Every finding on record at Aberdeen Heights

Based on observation and interview, the facility failed to ensure staff followed their abuse and neglect policy when a resident (Resident #3) told a Certified Nursing Assistant (CNA) and a Registered Nurse (RN) a black fellow beat him/her up. Neither the CNA or the RN reported the resident's allegation to the facility Administrator and/or Director of Nursing (DON). Six residents were sampled. The census was 34.Review of the facility Prohibition of Any Form of Abuse policy, last revised on 8/7/25, showed:-Any report of potential abuse, neglect or misappropriation of resident property must be reported to the Executive Director (Administrator)/DON or health care administrator immediately;-Policy: Residents have the right to be free from verbal, sexual, and physical and mental abuse;-It is the responsibility of employees to promptly report to community management any occurrence of neglect or resident abuse from other residents, staff, family or visitors, including injuries of unknown source and theft or misappropriation of resident property;-Staff are mandated reporters and must comply with state and federal regulations regarding reporting a suspected occurrence of neglect or resident abuse;-All reports of resident verbal, sexual, physical and mental abuse are promptly and thoroughly investigated by community management;-Allegations of abuse, neglect will be thoroughly investigated and reported by community management personnel, and corrective action will be taken depending on the results of the investigation.Review of Resident #3's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff dated 4/14/25, showed:-Speech Clarity: Clear speech, distinct intelligible words;-Makes Self Understood: Usually understood;-Ability to Understand Others: Usually understands;-Moderately impaired cognition.Review of the resident's medical diagnoses, located in the electronic medical record (EMR), showed a diagnosis of severe dementia and senile degeneration of the brain.Review of the resident's care plan, located in the EMR and dated 4/28/25, showed:-Focus: Impaired cognitive function/dementia and impaired thought processes; -Goal: The resident will be able to communicate basic needs on a daily basis; -Interventions/Tasks: Ask yes/no questions in order to determine the resident's needs. Communicate with the resident/family/caregivers regarding residents' capabilities and needs;-Focus: Activities of daily living (eating, dressing, grooming, walking, etc.) deficit related to limited mobility; -Goal: Will maintain activities of daily living; -Interventions/Tasks: Dependent for bathing and bed mobility. Hoyer lift (a machine used to transfer residents unable to bear weight) for transfers with 2 people. Review of the resident's progress note, located in the EMR and dated 6/30/25 at 3:05 P.M., showed staff completed a Brief Interview for Mental Status (BIMS, a cognitive assessment) which showed the resident had severe cognitive impairment.Observation on 8/14/25 at 1:31 P.M., showed CNA A and RN B transferred the resident from the Broda chair (a reclining chair) to the bed using a Hoyer lift. After the resident was in bed, he/she looked at CNA A and said a young black fellow beat him/her up. RN B, who was standing on the opposite side of the resident's bed asked the resident How did that happen? You have a camera in your room. The resident did not respond to the question and RN B did not ask any more questions before leaving the room.During an interview on 8/15/25 at 10:54 A.M., RN B said he/she did not report the resident's allegation to the Administrator or DON because the resident was confused, and staff check on the resident frequently. He/She did not believe the allegation occurred. He/She had been in-serviced on the facility abuse and neglect policy and he/she should have reported the resident's allegation.During an interview on 8/15/25 at 11:48 A.M., Certified Medication Technician G said if a resident told him/her a resident or staff member beat them up he/she would report it right away to the charge nurse, DON or Administrator. He/She would report regardless of if the resident was confused or not.During an interview on 8/15/25 at 11:55 A.M. CNA F said if a resident, even a confused resident, told him/her a resident or staff member had beat them up, he/she would report the allegation immediately to the charge nurse or any supervisor available. During an interview on 8/15/25 at 10:00 A.M., both the Administrator and DON said neither CNA A nor RN B reported anything to them about what the resident told them yesterday. The facility did have black male employees. The RN and CNA should have reported the resident's allegation to them immediately and they would have begun an immediate investigation. They expected staff to follow the facility's policy.

Based on observation, interview and record review, the facility failed to provide reasonable accommodation of individual needs and preferences by failing to ensure call lights were in reach or a call light pendant was worn for one resident (Resident #31). The sample was 13. The census was 35. Review of the facility's Resident Call System policy, revised 5/3/19, showed: -Policy: The community strives to provide an environment to promote resident safety, dignity, and a sense of well-being; The community will be equipped and maintained to protect the health and safety of the residents; -Procedure: The community shall have a call button or pull cord located next to each bed and in each resident bathroom. Review of Resident #31's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 2/23/25, showed: -Cognitively intact; -Dependent on staff for toileting, bathing, upper and lower body dressing; -Required maximum assist from staff for personal hygiene; -Frequently incontinent or bowel and bladder. Review of the resident's medical record, showed his/her diagnoses included a history of falling, urinary tract infections, macular degeneration (an eye disease that may cause distortion of vision or vision loss), anxiety, benign brain neoplasm (a non-cancerous growth) and muscle weakness. Review of the resident's care plan, in use at the time of survey, showed: -Focus: The resident at risk of falls due to a history of falling and currently has a fear of falling; -Interventions: Make sure the resident's call light/pendant is within reach when leaving the resident alone. Observation and interview on 5/5/25 at 8:31 A.M., showed the resident lay in bed. The resident's call light in his/her room was attached to the wall and positioned on the floor under the resident's recliner. The resident did not have his/her call light pendant on. The resident said he/she received a shower recently and the staff did not reapply the resident's call light pendant. The resident said he/she could not reach the call light that lay on the floor because he/she cannot get out of bed by him/herself. Observation on 5/5/25 at 9:35 A.M., showed the resident lay in bed, eating breakfast. The resident's call light in his/her room was attached to the wall and positioned on the floor under the resident's recliner. The resident was not wearing his/her call light pendant. Observation and interview on 5/5/25 at 10:19 A.M., showed Certified Medication Technician (CMT) H entered the resident room and provided the resident with a nutritional shake. After the resident consumed the shake, CMT H left the resident's room. The resident's call light was attached to the wall and positioned on the floor under the resident's recliner. The resident was not wearing his/her call light pendant. Observation on 5/5/25 at 11:00 A.M., and at 12:07 P.M., showed the resident lay in bed. The resident's call light in his/her room was attached to the wall and positioned on the floor under the resident's recliner. The resident was not wearing his/her call light pendant. Observation on 5/5/25 at 12:37 P.M., showed the resident lay in bed and CMT I delivered the resident's lunch tray to the resident's room. CMT I assisted the resident with his/her lunch tray by opening packages and drink lids. CMT I left the resident's room after assisting the resident with his/her lunch tray. The resident's call light was attached to the wall and positioned on the floor under the resident's recliner. The resident was not wearing his/her call light pendant. Observation and interview on 5/5/25 at 2:40 P.M., showed the resident lay in bed. The resident said he/she had just received a bed bath. The resident's call light was attached to the wall and positioned on the floor under the resident's recliner. The resident was not wearing his/her call light pendant. Observation on 5/5/25 at approximately 5:00 P.M., showed the resident lay in bed. The resident's call light was attached to the wall and positioned on the floor under the resident's recliner. The resident was not wearing his/her call light pendant. During an interview on 5/7/25 at 8:30 A.M., Licensed Practical Nurse C said the residents should always wear the call light pendant. If the call light pendant is not available or the resident is unable to use it, the call light in the resident's room should be placed within the resident's reach. Staff should make sure the resident has their call light within reach or is wearing their call light pendant each time they leave the resident's room. During an interview on 5/7/25 at 8:35 A.M., Certified Nursing Assistant G said the residents should always wear the call light pendant or have the room call light positioned to wear the resident could reach it. Staff should make sure the resident has their call light or call light pendant each time they leave the resident's room. During an interview on 5/7/24 at 12:41 P.M., the Director of Nursing said she expected staff to ensure the residents are wearing their call light pendant or the call light in their room is within the resident's reach each time staff leave the resident's room. All staff members are responsible to ensure all the residents have their call light.

