident received [MEDICATION NAME] daily and had not had a PT/INR test performed since admission 13 days prior. Record review of the nurses' notes for 10/16/14 through 10/30/14 showed the following information: -On 10/16/14, at 1:21 P.M., LPN C documented the staff placed the resident on the physician referral list related to weight fluctuations. LPN C did not document staff placed the resident on the referral list for the resident's physician to assess the resident's nose; -On 10/16/14, at 6:02 P.M., RN I documented Physician M evaluated the resident's lab results with no new orders received. RN I did not document any further assessment of the resident's nose; -On 10/16/14, RN I noted the results of the resident's UA (obtained on 10/14/14) in the resident's chart. The results of the UA showed blood in the urine; -On 10/17/14, at 6:44 A.M., RN A documented Physician M made rounds on 10/15/14, assessed the resident, and diagnosed the resident with a venous stasis ulcer of the right lower extremity. RN A did not document that staff assessed the resident's nose for further blood; -On 10/17/14, at 12:42 P.M., RN A documented the PA evaluated the dietitian's recommendations during rounds and received new orders for Two Cal (supplement with increased protein and calories) three times a day with meals and [MEDICATION NAME] (iron) one 325 mg tablet by mouth daily; -On 10/17/14, at 7:17 P.M., RN I documented Physician M reviewed the urine results with no new orders received. At 7:36 P.M., RN I notified Physician M of the radiology report with no new orders received. RN I did not document an assessment on the blood in the resident's nose or that staff notified the resident's physician; -On 10/20/14, at 10:15 A.M., the PA visited the facility and staff noted new orders for [MEDICATION NAME] one 50 mg tablet twice a day for ten days per a verbal order from Physician M. Physician M also ordered a BMP for the resident; -On 10/22/14, at 6:00 P.M., RN I documented Physician M saw the resident that day ordered a referral to the wound clinic, KCL (potassium) 20 mEq twice a day and to recheck K+ (potassium) in one week. He/she documented the orders were in the computer medical system and the computer lab program; -On 10/27/14, at 12:43 P.M., LPN C documented the resident left with a facility employee for a physician appointment at the orthopedic clinic. At 7:08 P.M. LPN Q documented the resident returned from the appointment at 5:55 P.M. with no new skin issues and new orders to be clarified in the morning on 10/28/14; -On 10/28/14, at 10:51 A.M., LPN C documented the orders from the orthopedic clinic were clarified: new orders for active range of motion with right shoulder, foot rest to be removed from wheelchair so he can use his legs more, standing between parallel bars and discontinue sling to right arm; -On 10/29/14, at 9:02 A.M., LPN C documented the resident left the facility with a staff member for a physician appointment at the wound clinic. At 11:39 A.M., LPN C documented the resident returned from the physician appointment with a new order for [MEDICATION NAME] 2% topical gel to wound area five minutes before dressing change and follow up with wound clinic in one week; -On 10/30/14, at 11:45 A.M., LPN N documented he/she received a verbal order from Physician K to give 8 mg [MEDICATION NAME] IM one time now. LPN N documented he/she gave that one time order to the resident. At 12:14 P.M., LPN C documented the resident had a large lump on the back of his/her left leg was in severe pain. He/she said he/she received a new order from Physician K to send the resident to the ER. At 12:19 P.M. he/she documented staff called for an ambulance at 11:45 A.M. to transfer the resident. Staff called the hospital at 11:55 A.M., and the ambulance arrived and prepared the resident for transfer. At 12:06 P.M., the resident left the facility. -On 10/30/14, at 3:24 P.M., RN D documented the resident had a large lump on the back of his/her left leg and the resident cried out in pain. The area measured approximately seven centimeters (cm) in length and 12 cm in width and protruded approximately four cm. LPN C called the resident's physician who came to the facility, assessed the resident and ordered the staff to send the resident to the hospital. Record review of the resident's medical record showed the following information: -The October 2014 Medication Administration Record [REDACTED] -The lab company did not perform a PT/INR test on the resident during his/her stay at the facility. During an interview on 11/18/14, at 2:00 P.M., the Director of Nursing (DON) said the RN supervisor enters lab orders into the lab computer system. The DON said if the staff does not enter lab orders into the computer, the lab company does not know to come and perform the lab draw. At 4:00 P.M., the DON said when the staff enters a PT/INR order into the computer it will flag and alert LPN E (medical records) to double check the order and medications. If the staff does not enter the labs, LPN E does not know to check. The DON said the certified medication technicians (CMTs) administer [MEDICATION NAME] and [MEDICATION NAME] per the orders and the RN supervisors are in charge of making sure the labs are entered and performed. During an interview on 11/18/14, at 2:43 P.M., RN A said he/she did not remember why he/she did not enter the resident's order for a PT/INR test into the lab computer system. It was overlooked. During an interview on 11/19/14, at 12:30 P.M., LPN O said he/she did not administer [MEDICATION NAME]/[MEDICATION NAME] and just monitored the resident in general. During a telephone interview on 11/24/14, at 2:02 