Every finding on record at Potosi Manor

Based on observation, interview, and record review, the facility failed to follow physician orders when medication was not given as ordered for one resident (Resident #3), when oxygen tubing was not changed as ordered for one resident (Resident #5) and when medical preparation was not given prior to a scheduled examination, resulting in the procedure needing to be rescheduled for one resident (Resident #31) out of 13 sampled residents. The facility's census was 52.Review of the facility's Oxygen Equipment policy, undated, showed: - All oxygen equipment changed every seven days when heated humidification is used and monthly when unheated humidification is used; - Did not address being changed weekly per the physician orders. Review of the facility's Physician Orders policy, undated, showed it did not address following physician orders. 1. Review of Resident #3's medical record showed: - admission date of 12/28/21; - Diagnoses of diabetes mellitus (a condition that affects the way the body processes blood sugar), vitamin deficiency, and end stage renal disease (ESRD - final, permanent stage of chronic kidney disease). Review of the resident's Physician Order Sheets (POS), dated March 2025, showed: - An order for Lokelma (medication to treat high potassium levels) powder, 10 grams (gm), once a day on Saturday and Sunday for high potassium, dated 09/03/25 and discontinued 03/10/26; - An order for pyridoxine (Vitamin B6), 100 milligrams (mg), one tablet three times a day for vitamin deficiency, dated 09/05/24; - An order for scopolamine (medication for motion sickness or nausea and vomiting) patch, one mg, one patch every three days for nausea and vomiting, dated 08/23/24; - An order for hydrocodone-acetaminophen (narcotic pain medication) 7.5-325 mg, one tablet every six hours as needed (PRN) for pain, dated 01/29/26; - An order for Lyrica (nerve pain medication), 25 mg, on Monday, Wednesday, and Friday after dialysis, dated 12/08/25 and discontinued 03/10/26; - An order for Zyrtec (allergy medication), five mg, one tablet daily for allergies, dated 10/24/25; - An order for Tresiba Flex-Touch insulin (a hormone produced by the pancreas that regulates blood sugar) pen (100 units/milliliter (ml), give 52 units subcutaneously (under the skin) once a day for diabetes mellitus, dated 10/24/25; - An order for irbesartan (blood pressure medication), 300 mg, one tablet daily for heart disease, dated 10/22/23; - An order for lorazepam (anxiety medication), 0.5 mg, give one tablet at 6:00 A.M. on mornings of dialysis treatment on Monday, Wednesday, and Friday for anxiety, dated 08/19/25 and discontinued 03/10/26. Review of the resident's Medication Administration Record (MAR), dated January 2026, showed: - The resident did not receive Lokelma due to being unavailable on 01/11/26, 01/17/26, and 01/24/26, for a total of three missed doses out of nine opportunities; - The resident did not receive Vitamin B6 due to being unavailable on 01/02/26 (three doses), 01/03/26 (three doses), 01/04/26 (two doses), 01/05/26 (three doses), 01/06/26 (one dose), 01/07/26 (two doses), 01/08/26 (three doses), 01/09/26 (three doses), 01/10/26 (three doses), and 01/11/26 (three doses), for a total of 26 missed doses out of 93 opportunities; - The resident did not receive a scopolamine patch due to being unavailable on 01/03/26, for a total of one missed dose out of 10 opportunities; - The resident did not receive Zyrtec due to being unavailable on 01/15/26, for a total of one missed dose out of 31 opportunities. Review of the resident's MAR, dated February 2026, showed: - The resident did not receive Vitamin B6 due to being unavailable on 02/10/26 (one dose), for a total of one missed dose out of 84 opportunities; - The resident only received 26 of 52 units of Tresiba insulin due to being unavailable on 02/15/26; - The resident did not receive irbesartan due to being unavailable on 02/09/26, for a total of one missed dose out of 28 opportunities; - The resident did not receive lorazepam due to being unavailable on 02/23/26, for a total of one missed dose out of 12 opportunities. Review of the resident's MAR, dated 03/01/26 through 3/12/26, showed: - The resident did not receive Lokelma due to being unavailable on 03/01/26 and 03/07/26, for a total of two missed doses out of three opportunities; - The resident did not receive PRN hydrocodone-acetaminophen due to being unavailable on 03/08/26 for pain rated 4/10; - The resident did not receive Lyrica due to being unavailable on 03/02/26, for a total of one missed dose out of four opportunities; - The resident did not receive Zyrtec due to being unavailable on 03/01/26, for a total of one missed dose out of 12 opportunities. During an interview on 03/10/26 at 11:41 A.M., Resident #3 said he/she runs out of medicine, like insulin and pain pills. Insulin hasn't been recent, but the pain medicine has been recent. That happens a lot. During an interview on 03/12/26 at 2:27 P.M., Certified Medication Technician (CMT) A said he/she is not aware of medications being unavailable. The only time a med wouldn't be available would maybe be if there is an insurance issue. He/She thinks the Lokelma might have been because of that. With regards to the Vitamin B6, they should have it available all the time since it's a stock medication. He/She thinks it was marked unavailable because the label changed, and they didn't realize it. That label change also happened with folic acid. They should pay better attention to that. The resident wouldn't refuse his Vitamin B6. 2. Review of Resident #5's medical record showed: - admission date of 05/15/19; - Diagnoses of chronic respiratory failure with hypoxia (lungs can't get enough oxygen into the blood, so the body does not receive the oxygen it needs); - An order for oxygen, two liters per minute via nasal cannula (a thin, flexible tube with two small prongs that fit into the nostrils to deliver supplemental oxygen), dated 11/22/24; - An order to change oxygen tubing weekly, dated 03/30/22. Review of the resident's MAR, dated 03/01/26 through 03/12/26, showed: - Tubing change on 03/01/26; - Tubing change on 03/08/26. Observation on 03/12/26 at 2:35 P.M., of Resident #5 showed the resident wore a nasal cannula connected to the concentrator with the tubing dated 02/22. During an interview on 03/12/26 at 2:56 P.M., Resident #5 said staff does not change the tubing often. One time it was almost a month, and the tubing was getting kind of stiff. During an interview on 03/12/26 at 3:00 P.M., Licensed Practical Nurse (LPN) B said nurses are responsible for changing the tubing or assuring it is changed. Anyone wearing oxygen should have an order to change the tubing. It is normally changed on Sunday nights. The tubing should be dated and initialed. During an interview on 3/13/26 at 11:00 A.M., the Administrator and Director of Nursing (DON) said they would expect physician orders to be followed, and oxygen tubing should be changed once a week on Sundays. 3. Review of Resident #31's medical record showed:- admission date of 12/26/25;- Diagnoses of anal cancer, constipation, and Crohn's disease (a chronic disease that causes inflammation in the digestive tract); - An order to administer one saline fleet enema (liquid, such as saline or water, into the rectum through the anus to treat severe constipation or to cleanse the bowel before medical procedures) prior to procedure – one to two hours prior to appointment (2:15 P.M.) and another 15 minutes following the first enema, dated 03/06/26. Review of the resident's Instruction Form for Procedure/Surgery, attached to the Resident #31's bedside table, showed: Procedure: rectal exam; Date of procedure: 03/06/26; Time: 2:15 P.M.; Orders or special instructions: First fleet administered two hours prior to appointment and 2nd fleet administered 15 minutes after first fleet enema; Signed: LPN B; Rescheduled: 04/24/26. Review of a Social Services Progress Note, dated 03/06/26, showed the resident was scheduled today for a rectal exam and an office visit. The resident did not get his preparation, so the appointment for today has been rescheduled to 04/24/26. The doctor's office to fax the new preparation order to the facility. During an interview on 03/10/26 at 11:15 A.M., Resident #31 said he/she was supposed to have medical testing completed on 03/06/26, but staff failed to administer the two fleet enemas that had to be completed before the exam. His/Her family member drove to pick him/her up and then staff said they would have to reschedule the appointment since they forgot to give the enemas. He/She was very upset because not only did it waste his/her family member's gas and time driving all the way there, but now he/she is left wondering if his/her cancer is spreading or worsening. It has caused him/her lots of worry and frustration. During an interview on 03/12/26 at 11:15 A.M., LNP B said he/she was working when the orders were received for Resident #31's enemas for a procedure. He/She entered the order, but was not working the day they should have been administered. The order should have popped up on the MAR/Treatment Administration Record (TAR) and the nurse working that shift would have been responsible for ensuring it was completed. He/she did not know why it was not completed. During an interview on 03/12/26 at 11:38 A.M., the Social Services Director said the nurse working the day Resident #31 was supposed to have the enema said he/she got busy and forgot to do it. The nurse quit, so he/she is no longer working here. When he/she heard Resident #31 missed the appointment, he/she called the doctor's office and got the appointment rescheduled. During an interview on 03/12/26 at 2:00 P.M., the DON said she would expect medications and treatments to be given and completed as ordered. She said Resident #31 missed his/her preparation for the medical procedure because the nurse did not give it. She does not know why the nurse did not administer the fleet enemas, and the nurse quit the following day. During an interview on 03/13/26 at 11:00 A.M., the Administrator and DON said they would expect physician orders to be followed as ordered, medications to be given as ordered and without errors, and oxygen tubing to be changed once a week on Sundays.