Based on observation, interview and record review, the facility failed to ensure residents who required activities of daily living (ADLs, bathing, dressing and toileting) assistance received necessary services to maintain adequate personal hygiene when staff left one resident soiled for an extended period (Resident #2). The sample size was 13. The census was 35. Review of the facility's Standards of Practice-Clinical Services policy, revised 2/3/25, showed: -Clinical Services policy and procedure preface: -The Clinical Services policies and procedures described in the manual should be used as guidelines for the nursing staff of the facility; Individual resident care decisions should be based on scientific principals in accordance with the skill an training of the caregiver; Additional clinical resources available from other sources or created in collaboration with the facility; -Philosophy: -Nursing is a process that includes assessment of the resident's state of being, determining a nursing diagnosis, planning and developing short and long-term goals; Implementing appropriate nursing interventions to assist the resident to reach their goals, and evaluation of the effectiveness of the nursing measures against established expected outcomes; The nursing interventions will promote positive functional consequences and outcomes for residents; -Residents have the right to nursing care based on this nursing assessment, and provided by the appropriate skill level, as predicted by acuity. -Nursing must work in an organized framework, providing an organized approach to practice that is responsive to the needs of residents, families, community, system and employees; -Purpose: Diagnose and treat responses to actual and potential adverse outcomes; -Goal: Promote each resident at his her maximum level of health functions; Health implies attaining, maintaining, restoring balance, living with chronic illness or disability; -Objective to meet goal: -Provide nursing care to residents on a continuum in a safe therapeutic environment; -Utilize a holistic (physician, emotional, spiritual, environmental, rehabilitative, preventative approach) to nursing practice. Review of Resident #2's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 4/4/25, showed: -Moderate cognitive impairment; -No rejection of care; -Required maximum assist from the staff for toilet hygiene and toilet transfers; -The resident is frequently incontinent; -Diagnoses included dementia, kidney disease and depression. Review of the resident's medical record, showed his/her diagnosis also included a history of urinary tract infections (UTI). Review of the resident's care plan, in use at the time of survey showed: -Focus: The resident has impaired physical function related to dementia and recent hospitalization ; -Interventions: The resident requires assistance for toilet hygiene; The resident wears incontinent products for minimal bladder incontinence and needs assistance changing them. During observation and interview on 5/5/25 at 9:15 A.M., the resident said he/she requires assistance from the staff to use the bathroom. He/She wears incontinent briefs in case he/she has an accident. Posted above the resident's bed in his/her room was a sign, undated, that showed: Toileting Program Recommendations: Assist the resident to the bathroom and change his/her brief as per the following: Before or after getting up in the A.M.; Before or after breakfast; Before or after lunch; Before or after dinner; Before and after going to bed for the evening; Please contact the therapy department with questions. During observation and interview on 5/5/25 at 10:27 A.M., the resident was in his/her room, in his/her wheelchair and said he/she has not been assisted to the bathroom since before breakfast. The resident said he/she is unable to propel him/herself to the bathroom. During an interview on 5/5/25 at 2:52 P.M., the resident was in his/her room, in his/her wheelchair, and said he/she was soiled and needed to use the bathroom. He/She said he/she has not gone into the bathroom since before breakfast. During observation and interview on 5/5/25 at 4:47 P.M., Certified Nursing Assistant (CNA) A propelled the resident in his/her wheelchair to the bathroom. CNA A assisted the resident with standing up, by pulling on the resident's waistband and without the use of a gait belt. CNA A instructed the resident to hold onto the grab bars located near the toilet. When the resident stood up, the resident's wheelchair cushion appeared very wet with a small puddle of liquid in the center that had an odor of urine. The resident's pants had a large area of wetness that covered the resident's buttocks and the back of his/her thighs. While the resident stood, CNA A pulled the resident's pants down and removed the resident's brief. The brief was entirely saturated with urine and liquid brown stool. Dried brown stool was located on the resident's upper buttocks and lower back. CNA A said, This is not a good look. CNA A used multiple incontinence wipes and applied pressure while removing the dried stool from the resident's skin. During an interview on 5/5/25 at 4:55 P.M., CNA A said he/she was not aware the last time the resident was taken to the bathroom or checked for incontinence and said he/she was relieved that the resident did not have any open wounds to his/her bottom. The facility has been using some agency nursing staff and CNA A didn't think the agency staff know the protocol on how often to check on the residents. All residents are to be checked for incontinence and/or encouraged to use the bathroom every two hours. During an interview on 5/7/25 at 8:30 A.M., Licensed Practical Nurse C said staff should check all residents, ask residents if they need anything or require assistance with care every two hours. During an interview on 5/7/25 at 12:51 P.M., the Director of Nursing (DON) said she expected staff to check on all residents to determine their care needs every two hours and as needed. The DON was not aware of the Toilet Recommendations sign in the resident's room but expected staff to follow the recommendations.

Based on observation, interview, and record review, the facility failed to ensure physician orders for oxygen usage were revised and current, which resulted in contradictory orders, with staff documenting both as completed for one resident(Resident #30). The facility also listed outdated information in the resident's care plan regarding the oxygen settings. The sample was 13. The census was 35. Review of the facility's oxygen therapy policy, dated 2/3/25, showed: -Policy: Oxygen is treated as a medication ordered by the physician. The order includes the amount per minute to be delivered, the device used for delivery, and during what times to deliver oxygen therapy; -Procedure: These delivery devices will be maintained in a sanitary manner. Change disposable prefilled humidifier bottle every 30 days. Non-disposable refillable humidifier bottles are changed every seven days. Change tubing once a week or when soiled. Label with resident name, date, time, staff initial tubing when changed. Document on the treatment administration record (TAR). When device is not in use, store in plastic or other bag to keep tubing and device off floor. Label bag with resident name, date, time, and staff initial. 1. Review of Resident #30's significant change Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 3/18/25, showed: -Cognitively intact; -Diagnoses included acute respiratory failure, muscle weakness, and congestive heart failure. Review of the resident's care plan, in use at the time of the survey, showed: -Focus: Resident uses oxygen therapy; -Goal: Resident will have no symptoms of poor oxygen absorption or signs of dehydration through the review date; -Interventions: Give medications as ordered by physician. Monitor/document side effects and effectiveness. Monitor for symptoms of respiratory distress and report to medical director (MD). Oxygen setting for oxygen via nasal canula at 2 Liters (L) continuously. Promote lung expansion and improve air exchange by positioning with proper body alignment. If tolerated, head of bed elevated to 30 degrees. Provide reassurance and allay anxiety: have an agreed-on method for the resident to call for assistance (e.g., call light, bell). Stay with the resident during episodes of respiratory distress. Review of the resident's physician's orders, dated 5/25, showed: -An order, dated 4/11/25, to titrate oxygen to keep saturations above 92 percent; -An order, dated 3/17/25, continuous oxygen at 2 L via nasal canula. Review of the resident's May 2025 TAR, showed: -On 5/1/25, 5/2/25, 5/3/25, 5/4/25, 5/5/25, 5/6/25, and 5/7/25, staff signed off that the resident received continuous oxygen via nasal canula at 2 L during the day shift. On 5/1/25, 5/2/25, 5/3/25, 5/4/25 and 5/5/25 staff signed off that the resident received continuous oxygen via nasal canula at 2 L during the evening shift. On 5/3/25 and 5/4/25 staff signed off that the resident received continuous oxygen via nasal canula at 2 L during the night shift; -On 5/1/25, 5/2/25, 5/3/25, 5/4/25, 5/5/25, 5/6/25, and 5/7/25, staff signed off that the resident's supplemental oxygen rate was titrated to keep the resident's oxygen saturations above 92 percent on day, evening, and night shifts. Observations on 5/5/25 at 10:18 A.M. and 2:56 P.M., showed the resident in his/her room in his/her chair. The resident's concentrator oxygen rate was set to 1 L. Observation on 5/6/25 at 6:34 A.M., showed the resident awake in his/her bed. The resident's concentrator oxygen rate was set to 1 L. Observation on 5/6/25 at 12:28 P.M., showed the resident in the dining room eating lunch. The resident was not using supplemental oxygen. Observation on 5/6/25 at 10:34 A.M., showed the resident in his/her room in his/her chair. The resident was not using supplemental oxygen. During an interview on 5/7/25 at 8:01 A.M., Licensed Practical Nurse (LPN) B said staff should follow the physician's orders for oxygen usage and rates. If a physician order is changed, the old order should be removed from the medication administration record (MAR). He/She said the resident does not require continuous oxygen and that the original order should have been removed. During an interview on 5/7/25 at 8:37 A.M., the Director of Nursing (DON) said she would expect staff to follow physician's orders for oxygen rates. If a physician order is changed, the old order should be removed from the MAR. Staff should be documenting on the current order and ensure they are only documenting treatments that have been done. During an interview on 5/7/25 at 1:04 P.M., the Administrator said he would expect staff to follow physician's orders for oxygen rates. If a physician order is changed, the old order should be removed from the MAR. Staff should be documenting on the current order and not the old order.