P.M., LPN E (Medical Records nurse) said the RN supervisor takes the orders and enters them into Vision (facility medical record). The staff enters lab orders (if any) into a separate computer system for the lab company. He/she then checks them again. He/she said Resident #1 had orders for [MEDICATION NAME] and a PT/INR, but he/she does not have access to the lab computer system to check on lab orders. The RN supervisors have access to the lab computer system. During a telephone interview on 11/24/14, at 2:11 P.M., RN B said he/she collects information and enters the information into the resident's Minimum Data Set (MDS- a federally mandated comprehensive assessment tool completed by facility staff). He/she said [MEDICATION NAME] orders do not necessarily trigger a possible problem for the care plan because the POS and MAR (kept separate in the medical record) are part of the care plan. He/she said all staff uses the care plan. He/she said he/she documented the resident had blood on a Kleenex after blowing his/her nose, but did not know if staff notified the resident's physician. He/she said nursing should know to check for signs and symptoms of bleeding and bruising if the resident is on [MEDICATION NAME]/[MEDICATION NAME]. During a telephone interview on 11/24/14, at 2:37 P.M., CMT H said he/she was not sure of the actions of [MEDICATION NAME]. He/she thought maybe it is a blood thinner and to monitor you would check the resident's blood pressure and then check on them 30 minutes after giving the medication. He/she said they have a current drug book on their medication cart if they need to look up something. During a telephone interview on 11/24/14, at 3:05 P.M., RN I said he/she was not aware of Resident #1 having blood on his/her Kleenex when he/she blew his/her nose and he/she was not aware of staff reporting it to the resident's physician. During a telephone interview on 11/24/14, at 3:30 P.M., Pharmacist J said he/she operates under the assumption that if [MEDICATION NAME] is ordered then the resident has a PT/INR order. He/she said there would be no concern until it (the PT/INR) was a month late. He/she said Resident #1 had a PT/INR order from 10/2/14, but when he/she did the monthly review on 10/22/14, he/she would not necessarily look for the lab results. He/she said the labs results are usually three to four weeks behind before they are scanned into the computer and when he/she does the monthly medication reviews he/she would not expect to see the results yet. If at the next monthly review there was no lab he/she would then remind the facility to do the lab work. Pharmacist J said the staff should be following the care plan and monitoring for signs and symptoms of bleeding. During a telephone interview on 11/25/14, at 9:25 A.M., CMT G said he/she administers [MEDICATION NAME] and it is a blood thinner. He/she said there was nothing for him/her to monitor, the charge nurse would monitor the resident. CMT G said his/her responsibility was to make sure the resident received the correct dosage. During an interview on 11/25/14, at 3:00 P.M., LPN C said on 10/15/14, when the resident blew his/her nose there was just a very small amount of red blood and nothing more. He/she said the resident did not have a bloody nose and he/she did not report it to the resident's physician. LPN C said the area on the resident's calf was reddish in color and by the time the paramedics arrived the area had grown in size. During an interview on 11/19/14, at 2:00 P.M., the administrator said the facility had no written policy and procedure (prior to 10/30/14) related to medications that required monitoring of labs such as [MEDICATION NAME]/[MEDICATION NAME] and PT/INR lab work. He/she said the computer system has a process to follow, but if the staff does not enter the labs into the system it does not trigger. At 2:40 P.M., the administrator said RN A did not enter the PT/INR order into the lab computer system and they (the facility) did not have a system at that time to check the lab computer system to ensure orders are entered. He/she said RN A overlooked entering the PT/INR lab order for Resident #1. The administrator said he/she was not aware of the resident's former PT/INR results and was not aware of any bleeding or bruising the resident had during his/her stay at the facility. He/she said the LPNs do an assessment every shift and he would expect the nursing staff to monitor the resident for signs and symptoms of bleeding. If nursing had observed symptoms of bruising and bleeding they would report this information to the resident's physician. Record review of the hospital records dated 10/30/14, showed the following information: -The emergency department (ED) admitted the resident on 10/30/14 with [DIAGNOSES REDACTED]. -A PT/INR lab completed in the ED showed results of a critically high PT level of 59.8 (over two times higher than the high end of the therapeutic range) and high INR level of 6.8 (therapeutic range is 2.0 to 3.5); -Hospital staff documented at 1:15 P.M., "the (was) hollering out please help me it hurts"; -An ultrasound of the left calf showed a fluid-filled mass (12.2 cm long x 8.2 cm x 4.6 cm); -At 4:09 P.M., hospital staff documented as the nurse walked toward the resident's room the nurse heard a gush and the resident yelling. Staff found 300 milliliters of blood on the floor and the resident's left calf bleeding profusely. Staff applied pressure and the bleeding went through the dressing; -The ED transferred the resident to another hospital for evaluation of soft tissue left leg bleeding due to supratherapeutic [MEDICATION NAME] anticoagulation. MO 545 and MO 048