Based on interview and record review, the facility failed to ensure communication forms that reflected ongoing coordination and collaboration between facility staff and the dialysis (a life-sustaining medical treatment that filters waste, toxins, and excess fluids from the blood when the kidneys have failed) staff were sent with two residents (Residents #3 and #42) out of two sampled dialysis residents on all dialysis days and failed to follow their policy to ensure Resident #3's arteriovenous (AV - connection of an artery and a vein) fistula (artificial blood vessel connections between an artery and a vein ) was checked daily for the thrill (vibrating sensation)/bruit (whooshing sound). The facility's census was 52. Review of the facility's policy, Dialysis, Care of a Resident Receiving, undated, showed:- Care of the AV shunt/fistula/graft (artificial blood vessel connections between an artery and a vein): Feel for the thrill sensation daily; Inspect the access for redness, swelling, or warmth; Watch for bleeding after dialysis;- Checking the thrill sensation: Nurses will check the thrill daily and document daily. This will be documented on the resident's treatment record; At the AV site, feel for a pulse. The pulse is the blood flow through the access; If no thrill sensation is felt, notify the physician;- Communication between the Facility and Dialysis Unit: The Dialysis Communication Record will be sent with the resident on each dialysis visit; All care concerns in the last 24 hours will be addressed, including last medications given and facility contact person; The dialysis unit will complete the lower portion of the report to include weight prior to and after dialysis, any labs completed, medication given, follow up information and any new physician orders; The lower portion will be signed by the dialysis nurse and returned to the facility; These records will be maintained in the medical record.1. Review of Resident #3's medical record showed:- admission date of 12/28/21;- Diagnoses of end stage renal disease (ESRD - the final, permanent stage of chronic kidney disease), muscle weakness, and hyperkalemia (high potassium).Review of the resident's Physician Order Sheets (POS), dated 03/12/26, showed:- An order for dialysis three times a week on Monday, Wednesday, and Friday, dated 05/30/25 and discontinued 03/10/26;- An order for dialysis three times a week on Tuesday, Thursday, and Saturday, dated 03/11/26;- An order to remove the pressure dressing from the fistula site in the morning the day after dialysis on Tuesday, Thursday, and Saturday, dated 12/29/21;- An order to check the AV fistula daily for the thrill/bruit on every shift on Tuesday, Thursday, and Saturday, dated 10/08/25 and discontinued 03/10/26;- An order to check the AV fistula daily for the thrill/bruit on Sunday, Wednesday, and Friday, dated 03/10/26;- The orders to check the AV fistula for the thrill/bruit daily do not include every day of the week per the policy.Review of the resident's care plan, revised 03/11/26, showed:- Resident receives dialysis related to ESRD;- Check AV fistula daily for the thrill/bruit;- Assure medications are administered before and after dialysis as ordered by the physician to ensure maximum effectiveness and to avoid adverse effects of the medications.Review of the resident's Progress Notes showed no dialysis due to the weather on 01/26/26.Review of the resident's Dialysis Communication Forms, dated 12/01/25 through 03/12/26, showed 29 forms not completed for 12/01/25, 12/10/25, 12/12/25, 12/15/25, 12/17/25, 12/19/25, 12/22/25, 12/24/25, 12/26/25, 12/29/25, 12/31/25, 01/02/26, 01/05/26, 01/07/26, 01/09/26, 01/12/26, 01/14/26, 01/16/26, 01/19/26, 01/21/26, 01/23/26, 01/28/26, 02/02/26, 02/13/26, 02/20/26 not completed by facility staff, 03/04/26, 03/06/26, 03/09/26, and 03/12/26.Review of the resident's Medication Administration Record (MAR), dated December 2025 through 03/12/26, showed the resident attended dialysis a total of 43 times with a total of 29 missed opportunities for the communication forms to be completed.During an interview on 03/10/26 at 11:41 A.M., Resident #3 said he/she had been going to dialysis on Monday, Wednesday, and Friday, but would now go Tuesday, Thursday, and Saturday starting next week. Staff took his/her vital signs in the morning, and he/she got medicines before dialysis. He/She came back at noon, and they gave his/her medicine and insulin. Staff didn't take vital signs after he/she came back from dialysis. When he/she got back, the form stayed in his/her backpack, then when he/she went to dialysis again, staff took it out. That meant with his/her dialysis schedule changing, when he/she went Thursday, they would get Monday's paper. 2. Review of Resident #42's medical record showed:- admission date of 12/10/24;- Diagnoses of ESRD, vitamin deficiency, and shortness of breath.Review of the resident's POS, dated 03/12/26, showed:- An order for dialysis three times per week with the dialysis center. Special instructions: Complete the dialysis communication form, send with the resident, upload the returned/completed communication form to the resident documents in the electronic health record (EHR) daily on Monday, Wednesday, and Friday, dated 07/30/25 and discontinued 02/25/26;- An order for dialysis three times per week with the dialysis center. Special Instructions: Complete the dialysis communication form observation, send with the resident, upload returned/completed communication form to the resident documents in the EHR daily on Monday, Wednesday, and Friday, dated 01/01/26 and discontinued 02/02/26;- An order for dialysis three times per week with the dialysis center. Special Instructions: Complete the dialysis communication form observation, send with the resident, upload returned/completed the communication form to the resident documents in the EHR daily on Tuesday, Thursday, and Saturday, dated 02/25/26;- An order to check the central venous catheter (CVC - a flexible tube inserted into a large vein to provide immediate access for dialysis) dressing every shift for signs and symptoms of infection, dated 01/01/26;- An order to check the AV fistula daily for the thrill/bruit, dated 07/30/25 and discontinued 12/11/25;- An order to remove the pressure dressing from the fistula site in the morning the day after dialysis, daily on Tuesday, Thursday, and Saturday, dated 11/17/25 and discontinued 12/11/25.Review of the resident's Care Plan, revised 01/20/26, showed:- Dialysis three times per week per physician orders;- Remove pressure dressing from the fistula site in the morning the day after dialysis.Review of the resident's Hemodialysis Communication forms, dated 12/01/25 through 03/12/26, showed 17 forms not completed for 12/12/25, 12/15/25 (no vital signs by the facility staff prior to dialysis) 01/02/26, 01/05/26, 01/09/26, 01/12/26, 01/16/26, 01/19/26, 01/21/26, 02/02/26, 02/09/26 (not signed by the facility staff), 02/11/26, and 02/16/26 (only vital signs completed and no facility staff signature), 02/20/26, 03/07/26, 03/10/26, and 03/12/26. Review of the resident's MAR, dated December 2025 through 03/12/26, showed the resident attended dialysis a total of 18 times with a total of 17 missed opportunities for the communication forms to be completed.During an interview on 03/11/26 at 9:05 A.M., Resident #42 said staff sometimes did vital signs before dialysis and sometimes they gave him/her the communication form. Staff didn't really do anything when he/she got back from dialysis, and they didn't ask for the communication form all the time. The other person who got dialysis had a folder, but he/she didn't have a folder. During an interview on 03/13/26 at 11:00 A.M., the Administrator said he would expect dialysis communication forms to be completed by both the facility and dialysis center for each dialysis visit treatment as per the regulation.During an interview on 03/18/26 at 2:57 P.M., the Director of Nursing (DON) said she did not find any notes on refusals for Resident #3, but one day dialysis was cancelled because of weather. Post dialysis, they have orders to monitor the access site every shift and, on Resident #3, to remove the pressure dressing the following day and monitor for bleeding.During an interview on 03/19/26 at 11:16 A.M., the DON said Resident #42 did have a shunt placed in his/her arm. Dialysis tried to access one time, and then it developed an infection and was removed. Resident #42 now had a CVC in the right chest for dialysis access. They did have orders to check the central line every shift. Dialysis was doing dressing changes and maintaining the CVC. The current order for Resident #3 was to check the AV fistula on Sunday, Wednesday, and Friday. She would correct the order to include Monday.During an interview on 03/23/26 at 8:07 A.M., the DON said that staff did not check the thrill/bruit on dialysis days because that was done at dialysis, and the resident had a pressure dressing on when he/she came back. When asked if a resident was scheduled for dialysis but refused, who would be checking the thrill/bruit on those days since the orders did not include staff checking it on those days, she said the nurses usually would check on those days, but she would put in an order to confirm they did.