Based on observation, interview and record review, the facility failed to follow acceptable infection control standards by not implementing Enhanced Barrier Precautions (EBP, an infection control intervention designed to reduce the transmission of multidrug-resistant organisms (MDROs) that employs targeted gown and glove use during high contact resident care activities) as recommended by the Centers for Disease Control and Prevention (CDC) and required by the Centers for Medicare and Medicaid Services (CMS) for residents with wounds requiring treatments and the facility failed to ensure staff used good infection control practices for one resident when providing perineum care (peri-care, cleansing of the genitals and anal area) (Resident #4). The sample was 13. The census was 35. Review of the facility's EBP policy, revised 1/9/24, showed: -EBP, refer to an infection control intervention designed to reduce transmission or MDRO that employs targeted gown and glove use during high contact resident care activities; -EBP are used in conjunction with standard precautions and expand the use of personal protective equipment (PPE) of applying of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs to staff hands and clothing; -EBP are indicated for residents with any of the following: -Infections or colonization with a CDC- targeted MDRO with contact precautions do not otherwise apply; -Wounds and/or indwelling medical devices even if the resident is not known to be infected or colonized (presence of bacteria in the body that is not causing symptoms) with MDRO; -Wounds generally include chronic (long term) wounds such as a pressure ulcer (a wound that develops with prolonged pressure), unhealed surgical wounds, diabetic foot ulcers and venous stasis ulcers (a wound on the legs that develops from damaged veins); -Wound care: Any skin opening requiring a dressing; -Use of EBP include gown and gloves; -Examples of high contact resident care activities requiring gown and glove use for EBP include: dressing, bathing or showering, transferring providing hygiene, changing lines, changing briefs or toileting, and wound care that requires a dressing. Review of the facility's Standards of Practice-Clinical Services policy, revised 2/3/25, showed: -Clinical Services policy and procedure preface: -The Clinical Services policies and procedures described in the manual should be used as guidelines for the nursing staff of the facility: Individual resident care decisions should be based on scientific principals in accordance with the skill and training of the caregiver; Additional clinical resources available from other sources or created in collaboration with the facility include, Mosby's Textbook for Long Term Care Assistants; -Philosophy: -Nursing is a process that includes assessment of the resident's state of being, determining a nursing diagnosis, planning and developing short and long-term goals; Implementing appropriate nursing interventions to assist the resident to reach theirs goals, and evaluation the effectiveness of the nursing measures against established expected outcomes; The nursing interventions will promote positive functional consequences and outcomes for residents; -Residents have the right to nursing care based on this nursing assessment, and provided by the appropriate skill level, as predicted by acuity; -Nursing must work in an organized framework, providing an organized approach to practice that is responsive to the needs of residents, families, community, system and employees; -Purpose: diagnose and treat responses to actual and potential adverse outcomes; -Goal: Promote each resident at his or her maximum level of health functions; Health implies attaining, maintaining, restoring balance, living with chronic illness or disability; -Objective to meet goal: -Provide nursing care to residents on a continuum in a safe therapeutic environment; -Utilize a holistic (physician, emotional, spiritual, environmental, rehabilitative, preventative approach) to nursing practice. Review of Mosby's Textbook for Long Term Care Assistants, Chapter: Perineal Care, undated, showed: -Peri-care involves cleaning the genital and anal area; These areas provide a warm, moist, and dark places for microbes (organisms of microscopic size); Cleaning prevents infections and odor and promotes comfort; Work from front to back or top to bottom; The urethral area (a tube in the body that carries urine to the outside of the body) or front area is the cleanest; The anal area (back or bottom) is the dirtiest; Therefore, clean from the urethra to the anal area; This prevents spreading bacteria from the anal area to the vagina and urinary system. Review of Resident #4's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 3/8/25, showed: -The resident has severe cognitive impairment; -Diagnoses included stroke, hemiplegia (weakness to one side of the body) and dementia; -Dependent on staff for toileting and personal hygiene; -Always incontinent of bowel and bladder; -The resident has one Stage 4 pressure ulcer (loss of skin and tissue, exposed bones, cartilage or tendon). Review of the resident's care plan, in use at the time of survey, showed: -Focus: The resident is on EBP for a chronic wound to his/her buttocks; -Interventions: The EBP guidelines are hanging in the resident's bathroom closet along with PPE needed; -Focus: The resident is at risk for all falls and requires a Hoyer lift (a specialized lift to transfer residents); -Intervention: Use lift for all transfers; -Focus: The resident has impaired physical function related to hemiplegia; -Interventions: Bathing and hygiene with max assist of one. Review of the resident's medical record, showed his/her diagnoses also included a history of urinary tract infections (UTI). Review of a list of residents who required EBP, showed the resident listed. Review of the resident's Physician Order Sheet (POS), showed an order, dated 3/19/25, EBP for wound. Observation and interview on 5/5/25 at 10:48 A.M., showed a small white sign at the top right side of the resident's door which read EBP. The resident's bathroom had a sign on the outside of the closet door indicating the resident required EBP. The resident was in his/her room sitting in his/her wheelchair. Certified Nursing Assistant (CNA) D and Certified Medication Technician (CMT) E wore gloves and attached the resident to the Hoyer (mechanical lift) lift pad. The resident was transferred with the use of the Hoyer lift by CNA D and CMT E into the resident's bed. The resident's pants were removed by CNA D and the resident's brief was soiled with urine. The resident turned side to side with the assistance of CNA D and CMT E to remove the Hoyer pad underneath the resident. The resident's knees and arms touched CNA D's and CMT E's uniform tops. The resident was positioned on his/her back. CNA D rolled the front part of the soiled brief between the resident's legs. The resident was then turned to his/her left side and the soiled brief was pulled through the resident's legs towards his/her backside. A dressing, dated 5/5/25, was located on the resident's right buttock. CNA D cleaned the resident's anal area with wet wipes. A clean brief was not applied. CNA D said it was so the resident could air out. With the same gloved hands, CNA D positioned the resident on his/her back, applied an offloading wedge under the resident and pulled the sheet and blanket over the resident. Peri-care was not provided to the resident's genitals. CNA D did not change gloves or perform hand hygiene after cleansing the resident's anal area. CNA D and CMT E did not wear an isolation gown during direct care of the resident. Observation on 5/5/25 at 2:55 P.M., showed Assistant Director of Nursing (ADON) and CNA F entered the resident's room and applied gloves and an isolation gown. The ADON and CNA F placed the resident into bed by using the Hoyer lift. The resident's pants were removed by the ADON and CNA F. The resident's brief was soiled with urine. The ADON and CNA F assisted the resident by turning him/her side to side to remove the Hoyer pad underneath the resident. A dressing, dated 5/5/25, was located on the resident's right buttock. The resident was turned to his/her back. The ADON rolled the front part of the resident's soiled brief between the resident's legs. The ADON and CNA F turned the resident to his/her left side. The ADON removed the soiled brief by pulling the brief through the resident's legs towards his/her backside. The ADON cleansed the resident's anal area with wet wipes. The ADON removed his/her gloves, removed the isolation gown, performed hand hygiene and applied clean gloves and a clean isolation gown. The ADON and CNA F applied a clean brief to the resident. Peri-care was not provided to the resident's genitals. During an interview on 5/7/25 at 8:30 A.M., Licensed Practical Nurse (LPN) C said the resident requires EBP during direct care due to the resident having a chronic wound. The staff should wear gloves and isolation gowns for residents who require EBP. When a resident is incontinent, the staff should clean the resident's genital area and the resident's bottom and buttocks. Staff should change gloves and perform hand hygiene after providing peri-care to the resident. Staff should not touch the resident or any items in the room with soiled gloves. During an interview on 5/7/25 at approximately 8:35 A.M., CNA G said he/she did not know what EBPs were. Staff should clean the resident's genitals and bottom area when the residents are incontinent. Rolling the brief between the resident's legs with a soiled brief does not count for cleaning the resident's genitals. Gloves need to be changed when going from a dirty area of the resident to a clean area of the resident. Staff should not touch the resident or items in the room with soiled gloves. During an interview on 5/7/25 at 12:51 P.M., the Director of Nursing said she expected staff to use EBP on residents who require the precautions. She expected staff to complete peri-care in its entirety by cleaning the resident's genitals. She expected staff to change gloves and perform hand hygiene after peri-care is completed.

Based on observation, interview and record review, the facility failed to follow their policies by failing to ensure glucometers (a machine that obtains a resident's blood glucose level by placing a drop of blood onto a strip inserted into the glucometer) were cleaned and disinfected with an approved germicidal agent. In addition, staff failed to ensure a barrier (such as a clean paper towel) was placed between the glucometer and any surface on which it was placed. The facility identified four residents who required blood glucose monitoring, two were observed and infection control problems were identified with both (Resident #31 and #30) The census was 34. Review of the facility's Preventing Reuse of Devices Used for Blood Glucose Monitoring policy, dated 11/2017, included the following: -Issue: Glucometers designed for use by a single resident should never be used for more than one resident. Many health care providers are under the mistaken belief that changing the lancet needle (used to [NAME] the fingertip to obtain a drop of blood) or cleaning the fingerstick device between uses prevents cross-contamination; it does not. Also, wiping a glucometer with alcohol after use is not adequate to prevent cross-contamination. If a glucometer is approved by the manufacturer for reuse and is to be used on multiple residents, it must be cleaned and disinfected after each use, per the manufacturer's instructions; -The Centers for Disease Control and Prevention (CDC), the Centers for Medicare and Medicaid Services (CMS), and the U.S. Food and Drug Administration (FDA) prohibit the reuse of lancets, fingerstick devices, and manufacturer-stated single-resident-use blood glucose meters on multiple residents due to the risk of transmitting bloodborne pathogens, including hepatitis B (an infectious disease caused by a virus that affects the liver), hepatitis C (an infectious disease caused by a virus that affects the liver), and HIV (a virus that attacks the immune system); -Safety Actions to Consider: -Ensure that glucometers and other waived testing devices used for multiple residents are approved for such use by the manufacturer, and that they are cleaned and disinfected after each test using a method that is consistent with the manufacturer's instructions; -Conduct staff orientation, training and competency assessment on waived testing equipment and processes; -Educate staff about why they are never to use lancets, fingerstick devices and glucometers (based on manufacturer instructions for use) on multiple residents; -Provide staff with appropriate products and supplies for cleaning and disinfecting blood glucose monitoring equipment, as stated in the manufacturer instructions for use. Review of the facility's Blood Glucose Monitoring policy, last revised on 10/11/21, included the following: -Policy: Laboratory services will be provided or obtained to meet the needs of residents. Labratories providing such services must meet specified federal requirements; -Procedure: Use of a Glucometer: Preventative maintenance is performed as recommended by manufacturer. Wipe machine down with wipes that meet OSHA (Home Occupational Safety and Health Administration)for blood borne pathogens per infection control manual procedure after each use if machine is used for multiple residents. 1. Review of Resident #31's significant change in status Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 11/21/23, showed diagnoses of diabetes mellitus (DM, high blood sugar), dementia and anxiety. Review of the resident's Physician Orders Sheet (POS), dated 12/2023, showed an order dated 11/14/23 for blood sugar (glucose) monitoring once daily. Observation on 12/5/23 at 7:18 A.M., showed Nurse A removed a glucometer from the medication cart. He/She laid it on top of the medication cart with no barrier between the glucometer and the top of the cart. He/She gathered supplies that included gloves, a finger stick device and an alcohol pad and entered the resident's room where the resident sat in a recliner. Prior to obtaining a drop of blood from the resident's fingertip, the nurse laid the glucometer on the armrest of the recliner with no barrier between the glucometer and the armrest. After obtaining the blood glucose reading, the nurse returned to the medication cart and laid the glucometer on top of the medication with no barrier between the glucometer and the top of the cart. The nurse used an alcohol wipe, cleaned the glucometer, then placed the glucometer back into the medication cart drawer. 2. Review of Resident #30's quarterly MDS, dated [DATE], showed diagnoses of diabetes mellitus, Alzheimer's Disease and dementia. Review of the resident's POS, dated 12/2023, showed an order, dated 7/13/23, for blood sugar monitoring three times a day. Observation on 12/5/23 at 7:22 A.M., showed Nurse A removed a glucometer from the medication cart and laid it on top of the medication cart without a barrier. He/She gathered his/her supplies and entered the resident's room where the resident sat in a wheelchair wearing long pants. The nurse laid the glucometer on the resident's right knee with no barrier between the resident's pants and the glucometer. Nurse A then moved the glucometer from the resident's knee to on top of a tissue box that sat on top of the resident's nightstand, without a barrier. After obtaining a drop of blood from the resident's fingertip, Nurse A returned to the medication cart and laid the glucometer on top of the medication cart with no barrier between the glucometer and the top of the medication cart. He/She used an alcohol pad to clean the glucometer and placed it back into the drawer. During an interview on 12/5/23 at 7:51 A.M., Nurse A said he/she had been using alcohol pads to clean the glucometers for quite some time. He/She did not know what the facility's policy was for cleaning glucometers or if a barrier should be placed between the glucometer and a surface. He/She removed three glucometers from the medication cart and said they are not assigned to any specific resident and are shared glucometers. The nurse opened all the drawers on the medication cart and there were no disinfectant products noted to specifically clean glucometers. 3. During an interview on 12/5/23 at 8:00 A.M., Nurse E, who worked on a different hall, opened the medication cart and said the facility just brought a container of Sani-Cloths (germicidal) disinfectant wipes a few minutes ago and placed them on the medication cart. He/She worked this past Sunday and there were no Sani-Cloths to use that day. He/She used alcohol wipes to clean the glucometers. He/She knew alcohol wipes were not approved to clean the glucometers. He/She did not tell anyone about not having the Sani-Cloths for use on Sunday. Observation of the Sani-Cloth container showed: Sani-Cloth, germicidal disposable wipe. Bactericidal, Tuberculocidal, and Virucidal in 2 minutes. Effective against: Bacteria, Multi-Drug Resistant Bacteria, Viruses, and Bloodborne Pathogens, including Hepatitis B, Hepatitis C and HIV. 4. During an interview on 12/5/23 at 9:01 A.M., the Director of Nurses (DON) said she was not sure about what the facility had approved for disinfecting glucometers. She would consult the policy. At 9:16 A.M., the DON said the policy showed glucometers should be cleaned with a disinfectant that meets OSHA requirements for bloodborne pathogens if a machine is used for multiple residents. The Assistant Director of Nurses (ADON) said each resident should have their own glucometer in a container in their room. She did not know that wasn't being done. 5. During an interview on 12/7/23 at 8:48 A.M., the ADON said only one of the four residents had a glucometer in their room for their own personal use. The other three glucometers were on the medication cart instead of in the residents' rooms. They should not have been shared between residents. 6. During an interview on 12/7/23 at 8:48 A.M., the Regional Nurse said their preference to disinfect a glucometer was the Sani-Cloth. Their policy was for staff to use a barrier between the glucometer and surfaces.