Based on interview and record review, the facility failed to ensure three of the three sampled Certified Nurse Aides (CNAs) received an annual performance review. The facility's census was 52.The facility did not provide a policy regarding CNA annual performance reviews.1. Review of CNA D's personnel file showed:- Hire date of 10/30/24;- No documentation of an annual performance review.2. Review of CNA E's personnel file showed:- Hire date of 10/04/24;- No documentation of an annual performance review.3. Review of CNA F's personnel file showed:- Hire date of 07/18/24;- No documentation of an annual performance review.During an interview on 03/12/26 at 2:12 P.M., the Director of Nursing (DON) said the prior Administrator did not do performance reviews, and they haven't been doing them.During an interview on 03/13/26 at 11:00 A.M., the Administrator said he would not necessarily expect performance reviews to be completed annually, and the facility does not have a policy. They follow the regulations.

Based on observation, interview, and record review, the facility failed to maintain a medication error rate of five percent or less when staff failed to prime insulin pens before the administration of insulin and administered the incorrect amount of insulin. There were 33 opportunities with three errors made, for an error rate of 9.09%. This affected two residents (Residents #2 and #23) out of 13 sampled residents. The facility's census was 52.Review of the facility's checklist, Insulin Pen Skills Checklist, undated, showed:- Gather necessary supplies on clean field;- Verify pen is within expiration date;- Cleanse the stopper with alcohol;- Attach safety needle;- Dial units as per physician's orders;- [NAME] gloves;- Cleanse area to be administered with alcohol;- Administer insulin;- Cleanse area again with alcohol and apply bandage if needed;- Dispose of needle in sharps container;- Remove gloves and perform hand hygiene. Review of the facility's policy, Medications, Errors and Drug Reactions, undated, showed:- Purpose: to safeguard the resident and provide emergency care as necessary;- If necessary, provide emergency care to resident;- Report all medication errors and adverse drug reactions to the attending physician, Director of Nursing (DON) and Administrator;- Document and follow the attending physician's orders;- Complete a resident assessment including the following: obtain vital signs and record, complete a body assessment, assess respiratory, cardiac, and circulatory status, assess every shift for at least 72 hours;- Open a medication error event in the electronic health record and complete the following: date error began/ended, date error found, error found by whom, document the correct order, describe the error, type of error, document if any adverse drug reactions are present, document implemented interventions, notify the resident's responsible party, and frequently observe the resident until condition is stable. Review of insulin lispro (a synthetic or human-derived hormone injected into the fatty tissue under the skin to regulate high blood sugar levels, commonly known as Humalog) pen (insulin in a pen-type device) manufacturer's instructions from pi.lilly.com showed:- Remove cap;- Attach needle;- Prime pen by turning dose selector to select two units;- Press and hold button to make sure drop of insulin appears;- Select dose;- Give injection;- After dose counter reaches zero, hold for 5-10 seconds;- After injection, remove needle and place in sharps container;- Place cap back on pen and store until next use. Review of insulin glargine (commonly known as Lantus) pen manufacturer's instructions from lantus.com showed:- Wash your hands;- Take off the pen cap, and make sure the insulin is clear and colorless. Do not use if it is cloudy or if you see particles, throw it away;- Wipe the rubber seal, remove the protective seal, and attach the needle;- Perform a safety test, dial a dose of two units and hold the pen upright and tap the insulin reservoir to get the air bubbles to rise up, press the button down and check for insulin on the needle tip;- If insulin doesn't come out, try the safety test two more times, and change the needle. If it still doesn't work, the pen may be damaged - do not use it;- Select your required dose, and cleanse the skin with an alcohol swab;- Inject the dose, keep the button pressed, and count to 10;- Remove and discard the needle, place in a sharps container;- Put the pen cap back on and store the pen. 1. Review of Resident #2's Physician Order Sheet (POS), dated 03/13/26, showed:- An order for Humalog Kwik pen insulin (insulin lispro) 100 units/milliliter (ml) per sliding scale, subcutaneously (under the skin), before meals and at bedtime, dated 02/07/26;- An order for Humalog Kwik pen (insulin lispro) 100 units/ml, 15 units subcutaneously, along with sliding scale, before meals and at bedtime, dated 02/25/26;- An order for Lantus (insulin glargine) 100 units/ml (3ml), 52 units subcutaneously twice a day, dated 02/18/26. Observation on 03/13/26 at 8:00 A.M., showed:- The DON obtained the resident's finger stick blood sugar (FSBS) with a reading of 263;- The DON obtained the insulin lispro pen from the medicine cart and adjusted the pen to the amount of insulin ordered;- The DON did not prime the pen with two units of insulin per the manufacturer's instructions prior to administering the ordered dose to the resident;- The DON obtained the Lantus insulin pen from the medicine cart and adjusted the pen to the amount of insulin ordered;- The DON did not prime the pen with two units of insulin per the manufacturer's instructions prior to administering the ordered dose to the resident.2. Review of Resident #23's POS, dated 03/13/26, showed:- An order for insulin glargine 300 units/ml (3ml), 20 units subcutaneously, twice a day, dated 02/12/26;- An order for insulin lispro 100 units/ml, subcutaneously per sliding scale before meals and at bedtime, dated 02/12/26.Observation on 03/13/26 at 8:15 A.M., showed:- The DON obtained the resident's FSBS with a reading of 251;- The DON primed the insulin pen;- The DON administered 20 units of insulin lispro to the resident when the physician's order was for 6 units per sliding scale;- The DON administered the incorrect dose of insulin lispro to the resident.- The DON immediately called the physician regarding the error and was told to hold the resident's insulin glargine 20 units and to monitor the resident's blood sugar every hour and to monitor for symptoms. The DON made a progress note regarding the error.During an interview on 03/13/26 at 9:02 A.M., the DON said insulin pens should typically be primed with two units of insulin, but there is one type that requires the pen to be primed with three units. Medication administration should be error free.During an interview on 03/13/26 at 11:00 A.M., the Administrator and DON said they would expect medications to be given as ordered and without errors, for insulin pens to be primed per manufacturer's instructions, and for the medication error rate to be less than 5%.