Based on observation, interview and record review, the facility failed to ensure a medication error rate of less than 5%. Out of 28 opportunities observed, two errors occurred resulting in a 7.14% error rate (Resident #9). The census was 34. Review of the facility's Medication Administration policy, revised on 3/15/22, included the following: -Policy: Medications are administered as prescribed in accordance with the good nursing principles and practices and only by persons legally authorized to do so; -It is the responsibility of the nursing professional to be aware of the clinical rationale for the medication, classification, action, correct dosage and side effects of medication before administration and to monitor to determine if there is progress toward goals and/or emergencies of adverse consequences; -A primary care provider order that includes dosage, route, frequency, duration and other required considerations is required for administration of medication; -Procedure: -Prior to administration, the medication and dosage schedule on the electronic Medication Administration Record (EMAR) is compared with the medication label; -Read label 3 times: When removing from drawer, before pouring, and after pouring. Document on the EMAR after medication is poured; -If there is a discrepancy between the EMAR and the label, check the physician order sheet before administering medication; -Prepare or pour each dose of medication using an appropriate measuring device. Read and follow any special instructions written on labels. Review of Resident #9's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 11/15/23, showed diagnoses of dementia, anxiety and depression. Observation on 12/6/23 at 7:49 A.M., showed Certified Medication Technician (CMT) F stood at the medication cart outside the resident's room and prepared the resident's morning medications with the surveyor observing. The tablets and pills were packaged in a medication strip which showed the name of each medication, the dosage of each medication, and the quantity of each medication. After checking each medication in the strip against the orders on the EMAR, the CMT removed the medications from the medication strip, placed them in the medication administration cup, then handed the medication strip to the surveyor who recorded each medication which included: 1 tablet of duloxetine DR (an antidepressant) 20 milligrams (mg), and 1 tablet of Certivite (a multivitamin with minerals). The CMT gave the resident the medications who took all the medications with a glass of water. Review of the resident's record on 12/6/23 at 11:15 A.M., showed the resident's medications were reconciled with the physician's order sheet which showed no current order for the duloxetine DR and Certivite. During an interview on 12/7/23 at 8:48 A.M., the Director of Nurses (DON) said the medication administration policy was current and she expected staff to follow the policy. She expected the CMT to have held the duloxetine DR and Certivite and consulted with a nurse as to why the medications were not listed on the EMAR. After reviewing the resident's orders, it was determined the duloxetine DR had been discontinued on 10/12/23, and the Certivite had been discontinued on 6/8/23. The facility notified the pharmacy when the medications were discontinued, but the pharmacy did not remove the medications from the medication strips, delivered weekly to the facility. The resident received the medications since they were discontinued. The DON expected a nurse or CMT to have noticed the discontinued medications prior and contacted the pharmacy to have the medications removed from the medication strips. During an interview on 12/7/23 at 10:19 A.M., CMT F said he/she spoke to the DON about the duloxetine DR and the Certivite. After checking the medications on the medication strip, he/she knew those medications were not on the EMAR, but gave them anyway. He/She should have questioned why they were in the medication strip, but not on the EMAR prior to administering them. He/She really had no excuse not to do that.

Based on observation, interview and record review, facility staff failed to follow the facility's Injectable Medication/Storage and Stability policy by failing to record the dates insulin pens had been opened so they could be discarded if necessary if not completely used by the discard dates. Four residents had been identified by the facility as having orders for insulin, and problems were identified with all four (Residents #15, #21, #30 and #31). In addition, staff failed to consistently check/document the temperature of the medication refrigerator in the medication room. The census was 34. Review of the facility's Medications: Vials and Ampules (small sealed vial) of Injectable Meds policy, last revised on 10/8/21, included the following: -Policy: Vials and ampules of injectable medications are used in accordance with the manufacturer's recommendations or the provider pharmacy's directions for storage, use and disposal; -Procedure: -The date opened is recorded on multidose vials (on the vial label or an accessory label affixed for that purpose); -Refer to insulin storage and stability information chart for storage information; -Review of the Insulin Storage and Stability Information Chart, included the following for insulin pens/cartridges: -Novolog (fast acting insulin): Stored at room temperature, unopened or opened, 28 days; -Humalog (fast acting insulin, generic name lispro): Stored at room temperature, unopened or opened, 28 days; -Lantus (long lasting insulin, generic name glargine): Stored at room temperature, unopened or opened, 28 days. 1. Review of Resident #15's electronic health record (EHR), showed: -Diagnosis of diabetes mellitus (DM, high blood glucose/sugar); -Physician's Order Sheet (POS), showed: -An order dated 11/4/22, for Novolog flexpen (a pen type device used to inject the insulin) to be administered per sliding scale (the amount administered is determined by the blood glucose level) before meals; -An order dated 10/28/22, for insulin gargline, 30 units (u) every morning. Review of Resident #21's EHR, showed: -Diagnosis of DM; -POS, showed: An order dated 10/30/23, for Humalog Kwikpen before meals per sliding scale. Review of Resident #30's EHR, showed: -Diagnosis of DM; -POS, showed: -An order dated 7/13/23, for Humalog Kwikpen to be administered per sliding scale; -An order dated 7/14/23, for Lantus 10 u every morning. Review of Resident #31's EHR, showed: -Diagnosis of DM; -POS, showed: An order dated 10/30/23, for Lantus 25 u once daily. Observation with the Assistant Director of Nurses (ADON) on 12/4/23 at 2:00 P.M., showed two of the three nurse medication carts contained insulin pens. Observation of the insulin pens, showed: -Resident #15 had one opened Lantus pen that had been dated, and one opened and undated Novolog flexpen; -Resident #21 had two opened and undated lispro pens and one opened and undated glargine pen; -Resident #30 had one opened and undated Lantus pen, and one opened and dated Humalog Kwikpen; -Resident #31 had two opened Lantus pens, one was dated and one was undated; -Of the 9 insulin pens observed, three were opened and dated, and six were opened and undated. During an interview on 12/4/23 at 2:25 P.M., the ADON said staff were to write the date the pen was first used on a label on the pen. The standard time a pen could be used after opening was 28 to 30 days. If the pen had not been used in its entirety by 28 to 30 days, the pen was to be discarded. If staff did not record the date of opening, they would not be able to determine the date the pen should be discarded. During an interview on 12/7/23 at 8:48 A.M., the DON said insulin pens should be dated when opened. Staff were to write the date of first use on the insulin pen. Insulin should be discarded between 28 to 30 days after opening. 2. Review of the instructions printed on the Refrigerator Temperature log in the medication room, on 12/4/23 at 1:48 P.M., showed: -Instructions for staff to check the temperatures in both the freezer and the refrigerator compartments twice each working day. Place an X in the box that corresponded with the temperature, the time of the temperature reading and staff initials; -Review of the temperature logs showed: -October: The temperature was checked 24 of 62 times; -November: The temperature was checked 22 of 60 times; -December: The temperature was checked 2 of 7 times; -Observation of the refrigerator showed a functioning thermometer and multiple resident medications. During an interview on 12/4/23 at 1:55 P.M., the ADON said the nurses were responsible to check the refrigerator's temperature twice a day and record it on the temperature log. She was not aware the nurses had not been checking the temperatures. 3. During an interview on 12/7/23 at 8:48 A.M., the DON said the skilled nursing facility had one medication room with a refrigerator for medications. She expected staff to monitor the refrigerator temperature twice a day per the instructions on the temperature log.