Based on observation and interview, the facility failed to provide a safe and functional environment by allowing items to be stored on top of overbed light fixtures for residents in seven rooms. Storing items on the overbed light creates a hazard of the items falling on the resident below and does not utilize the light fixtures as intended. The deficient practice had the potential to affect all residents and staff in the facility. The facility census was 52.The facility did not provide a policy regarding overbed light safety. Observation of resident rooms showed: - On 03/10/26 at 11:26 A.M., room [ROOM NUMBER] with multiple stuffed animals on the light fixture above the bed by the door and above the bed by the window; - On 03/10/26 at 11:38 A.M., room [ROOM NUMBER] with two hats and a stuffed animal on the light fixture above the bed by the window; - On 03/12/26 at 9:10 A.M., room [ROOM NUMBER] with two picture frames and three small flower decorations on the light fixture above the bed by the window; - On 03/10/26 at 11:15 A.M., room [ROOM NUMBER] with two canvas pictures and some flowers on the light fixture above the bed by the door; - On 03/12/26 at 2:08 P.M., room [ROOM NUMBER] with a horse picture on the light fixture above the bed by the door; - On 03/12/26 at 2:10 P.M., room [ROOM NUMBER] with two framed pictures and a piece of paper with a drawing on it on the light fixture above the bed by the door; - On 03/12/26 at 2:12 P.M., room [ROOM NUMBER] with two crocheted plant decorations hanging from either side of the light fixture above the bed by the window. During an interview on 03/12/26 at 2:10 P.M., Certified Nurse Aide (CNA) C said he/she does not put things on top of the lights in the resident rooms, but family members will often place pictures and items on them. During an interview on 03/12/26 at 2:00 P.M., the Director of Nursing (DON) said items should not be placed on the light fixtures due to possible hazards. During an interview on 03/13/26 at 11:00 A.M., the Administrator and DON said they would expect overbed light fixtures to be free from items due to possible hazards.

Based on interview and record review, the facility failed to provide the required 12 hours of in-services per year to include dementia management, abuse/neglect prevention, areas of personal weakness, areas of concern based on the facility assessment, the care of cognitively impaired residents and the care of residents with special needs for three Certified Nurse Aides (CNAs D, E, and F) out of three sampled CNAs. The deficient practice had the potential to affect all residents. The facility's census was 52.The facility did not provide a policy regarding nurse aide training and in-service requirements. 1. Review of CNA D's personnel file showed:- Hire date of 10/30/24;- No in-services recorded from 10/30/24-02/27/26;- No documented trainings for dementia management, abuse/neglect prevention, areas of personal weakness, the care of cognitively impaired residents, and the care of residents with special needs. 2. Review of CNA E's personnel file showed:- Hire date of 10/04/24;- A total of eight in-services, dated from 02/24/25 through 02/27/26, with the length of each in-service not documented;- No documented trainings for dementia management, areas of personal weakness, the care of cognitively impaired residents, and the care of residents with special needs. 3. Review of CNA F's personnel file showed:- Hire date of 07/18/24;- No in-services recorded from 07/18/24 through 02/27/26;- No documented trainings for dementia management, abuse/neglect prevention, areas of personal weakness, the care of cognitively impaired residents, and the care of residents with special needs.During an interview on 03/12/26 at 11:15 A.M., the Director of Nursing (DON) said she has no recorded in-services for CNA D and CNA F because they work as needed (PRN).During an interview on 03/12/26 at 3:00 P.M., Licensed Practical Nurse (LPN) G said in-services are conducted by the DON and himself/herself. Staff should have at least 12 in-services per year and should include resident rights, peri care, hand hygiene, privacy, and workplace violence. He/She couldn't remember them all and provided a typed list of upcoming in-services which included two in-services in each month for March, April, May, June, and July to include the required training for abuse/neglect and misappropriation.During an interview on 03/13/26 at 11:00 A.M., the Administrator and DON said they would expect nurse aides to have at least 12 hours of in-services a year to include dementia care/management and the care of cognitively impaired residents.

Based on observation, interview, and record review, the facility failed to post the nurse staffing data at the beginning of each shift for three of four observed days. The facility's census was 52.The facility did not provide a policy regarding daily staffing data postings.Observations of the posted nurse staffing data showed:- On 03/11/26 at 10:15 A.M., nurse staffing data posted and dated 03/10/26, including the census, and total number and actual hours worked per shift by licensed and unlicensed staff responsible for resident care;- On 03/12/26 at 12:00 P.M., nurse staffing data posted and dated 03/10/26, including the census, and total number and actual hours worked per shift by licensed and unlicensed staff responsible for resident care;- On 03/13/26 at 9:00 A.M., nurse staffing data posted and dated 03/10/26, including the census, and total number and actual hours worked per shift by licensed and unlicensed staff responsible for resident care.During an interview on 03/13/26 at 9:02 A.M., the Director of Nursing (DON) said Licensed Practical Nurse (LPN) G updates the staffing postings, and they should be updated daily.During an interview on 03/13/26 at 11:00 A.M., the Administrator and DON said they would expect staffing to be posted daily.

Based on interview and record review, the facility failed to protect one confused and vulnerable resident's (Resident #1), out of four sampled residents, right to be free from physical abuse during medication administration, when facility staff held the resident's hands and forced his/her medication in his/her mouth- resulting in the resident sobbing and screaming the staff were devils. The facility census was 62. On 10/22/24 at 2:00 P.M., the Administrator was notified of the past non-compliance immediate jeopardy (IJ) which began on 10/19/24. Upon discovery, the facility immediately conducted an investigation, removed and terminated the staff involved, and inserviced staff on abuse and neglect and medication administration. The IJ was corrected on 10/21/24. Review of the facility's policy titled, Abuse Prohibition Protocol Manual, undated, showed: -Each resident will be free from abuse. Abuse can include verbal, mental, sexual, or physical abuse, misappropriation of resident property and exploitation, corporal punishment or involuntary seclusion; -Residents will be free from physical or chemical restraints imposed for purposes of discipline or convenience and that are not required to treat the resident's medical symptoms. The facility did not provide a policy for medication administration relating to handling medication refusals and/or refusals by combative residents. 1. Review of Resident #1's medical record showed: -admitted on [DATE]; -Diagnoses of anxiety disorder, dementia with severe agitation, disorientation, and severe major depressive disorder with psychotic features (depression along with a loss of touch with reality). -History of refusing medications. Review of Resident #1's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 08/27/24, showed the resident was severely cognitively impaired. Review of the Facility Reported Incident dated 10/21/24, showed: - On 10/21/24, the administrator received a handwritten account of an incident which occurred on 10/19/24 from Certified Nurse Aide (CNA) C; - CNA C reported on 10/19/24 he/she heard Resident #1 yelling and went to check. CNA C walked upon and observed Certified Medication Technician (CMT) A push Resident #1's head and pinch the resident's nose until the resident opened his/her mouth while Licensed Practical Nurse (LPN) B held the resident's wrists. CMT A shoved the medication and yogurt mixture into Resident #1's mouth. CMT A and LPN A released the resident and the resident stumbled into CNA C sobbing with his/her face covered in yogurt screaming the nurse and CMT were devils. CMT A told CNA C you didn't see anything. - The administrator immediately began an investigation, terminated all staff involved after receiving written statements and inserviced all staff on abuse and neglect, reporting timely and techniques and expectations from staff regarding dealing with a confused resident. During an interview on 10/22/24 at 11:06 A.M., CNA C said on 10/19/24 at 4:15 P.M. he/she heard Resident #1 yell in the 100 hallway while he/she was gathering supplies for a resident's shower. CNA C said he/she went down the 100 hallway to check on Resident #1 and observed CMT A push Resident #1's head and pinch the resident's nose until the resident opened his/her mouth while LPN B held the resident's wrists. CMT A shoved the medication and yogurt mixture into Resident #1's mouth. CMT A and LPN A released the resident and the resident stumbled into CNA C sobbing, with his/her face covered in yogurt and screaming the nurse and CMT were devils. CMT A told CNA C you didn't see anything. During an interview on 10/22/24 at 11:11 A.M. CMT A said on 10/19/24 at approximately 4:15 P.M. he/she attempted to give medications to Resident #1 and the resident refused and spit at him/her. CMT A again attempted to give medications to Resident #1 and the resident attempted to scratch him/her. CMT A called LPN B over to hold the resident's hands while CMT A held the resident's head back and pinched the resident's nose until the resident opened his/her mouth. CMT A gave the resident the medication and yogurt mixture when the resident opened his/her mouth. CMT A said he/she knows he/she should not have administered the medications in that manner. CMT A said he/she was overwhelmed from working too much and the incident should have never happened. During an interview on 10/22/24 at 12:03 P.M., LPN B said on 10/19/24 around 4:15 P.M., CMT A yelled for assistance with Resident #1. LPN B said as he/she approached CMT A, he/she observed Resident #1 attempting to scratch CMT A while the CMT was attempting to give the resident his/her medication. LPN B said he/she went over and held Resident #1's wrists so the resident couldn't scratch CMT A. CMT A proceeded to push the resident's head back and pinched the resident's nostrils until the resident opened his/her mouth then shoved the medication and yogurt mixture in. CMT A told CNA C, who had observed the medication administration, you didn't see anything and walked off. LPN B said he/she was caught off guard by CMT A pushing the resident's head back and pinching the resident's nose and it should not have happened. LPN B said he/she knew it was wrong and should have reported it, but he/she was new to the facility and was afraid to say anything. LPN B said he/she should not have held the resident's wrists. During an interview on 10/22/24 at 12:38 P.M., the resident's family member said he/she would not expect the facility to act in a physical manner when administering medications to Resident #1. He/she said the resident should have been talked to and handled with patience. During an interview on 10/22/24 at 1:45 P.M., the Quality Assurance Nurse Consultant (QA Nurse) said if a resident is agitated and refusing medications he/she would expect staff to attempt to calm and redirect the resident. QA Nurse said staff should attempt to give the medications again after the resident has calmed down or attempt to have a different staff member give medications. Residents should never be forced to take their medications. During an interview on 10/22/24 at 1:50 P.M., the Administrator said he/she would expect staff to honor the wishes of the resident if a resident refuses their medications and document the refusal. During an interview on 10/22/24 at 1:25 P.M., the Nurse Practitioner (NP) said it is unacceptable to hold a resident's nose to attempt to administer medications. Staff should redirect, try again later to administer medications, or have a different staff member administer the medications. During an interview on 10/22/24 at 2:44 P.M. the Medical Doctor (MD) said he/she was aware of the situation that occurred on 10/19/24 involving staff and Resident #1. The MD said administering medications in that manner is not acceptable. Complaint #MO243888

Based on interview and record review, the facility failed to have a Quality Assurance and Performance Improvement (QAPI, a program to improve the processes for the delivery of health care and quality of life for the residents) program in place with policies and protocols describing how the facility will identify and correct its own quality deficiencies. This deficient practice had the potential to affect all residents in the facility. The facility's census was 62. The facility did not provide a policy related to the QAPI program. Review of the facility's QAPI binder showed: - The most recent QAPI Plan dated 2019; - A template showing how to create a QAPI plan; - No current QAPI plan that contained the necessary policies and protocols describing how they would identify and correct their quality deficiencies, track and measure performance, and establish goals and thresholds for performance measurement. During an interview on 10/11/24 at 10:41 A.M., the Administrator said she had no QAPI agendas for any meetings. She would expect to have an agenda for each meeting, showing what was discussed and how it's going to be addressed and monitored. She had nothing showing monitoring of any issues and no Performance Improvement Plans (PIPs) in place. She tried to deal with issues that came up in morning meetings. She spoke with another administrator in the company who said they don't have a QAPI policy and that they would just go by the regulations. She would expect the facility to have a QAPI program in place.

Based on interview and record review, the facility failed to ensure the Quality Assessment and Assurance/Quality Assurance Performance Improvement (QAA/QAPI) committee developed and implemented an appropriate plan of action to correct identified quality deficiencies. This had the potential to affect all residents in the facility. The facility census was 62. The facility did not provide a QAPI plan or policy. Review of documentation provided by the Administrator showed: - A template to create a QAPI plan, but no current QAPI plan; - The most current QAPI plan dated 2019. During an interview on 10/10/24 at 3:51 P.M., the Administrator said she does not have any Performance Improvement Projects (PIPs) in place. They do have a morning stand up meeting and try to look into things that come up in those meetings. During an interview on 10/11/24 at 10:41 A.M., the Administrator said she has no QAPI agendas for any meetings, only sign in sheets. She said she should have an agenda for each meeting that has been held, showing what they have discussed and how any issues are addressed and monitored, but she currently has nothing like that in place. She would expect the facility to have a QAPI program in place.