Based on interview and record review, the facility failed to ensure one resident (Resident #1) received care in a safe environment when a staff member used a Hoyer lift (full body lift) to transfer the resident by him/herself and did not properly position the resident into his/her tilt wheelchair (a tilting wheelchair has a seat frame that tilts backward in varying degrees), which caused the resident to fall out of the chair. This resulted in the resident sustaining a fractured leg. The sample size was three. The census was 36. Review of the Lifting and Transferring Residents policy, dated 10/11/21, showed the following: -The facility will provide a safe work environment for resident care areas by providing and requiring the use of safety materials, equipment and training designed to prevent injury; -Healthcare professionals will practice safe lifting, transporting and proper back care; -Staff is responsible for utilizing proper body mechanics, lifting techniques and resident safety. Failure to utilize a mechanical resident lift when the use of this equipment is indicated in the resident's care plan may result in disciplinary action up to and including termination of employment; -All residents must be lifted or transferred according to the determined procedure; -The appropriate procedure for each resident appears in the resident care plan; -Residents who require assistance in transferring are transferred using a gait/transfer belt or with a lift; -All lifts performed with a mechanical lift must be performed with two staff members present; -Approved techniques for lifting, transfer and body mechanics are discussed and demonstrated during each orientation program for nursing personnel; -Procedure: 1. The Director of Nursing or designee will educate the staff in utilizing proper body mechanics and lifting techniques. Appropriate lifting and safety equipment will be available for the staff and they will be educated on the use; 2. Staff will utilize the proper transfer procedure for each resident. This includes the use of the resident transfer devices or other lifting equipment and applying body mechanics. Review of Resident #1's face sheet, showed the following: -admitted [DATE]; -Diagnoses included [CONDITION(S)] (paralysis of one side of the body, usually resulting from a stroke or other [CONDITION(S)]) following unspecified [CONDITION(S)] disease (a group of conditions that affect blood flow and the blood vessels in the brain) affecting the left dominant side, dementia and abnormal posture. Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 11/24/21, showed the following: -Severely impaired cognitive status; -Sometimes understands others; -Extensive assistance of one person required for bed mobility; -Total dependence: One person assistance required for dressing and personal hygiene; -Total dependence: Two person assistance required for transfers and toilet use; -Mobility-Substantial/maximal assistance needed to roll left and right; -Chair/bed to chair transfer: Dependent; helper does all the effort. Resident does none of the effort to complete the activity. Review of the resident's care plan, dated 9/9/21, showed the following: -Strength/Weakness: Activities of daily living (ADL) Function/Rehabilitation potential; -Approach: Use a Hoyer lift for transfers with two person assist; -Strength/Weakness: Falls; weakness and need for assist with all transfers; balance issues; -Approach: Use lift for transfers; Resident will tell you he/she can transfer without the lift at times. Do not take his/her word for it. He/she uses the Hoyer lift with two person assist for all transfers. Review of the resident's physician's orders, dated 1/19/21, showed the following: -Mobility status: Use lift with two persons for all transfers; -Manual wheelchair with tilt for abnormal posture. Review of the resident's progress notes, showed the following: -On 1/18/22 at 9:12 A.M., the nurse was called to the resident's room at 6:15 A.M., by the certified nurses' assistant (CNA). The resident was supine (face upward) on the floor in front of his/her wheelchair. The CNA stated the resident had tipped forward after being placed in the wheelchair. Staff assessed the resident for injuries and none were noted. He/she was able to move all of his/her extremities. The CNA stated he/she witnessed the resident tip forward from the wheelchair but did not hit his/her head. The CNA wrote a statement to verify. Vitals were stable. Staff called the resident's physician and spoke with an on-call answering service to relay the message with a call back number. Staff notified the resident's responsible party. The oncoming nurse was aware, as well as the nursing supervisor. Staff would continue to closely monitor. At 2:30 P.M., the resident had no complaints of pain. At 9:14 P.M., the resident had no complaints of pain; -On 1/19/22 at 6:37 A.M., the resident did not complain of pain when asked. In the early morning, when the CNA provided care, the resident complained of pain when moving/touching his/her left thigh/knee. The knee was slightly swollen and hard to the touch. At 6:47 A.M., staff placed a call to the resident's physician's exchange. At 6:51 A.M., the physician returned the call and ordered an x-ray on the left knee and thigh. At 7:23 A.M., staff contacted the company for the x-ray. Review of the resident's x-ray dated 1/19/22, showed there was an acute comminuted fracture (a comminuted fracture is a break or splinter of the bone into more than two fragments) of the left distal diaphysis femur (the distal femur is the area of the leg just above the knee joint). Further review of the resident's progress notes, showed: -On 1/19/22 at 11:41 A.M., the resident had pain and swelling to his/her lower left extremity. The resident had an x-ray of the left thigh and knee and it showed an acute fracture of the left femur. Staff reported the fracture to the nurse practitioner who gave orders for the resident to be sent to the hospital; -On 1/20/22 at 1:18 P.M., post investigation noted fall after improper supervision of positioning. Review of the nursing supervisor/assistant Director of Nursing's (ADON) written investigation, dated 1/19/22, showed on 1/18/22 in the morning, Registered Nurse (RN) D reported the resident had been assisted up, and CNA I came to him/her because the resident slid out of his/her wheelchair. RN D stated the CNA had already gone home but was giving a written statement. He/she reported the resident did not hit his/her head and had no apparent injuries. On 1/19/22, the resident's left leg looked swollen and he/she complained of some discomfort. The physician was notified and ordered an x-ray. The x-ray showed a fracture. The resident was sent to the hospital for evaluation and treatment. The resident had no complaints of discomfort that morning or evening but complained during the night. Upon investigation, the nursing supervisor found CNA I transferred the resident by him/herself with the Hoyer lift and placed him/her in the wheelchair. This was a gross violation of policy and procedure, which states two staff for all mechanical lifts and transfers. The fall might have been prevented by following policy and procedure. The employee was removed from work following the completed investigation. During an interview on 2/1/22 at 8:30 A.M., the nursing supervisor said she came in on 1/18/22 around 7:00 A.M. It was at the very end of the night shift. She went around to the different departments to ask how the night went and RN D told her Resident #1 had a fall. She asked the RN if the staff member used the Hoyer lift by him/herself and the RN replied, Yes. She did not get to interview CNA I because he/she was already gone for the day. The CNA had been given orientation about the lift and staff are trained not to use the lift by themselves. During mechanical transfers, one person would handle the lift and the other person would guide the resident into the wheelchair. This was important for the resident because he/she did not have upper body control and cannot lean forward or back by him/herself. There always has to be a tilt in the wheelchair to keep him/her positioned correctly, or he/she could fall out. The nursing supervisor felt like if there had been another person helping with the transfer, the resident would have been correctly positioned in the wheelchair. She asked all of the other staff if they helped transfer the resident, and they told her no. She did not know the resident had an injury. The nurse told her there were no injuries, and she did not assess the resident