Based on interview and record review, the facility failed to maintain quarterly Quality Assessment and Assurance/Quality Assurance Performance Improvement (QAA/QAPI) committee meetings with the required members. The facility's census was 62. The facility did not provide a QAPI policy. Review of the QAPI meeting sign in sheets, provided by the Administrator, showed: - Meetings were held in November 2023, January 2024, and July 2024; - The medical director did not attend any of the meetings. During an interview on 10/10/24 at 3:51 P.M., the Administrator said the medical director is hard to catch when he is in the building. He is so busy that it's difficult for him to come to a 30 minute meeting. She will try to go over things with him, but he doesn't come to quarterly meetings. She would expect meetings to be held quarterly and for the medical director to come to QAPI meetings.

Based on observation, interview and record review, the facility failed to ensure two nurse aides (NAs) completed a nurse aide training program within four months of his/her employment at the facility. The facility's census was 62. The facility did not provide a policy related to the NA training program. 1. Review of NA A's personnel file showed: - A hire date of 02/02/24; - NA A currently enrolled in class; - The facility failed to ensure the completion of the program within four months of NA A's hire date. 2. Review of NA E's personnel file showed: - A hire date of 08/15/23; - NA E currently enrolled in class; - The facility failed to ensure the completion of the program within four months of NA E's hire date. Observation on 10/11/24 at 2:15 P.M. showed NA A provided incontinent care for Resident #36. During an interview on 10/11/24 at 11:00 A.M., the Administrator said that two NAs were still working the floor as NAs, and she knew that it would be an issue. During an interview on 10/11/24 at 3:42 P.M., the Administrator said that she would expect NAs to be certified within four months of hire and that there is a plan in place for the two NAs to get certified.

Based on observation, interview, and record review, the facility failed to store food under sanitary conditions, increasing the risk of food-borne illness. This deficient practice had the potential to affect all residents. The facility census was 62. Review of the facility's policy titled, Receiving and Storage of Food, dated May 2015, showed: - The Dining Service Manager (DSM) is responsible for receiving and storing food and non-food items; - Follow the rule of First In, First Out; - Food is stored in designated areas; - Keep all foods in clean, undamaged wrappers or packages; - Reseal open boxes effectively; - Keep storage areas clean and dry. Observation on 10/08/24 at 11:35 A.M. showed: - Four unopened wrinkled boxes of salt that had become solid with a grainy substance on the outside of the boxes; - A potato chip laying on the shelf next to the salt boxes; - A package of opened marshmallows, exposed to air; - One opened gallon of pancake syrup, undated, with about one inch of syrup remaining in the bottom of the container; - One unopened gallon jug of vinegar, with black debris all over the jug; - Two unopened and undated containers of scalloped potatoes; - One unopened and undated gallon jug of lemon juice; - One opened, undated five pound container of peanut butter, with peanut butter on the edge of the lid; - Two unlabeled and undated 35 quart containers of dry cereal; - One 35-quart container, labeled crisp rice cereal, almost empty and dated 7/4; - One 35-quart container, labeled toasted oat cereal, almost full and dated 7/25; - One unopened and undated eight pound container of salsa; - One undated 35-quart tote/container of powdered milk with a golf ball sized amount of water, debris and a black, mold-like substance on the top of the lid. Observation on 10/10/24 at 10:15 A.M. showed: - Four unopened wrinkled boxes of salt that had become solid with a grainy substance on the outside of the boxes; - One opened gallon of pancake syrup, undated, with about one inch of syrup remaining in the bottom of the container; - Two unlabeled and undated 35-quart containers of dry cereal; - One 35-quart container, labeled crisp rice cereal, almost empty and dated 7/4; - One 35-quart container, labeled toasted oat cereal, almost full and dated 7/25; - One undated 35-quart tote/container of powdered milk. During an interview on 10/10/24 at 12:00 P.M., the Dietary Manager said when a shipment is received, it is labeled with the date. If it is something that needs placed in a different container, it is labeled and dated. Refrigerated items are labeled, dated and used within three days. Totes and containers containing food should also be labeled and dated. During an interview on 10/11/24 at 3:43 P.M., the Administrator said she would expect food items to be labeled, dated, and free from debris.

Based on observation, interview, and record review, the facility failed to maintain proper infection control practices during incontinent care for two residents (Resident #8 and #36) outside of the 16 sampled residents. The facility failed to ensure proper Tuberculosis (TB-a communicable disease that affects the lungs, characterized by fever, cough and difficulty breathing) screening of three residents (Resident #19, #38 and #45) out of five sampled residents. The facility's census was 62. Review of the facility's policy titled, Handwashing, undated, showed: - Purpose to reduce transmission of organisms from resident to resident, staff to resident, and resident to staff; - Use of soap, comfortably hot water, and disposable towel; - Soap hands well and briskly rub together, paying attention to areas between fingers; - Rinse hands lowered to allow soiled water to drain into sink; - Do not splash water on clothing and do not touch sink; - Use disposable towel to turn faucet off and dry hands. 1. Observation on 10/11/24 at 1:15 P.M. of incontinent care for Resident #8 showed: - Certified Nurse Assistant (CNA) C and (CNA) D did not wash or sanitize hands prior to beginning care; - CNA C and CNA D donned gloves and assisted the resident out of the wheelchair and into bed; - CNA D obtained peri-wipes from the resident's bedside drawer; - CNA C removed the resident's pants and soiled brief; - CNA C cleaned the resident with a peri-wipe front to back three times, placed soiled wipes in a trash bag, closed the wipe container, then disposed of gloves; - CNA C and CNA D repositioned the resident and covered him/her back up; - CNA C took the trash out of the room and down the hall to the soiled hold room to dispose of before sanitizing hands. During an interview on 10/11/24 at 1:30 P.M., CNA C said he/she would normally wash and or sanitize hands before and after providing peri-care on a resident. 2. Observation on 10/11/24 at 2:15 P.M. of incontinent care for Resident #36 showed: - CNA B and Nursing Assistant (NA) A donned gowns, gloves, and masks upon entry into the room; - CNA B cleaned the resident and the resident's catheter with wipes; - With the same soiled gloves, CNA B and NA A assisted the resident in rolling onto his/her right side; - With the same soiled gloves, CNA B wiped stool from the resident's buttocks and rolled the soiled bed pad underneath the resident; - With the same soiled gloves, CNA B and NA A rolled the resident onto his/her back and removed the soiled bed pad; - With the same soiled gloves, CNA B and NA A repositioned the resident and covered him/her up; - With the same soiled gloves, CNA B and NA A bagged up the trash and soiled linens, removed gowns, gloves, and masks and washed hands before leaving the room. During an interview on 10/11/24 at 2:30 P.M., CNA B said he/she should have changed gloves when he/she changed sides and after cleaning from front to back. Review of the facility's policy titled, Tuberculosis Control, undated, showed: - All residents new to long term care, who do not have documentation of a previous skin test reaction, or a history of adequate treatment of tuberculosis disease, shall have the initial test of Mantoux Purified Protein Derivative (PPD-a diagnostic test used to screen and diagnose TB) two step skin test to rule out tuberculosis within one month prior to or one week after admission; - If initial test result (measured by observing site of test for raised formation) is 0-9 millimeters (mm), the second test, which can be given after admission, should be given at least one week and no more than three weeks after the first test; - Documentation of a chest X-ray, ruling out tuberculosis within one month prior to admission, along with an evaluation to rule out signs and symptoms, may be acceptable on an interim basis until the Mantoux PPD two-step test is completed; - Residents are to be evaluated, at least annually, to assure absence of signs and symptoms for TB. 3. Review of Resident #19's medical record showed: - admitted [DATE]; - Screening assessment completed on 10/01/24; - First step TB test not given until 10/04/24 with no read date; - Documented refusal for second step. 4. Review of Resident #38's medical record showed: - admitted [DATE]; - First step given on 07/31/24, read on 08/03/24, results of 0 mm; - Second step not completed within recommended time frame; - First step repeated on 10/03/24, read on 10/05, results of 0 mm; - Second step repeated on 10/10/24. 5. Review of Resident 45's medical record showed: - admitted [DATE]; - Screening assessment done on 10/01/24; - No documentation of the two step testing. During an interview on 10/11/24 at 1:00 P.M., the Administrator said they waited too long to do the second step for Resident #38 and had to restart the test. During an interview on 10/11/24 at 1:10 P.M., the Quality Assurance (QA) Nurse said they would have to restart the two step for Resident #45, as it had been missed. It may have been initiated, but not completed. A screening was completed for Resident #19 on 10/01/24, due to refusal of the TB test. An audit was done and everyone in the building was screened and the tests were restarted for those that had been missed. Some did not have the proper documentation. During an interview on 10/11/24 at 3:43 P.M., the Administrator said she would expect residents' TB tests to be given and read in the recommended time frame.

Based on observation and interview, the facility failed to ensure the dumspters were closed at all times and maintained to keep pests out and/or keep garbage contained in the dumpster. The facility's census was 62. Review of the facility's policy titled, Waste Disposal, dated May 2015, showed: - Dumpster lids are to be closed at all times; - Dumpster and dumpster area are to be kept clean and free of debris. Observations of the dumpster showed: - On 10/09/24 at 2:41 P.M., the back right lid was concaved/bent, not covering the dumpster and the front left lid not closed; - On 10/10/24 at 8:17 A.M., lids on both left and right front of the dumpster not closed and trash bags overflowing; - On 10/10/24 at 1:19 P.M., lids on both left and right front of the dumpster not closed and trash bags overflowing; - On 10/11/24 at 08:37 A.M., the left front lid not closed with a trash bag resting on top of the closed right lid. During an interview on 10/11/24 at 3:43 P.M., the Administrator said she would expect dumpster lids to be closed and trash to be inside of the dumpster, and not on top.

Based on observation, interview, and record review, the facility failed to store and distribute food under sanitary conditions, increasing the risk of cross-contamination and food-borne illness. These deficient practices had the potential to affect all residents. The facility census was 56. Review of the facility's policy titled, Nutrition and Dining Services Manual Guidelines, dated April 2011, showed: - It is the responsibility of the Dining Services Manager to enforce the cleaning schedules and to monitor the completion of assigned cleaning tasks; - Daily, weekly, and monthly cleaning schedules prepared by the Dining Services Manager with all cleaning tasks listed will be posted in the Dietary Department; - The employee will initial in the column under the day the task is completed; - Purpose is to develop detailed cleaning schedules to ensure sanitation is at acceptable standards; - Cleaning schedules should be kept on file for one year; - Wash outside of dishwasher and entire dishwashing area; - Clean top and outside of dish machine; - Areas behind and under equipment must be clean and in good repair; - Pots and pans are to be free of carbon buildup, grease and food particles; - Refrigerator gaskets are to be routinely cleaned and must be free of mold and in good repair. Observations on 07/25/23 at 11:30 A.M., and 07/27/23 at 08:45 A.M., of the kitchen area showed: - A six-burner gas range cook stove with black carbon buildup and brown colored grime on all burners, metal back splash, sides and front; - A gas griddle attached to the cook stove with black carbon and brown colored grime buildup on the cooking surface and all sides, and missing one of three burner control knobs; - Two deep fryer baskets with brown grime buildup on the baskets and the handles; - Two eight inch (in.) skillets with black carbon and brown grime buildup on the inside and outside of the skillets; - Four large skillets with black carbon and brown grime buildup on the outside and the handles; - Two 24-count muffin pans with brown grime buildup inside all the baking cups; - A two-bay plate warmer oven with brown grime on the inside bays and the outside; - An Ice machine with buildup of a white substance on all four outside panels; - A three-bay metal sink with a brown colored spotty substance on the outside of each bay, and a two handle metal faucet with continuous dripping water and covered with a white colored substance; - A dish machine with a white substance buildup and grime on all four outside panels, the top two attached black colored water hoses with brown grime buildup, and two attached copper pipes with grime and a blue colored substance; - A garbage disposal attached to the dish machine with brown grime buildup on the top and sides; - Two 4 in. x 4 in. ceramic tiles pulled away from the wall by the drain pipe of the dish machine; - The wall behind the dish machine covered with brown grime buildup; - The two-bay metal sink with brown grime buildup on the outside of both bays and the attached garbage disposal covered with brown grime; - A small electrical breaker box located on the wall behind the two-bay sink with brown grime buildup on the top and sides; - A five-bay steam table with brown grime buildup on the outside of each end; - A two-door refrigerator with the right side door seal broken and hung from the top of the door, and brown grime buildup on the front and sides; - A single door refrigerator with brown grime buildup on the front and sides; - No documentation of a kitchen cleaning schedule and/or a kitchen cleaning checklist. During an interview on 07/25/23 at 11:31 A.M., the Dietary Manager said he/she knew the kitchen equipment could use a good cleaning and he/she had purchased some heavy duty cleaning supplies to work on that. During an interview on 07/27/23 at 8:45 A.M., Cook E said they did not have a cleaning schedule for the kitchen, but that could help keep the kitchen cleaner on a continuous basis. During an interview on 07/27/23 at 9:45 A.M., the Administrator said he/she was aware the kitchen needed a deep cleaning and they had a hard time keeping staff hired for the kitchen. They will get it cleaned and start using a cleaning schedule log sheet so that the staff will know what they were expected to clean each day.

Based on interview and record review, the facility failed to ensure a comprehensive Minimum Data Set (MDS), a federally mandated assessment to be completed by the facility staff, had been completed in a timely manner, for two residents (Resident #209 and #210) out of 14 sampled residents and two residents (Resident #15 and #21) outside the sample. The facility's census was 56. The facility did not provide a MDS policy. 1. Review of Resident #15's medical record showed: - admitted on [DATE]; - A quarterly MDS, dated [DATE]; - An annual MDS, dated [DATE], 150 days late. Review of Resident #21's medical record showed: - admitted on [DATE]; - A quarterly MDS, dated [DATE]; - An annual MDS, dated [DATE], 156 days late. Review of Resident #209's medical record showed: - admitted on [DATE]; - No documentation of an admission MDS; - The facility failed to complete an admission MDS within 14 days of the resident's admission. Review of Resident #210's medical record showed: - admitted on [DATE]; - No documentation of an admission MDS; - The facility failed to complete an admission MDS within 14 days of the resident's admission. During an interview on 07/27/23 at 9:15 A.M., the MDS Coordinator said the admission MDS assessments should be completed within 14 days of admission. During an interview on 07/27/23 at 9:30 A.M., the MDS Coordinator said she had submitted the MDS's on time. During an interview on 07/27/23 at 1:00 P.M., the MDS Coordinator provided a MDS 3.0 Final Validation Report (a report documenting whether the MDS had been accepted or rejected by Centers for Medicare & Medicaid Services (CMS) showed the MDS's had been submitted on 07/27/23. She thought the MDS's had been uploaded in June 2023, however she had just completed the process and received the validation report at this time. During an interview on 07/27/23 at 1:30 P.M., the Administrator said MDS assessments should be completed within 14 days of admission. The facility did not have an MDS policy, they follow the Resident Assessment Instrument (RAI) manual. During an interview on 07/27/23 at 1:40 P.M.,the Administrator said the MDS Coordinator had informed her of the MDS's not being transmitted correctly. She would expect the MDS's to be done in a timely manner. 47447

Based on observation, interview, and record review, the facility failed to ensure the dignity of three residents (Resident #4, #37, #39) out of three sampled residents with a properly covered urinary catheter bag (a bag for collecting urine from a tube inserted in the bladder). The facility census was 56. Review of the facility's policy titled, Resident Rights, dated March 2017, showed: - The resident has the right to a dignified existence, self-determination, and communications with and access to persons and services inside and outside the facility; - The resident has a right to confidentiality, privacy and respect. 1. Review of Resident #4's medical record showed: - admitted [DATE]; - Diagnoses of congestive heart failure (a condition in which the heart doesn't pump blood adequately) and obstructive and reflux uropathy (when urine cannot drain through the urinary tract); - A physician order, dated 06/27/23, to perform catheter care every shift. Observations on 07/25/23 at 10:12 A.M., and 12:29 P.M., and on 07/26/23 at 9:32 A.M., showed the resident lay in bed with an uncovered and partially full urinary drainage collection bag that hung on the side of the bedframe that faced the open doorway. Review of Resident #37's medical record showed: - admitted [DATE]; - Diagnoses of hemiplegia (paralysis of one side of the body and hemiparesis (one-sided muscle weakness) following a cerebral infarction (stroke) affecting the right dominant side and neuromuscular dysfunction of the bladder (nerves and muscles of bladder don't work); - A physician order, dated 04/17/23, to provide Foley catheter (an indwelling catheter) care twice a day. Observations showed: - On 07/24/23 at 8:25 P.M., the resident lay in bed with an uncovered and partially full urinary drainage collection bag that hung on the side of the bedframe that faced the open doorway; - On 07/25/23 2:41 P.M., the resident lay in bed with the uncovered and partially full urinary drainage collection bag that hung on the opposite side of the bedframe visible from the open doorway; - On 07/26/23 3:20 P.M., the resident lay in bed with the uncovered and partially full urinary drainage collection bag that hung on the opposite side of the bedframe visible from the open doorway. Review of Resident #39's medical record showed: - admitted [DATE]; - Diagnoses of unspecified injury of urethra (a tube that conveys urine from bladder to outside the body), urinary retention and benign prostatic hyperplasia (enlarged prostate); -A physician order, dated 06/23/23, to perform catheter care every shift and to change catheter on Friday every 3 weeks. Observations showed: - On 07/24/23 at 7:57 P.M., the resident lay in bed with the catheter bag with amber-colored urine in the urinary drainage collection bag visible from the doorway and with the resident's roommate able to visualize the bag; - On 07/25/23 at 2:52 P.M., the resident lay in bed with the urinary drainage collection bag with dark yellow urine visible from the doorway; - On 07/26/23 at 3:00 P.M., the resident lay in bed with the uncovered and partially full urinary drainage collection bag that hung on the side of the bedframe that faced the open doorway; - On 07/27/23 at 9:52 A.M., the resident lay in bed with the uncovered and partially full urinary drainage collection bag that hung on the side of the bedframe that faced the open doorway with the resident's roommate able to visualize the bag. During an interview on 07/27/23 at 11:46 A.M., Licensed Practical Nurse (LPN) B said that a dignity bag should be used to cover a urinary drainage collection bag on a resident's wheelchair and on the bed at all times. During an interview on 07/27/23 at 11:47 A.M., Certified Nurse Aide (CNA) C said that a dignity bag should be used to cover a urinary drainage collection bag on a resident's wheelchair and on the bed. During an interview on 07/27/23 at 12:31 P.M., the Director of Nursing (DON) said that a catheter bag should be placed in a dignity bag when transferred into a wheelchair and when a resident was moved back to their bed, the catheter bag should be placed in the dignity bag on the bed.

Based on interview and record review, the facility failed to complete a quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by the facility staff, within the required timeframe for one resident (Resident #8) outside the 14 sampled residents. The facility's census was 56. The facility did not provide a MDS policy. 1. Review of Resident #8's medical record showed: - An admitted [DATE]; - A quarterly MDS, dated [DATE]; - The facility did not complete a quarterly MDS for the resident within 92 days of the last MDS. During an interview on 07/27/23 at 9:30 A.M., the MDS Coordinator said she had submitted the MDS on time. During an interview on 07/27/23 at 1:00 P.M., the MDS Coordinator provided a MDS 3.0 Final Validation Report (a report documenting whether the MDS had been accepted or rejected by Centers for Medicare & Medicaid Services (CMS) showed the MDS had been submitted on 07/27/23. She thought the MDS had been uploaded in June 2023, however she had just completed the process and received the validation report at this time. During an interview on 07/27/23 at 1:40 P.M., the Administrator said the MDS Coordinator had informed her of the MDS not being transmitted correctly and uploaded the MDS today. She would expect the MDS's to be done in a timely manner. The facility did not have an MDS policy, the facility follows the Resident Assessment Instrument (RAI) manual.

Based on interview and record review, the facility failed to issue the Skilled Nursing Facility Advanced Beneficiary Notices (SNFABN) when Medicare covered services had ended for two residents (Resident #11 and #44) out of three sampled residents. The facility census was 56. Review of the facility's policy titled, Form Instructions Skilled Nursing Facility Advanced Beneficiary Notice of Non-Coverage (SNFABN), not dated, showed: - Medicare requires SNF's to issue the SNFABN to Original Medicare, also called fee-for-service (FFS), beneficiaries prior to providing care that Medicare usually covers, but may not pay for in this instance because the care is: not medically reasonable and necessary; or considered custodial. The SNFABN provides information to the beneficiary so that he/she can decide whether or not to get the care that may not be paid for by Medicare and assume financial responsibility. 1. Review of Resident #11's Notice of Medicare Non-Coverage (NOMNC) showed: - The resident discharged from skilled services on 01/27/23, with skilled Medicare days remaining; - The resident remained in the facility; - The facility failed to provide a SNFABN to the resident. Review of Resident #44's NOMNC showed: - The resident discharged from skilled services on 12/20/22, with skilled Medicare days remaining; - The resident remained in the facility; - The facility failed to provide a SNFABN to the resident. During an interview on 07/27/23 at 9:30 A.M., the Bookkeeper said that he/she was new to his/her position and did not recall seeing the SNFABN form before. He/She did not know to provide the residents with that form. During an interview on 07/27/23 at 1:32 P.M., the Administrator said that she would expect a resident who was discharge from Medicare A, with remaining skilled Medicare days, to be given a SNFABN notice.