herself at that time. She reported the incident to the Director of Nursing (DON). The next day when she got to the department, staff told her the resident had been complaining of pain through the night. She went to assess the resident. There was a weird shape over the kneecap. There was no bruising but it did not look like the other leg. She called the resident's physician who ordered an x-ray. The x-ray showed his/her leg was fractured. During an interview on 2/1/22 at 9:55 A.M., the resident said he/she did not remember falling, then said he/she thought he/she fell out of his/her chair. He/she did not remember which staff were working with him/her or how many staff were in the room on the day of the fall. Review of RN D's written statement, dated 1/18/22, showed on 1/18/22 at 6:15 A.M., CNA I came to the nurse's station to inform the nurse, the resident was on the floor. He/she went back to the resident's room with the CNA and saw the resident lying supine on his/her back with both knees bent. He/she was in front of his/her wheelchair. The seat of the wheelchair was tilted forward. The nurse assessed the resident for injuries and he/she was able to move both lower extremities without difficulty. The CNA said he/she witnessed the resident tip forward from the wheelchair and that he/she did not hurt or hit his/her head. CNA I did not ask the nurse for help before getting him/her out of bed by him/herself. The resident's vitals were stable. The nurse went to get another CNA (F) to help assist the resident back into the wheelchair. The nurse notified the resident's physician, the oncoming nurse and the nursing supervisor. During an interview on 2/1/22 at 11:23 A.M., RN D said at approximately 6:15 A.M. on 1/18/22, CNA I came to the nurse's station to report the resident was on the floor. When he/she entered the room, the resident was on his/her back with his/he knees bent in front of his/her wheelchair. The nurse assessed the resident and did not see any injuries. CNA I told him/her, the fall was witnessed. The resident was not all the way back in his/her chair and tipped forward, falling out of the chair. The resident was on the floor between the Hoyer lift and the wheelchair. The CNA had not asked RN D for help in transferring the resident to the wheelchair. She did not know the CNA was going to get the resident up by him/herself. He/she had not worked with the CNA before. There was no one else in the room with the resident. He/she reminded the CNA that he/she needed two people to transfer residents with a Hoyer lift and that he/she needed to ask for help if he/she needed it. Review of CNA I's written statement, dated 1/18/22, showed the resident had just come out of the Hoyer lift and was seated in his/her wheelchair and started leaning forward. The CNA tried to tell him/her to sit back in his/her seat, but by the time he/she was able to run to her, the resident had already slid out of the chair. During an interview on 2/25/22 at 9:00 A.M., CNA I said he/she went in and changed the resident and got him/her dressed that morning. He/she put the Hoyer pad underneath the resident and went to get another staff to help with the transfer. The other staff member came in and helped with the transfer. He/she could not remember his/her name, but he/she told administration about the other person when they asked. He/she did not know why the nurse would say he/she did the transfer by him/herself. Review of CNA E's written statement, dated 1/24/22, showed on 1/18/22, he/she was not asked by CNA I to help with transfers of any kind. During an interview on 2/1/22 at 1:40 P.M., CNA E said he/she worked the floor with CNA I the night of the incident. The CNA did not ask for assistance getting the resident up that morning. CNA E did not know the resident had a fall until he/she was getting ready to leave for the day. All staff were trained to use two people when using a Hoyer lift. Review of CNA F's written statement, dated 1/24/22, showed RN D came to his/her floor on 1/18/22 to ask him/her to help with a resident who had fallen on the floor. When he/she got to the room, the resident was on the floor and neither of the staff knew how to get him/her up with the Hoyer, so he/she assisted CNA I with getting the resident back into his/her chair. During an interview on 2/1/22 at 1:30 P.M., Licensed Practical Nurse (LPN) G said the resident did not complain about pain until around 5:00 to 6:00 A.M., on 1/19/22. He/she noticed the resident's leg was swollen and notified the nursing supervisor. During an interview on 2/1/22 at 9:10 A.M., the DON said RN D told her about the fall that morning but said he/she had good range of motion and was fine. It took two CNAs to get him/her off the floor. CNA I transferred the resident by him/herself. This went against policy, as all Hoyer transfers required two people. The resident was not complaining of pain but did have some confusion as he/she denied having a fall later in the day. Later, maybe the next day, someone told her something was wrong with the resident's knee. During interviews on 2/1/22 at 8:20 A.M. and at 3:00 P.M., the administrator said the staff member should have asked for help when doing the transfer. The resident had a special tilting wheelchair because he/she could not position him/herself well and had to be placed back in the wheelchair or he/she would fall out. This would be hard to do with one person when transferring. MO 110

Based on interview and record review, the facility failed to follow their abuse policy and allowed an alleged staff member to come back to work prior to the completion of an investigation, following an inappropriate transfer which resulted in a resident's (Resident #1's) fall. The sample size was three. The census was 36. Review of the facility's Abuse Prevention, Intervention, Reporting and Investigation Policy, dated 10/11/21, showed the following: -Residents have the right to be free from verbal, sexual, physical and mental abuse, corporal punishment, exploitation, and involuntary seclusion; -All reports of resident verbal, sexual, physical and mental abuse, corporal punishment, involuntary seclusion, neglect, exploitation or misappropriation of resident property, and protection of resident privacy are promptly and thoroughly investigated by community management; -Allegations of abuse, neglect, exploitation and misappropriation of property will be thoroughly investigated and reported by management personnel and corrective action will be taken depending on the results of the investigation; -Neglect is defined as failure of the community, its employees or service providers to provide goods and services, to a resident that are necessary to avoid physical harm, pain mental anguish or emotional distress; -Investigation: When an occurrence or suspected occurrence occurs, the Executive Director, Health Services Director, Director of Nursing for Assisted Living or nursing designee investigates the allegation; a. The nurse conducting the investigation initiates the root cause analysis: At a minimum: i. Reviews the completed occurrence event; ii. Reviews the resident's record to determine events leading up to the event; iii. Interviews the persons reporting the event; iv. Interviews any witnesses to the event; v. Interviews the resident (if appropriate); vi. Contacts the resident's attending physician to determine the current mental status of the resident; vii. Interviews the resident's roommate, family members and visitors; xii. If abuse is alleged, residents are to be protected and staff member removed from duties until investigation is completed; -Residents and staff are to be protected from re-occurrence by ensuring: -Accused employees are removed from resident contact immediately and may be suspended from duty until the results of the investigation are reviewed. Review of Resident #1's face sheet, showed the following: -admitted [DATE]; -diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 11/24/21, showed the following: -Severely impaired cognitive status; -Sometimes understands others; -Extensive assistance of one person required for bed mobility; -Total dependence: One person assistance required for dressing and personal hygiene; -Total dependence: Two person assistance required for transfers and toilet use; -Mobility-Substantial/maximal assistance needed to roll left and right; -Chair/bed to chair transfer: Dependent; helper does all the effort. Resident does none of the effort to complete the activity. Review of the resident's care plan, dated 9/9/21, showed the following: -Strength/Weakness: Activities of daily living (ADL) Function/Rehabilitation potential; -Approach: Use a Hoyer lift for transfers with two person assist; -Strength/Weakness: Falls; weakness and need for assist with all transfers; balance issues; -Approach: Use lift for transfers; Resident will tell you he/she can transfer without the lift at times. Do not take his/her word for it. He/she uses the Hoyer lift with two person assist for all transfers. Review of the resident's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] -Mobility status: Use lift with two persons for all transfers; -Manual wheelchair with tilt for abnormal posture. Review of the resident's progress notes, showed the following: -On 1/18/22 at 9:12 A.M., the nurse was called to the resident's room at 6:15 A.M., by the certified nurses' assistant (CNA). The resident was supine (face upward) on the floor in front of his/her wheelchair. The CNA stated the resident had tipped forward after being placed in the wheelchair. Staff assessed the resident for injuries and none were noted. He/she was able to move all of his/her extremities. The CNA stated he/she witnessed the resident tip forward from the wheelchair but did not hit his/her head. The CNA wrote a statement to verify. Vitals were stable. Staff called the resident's physician and spoke with an on-call answering service to relay the message with a call back number. Staff notified the resident's responsible party. The oncoming nurse was aware, as well as the nursing supervisor. Staff would continue to closely monitor. At 2:30 P.M., the resident had no complaints of pain. At 9:14 P.M., the resident had no complaints of pain; -On 1/19/22 at 6:37 A.M., the resident did not complain of pain when asked. In the early morning, when the CNA provided care, the resident complained of pain when moving/touching his/her left thigh/knee. The knee was slightly swollen and hard to the touch. At 6:47 A.M., staff placed a call to the resident's physician's exchange. At 6:51 A.M., the physician returned the call and ordered an x-ray on the left knee and thigh. At 7:23 A.M., staff contacted the company for the x-ray; -On 1/19/22 at 11:41 A.M., the resident had pain and swelling to his/her lower left extremity. The resident had an x-ray of the left thigh and knee and it showed an acute fracture of the left femur. Staff reported the fracture to the nurse practitioner who gave orders for the resident to be sent to the hospital; -On 1/20/22 at 1:18 P.M., post investigation noted fall after improper supervision of positioning. Review of the nursing supervisor/assistant Director of Nursing's (ADON) written investigation, dated 1/19/22, showed on 1/18/22 in the morning, Registered Nurse (RN) D reported the resident had been assisted up, and CNA I came to him/her because the resident slid out of his/her wheelchair. RN D stated the CNA had already gone home but was giving a written statement. He/she reported the resident did not hit his/her head and had no apparent injuries. On 1/19/22, the resident's left leg looked swollen and he/she complained of some discomfort. The physician was notified and ordered an x-ray. The x-ray showed a fracture. Upon investigation, the nursing supervisor found CNA I transferred the resident by him/herself with the Hoyer lift and placed him/her in the wheelchair. This was a gross violation of policy and procedure, which states two staff for all mechanical lifts and transfers. The fall might have been prevented by following policy and procedure. The employee was removed from work following the completed investigation. During an interview on 2/1/22 at 8:30 A.M., the nursing supervisor said she came in on 1/18/22 around 7:00 A.M. It was at the very end of the night shift. She went around to the different departments to ask how the night went and RN D told her Resident #1 had a fall. She asked the RN if the staff member used the Hoyer lift by him/herself and the RN replied, Yes. She reported the incident to the Director of Nursing (DON). She thought the DON called CNA I and told him/her not to come back to work that night on 1/18/22, but he/she showed up to work anyway. At approximately 3:00 A.M. on 1/19/22, CNA I called 911 and had him/herself transported to the hospital. During an interview on 2/1/22 at 11:23 A.M., RN D said at approximately 6:15 A.M. on 1/18/22, CNA I came to the nurse's station to report the resident was on the floor. When he/she entered the room, the resident was on his/her back with his/he knees bent in front of his/her wheelchair. The nurse assessed the resident and did not see any injuries. CNA I told him/her, the fall was witnessed. The resident was not all the way back in his/her chair and tipped forward, falling out of the chair. The CNA had not asked RN D for help in transferring the resident to the wheelchair. She did not know the CNA was going to get the resident up by him/herself. There was no one else in the room with the resident. He/she reminded the CNA that he/she needed two people to transfer residents with a Hoyer lift and that he/she needed to ask for help if he/she needed it. Review of CNA I's written statement, dated 1/18/22, showed the resident had just come out of the Hoyer lift and was seated in his/her wheelchair and started leaning forward. The CNA tried to tell him/her to sit back in his/her seat, but by the time he/she was able to run to her, the resident had already slid out of the chair. During an interview on 2/25/22 at 9:00 A.M., CNA I said he/she went in and changed the resident and got him/her dressed that morning. He/she put the Hoyer pad underneath the resident and went to get another staff to help with the transfer. The other staff member came in and helped with the transfer. He/she could not remember his/her name, but he/she told administration about the other person when they asked. He/she did not know why the nurse would say he/she did the transfer by him/herself. The nurse had him/her write a statement and then he/she thought it was over. No one called to follow up with him/her for for a few days. He/she did not know he/she was not supposed to come into work that night on 1/18/22, because no one told him/her not to come in. During an interview on 2/1/22 at 1:30 P.M., Licensed Practical Nurse (LPN) G said the resident did not complain about pain until around 5:00 to 6:00 A.M., on 1/19/22. He/she noticed the resident's leg was swollen and notified the nursing supervisor. He/she did not know the CNA was not supposed to work that night (night shift 1/18/22 to 1/19/22). He/she called the DON after the CNA called 911 and left the building without notifying anyone. During an interview on 2/1/22 at 9:10 A.M., the DON said RN D told her about the fall that morning but said he/she had good range of motion and was fine. CNA I transferred the resident by him/herself. This went against policy, as all Hoyer transfers required two people. The resident was not complaining of pain but did have some confusion as he/she denied having a fall later in the day. Later, maybe the next day, someone told her something was wrong with the resident's knee. It was warm to the touch. The nursing supervisor started the investigation and got a written statement from CNA I. The DON did not personally talk to CNA I, although she tried to call him/her twice. She thought human resources was going to follow up and call the CNA and tell him/her not to come to work pending an investigation. She did not know the CNA was going to come back into work that night. It is policy to call and tell staff they cannot come in when there is an investigation going on. At around 2:00 A.M. on 1/19/22, the night nurse called and said CNA I had left the building without notice. The police showed up and told them he/she called 911 and had him/herself transferred to the hospital. He/she was on the schedule to work, but the DON had scratched his/her name off. He/she did not know exactly what time the CNA came in. He/she did not let the oncoming staff know the CNA should not be in the building, due to confidentiality issues. Ultimately, it was her responsibility to make sure the staff member did not come back to work until the investigation was completed. During an interview on 2/1/22 at 1:10 P.M., the human resources manager said she did not find out about the investigation until she received an email about the CNA calling 911 and leaving the building. No one contacted her about an inappropriate lift. She could not contact the staff member if she did not know about the investigation. Normally, they would notify her and then she would call the staff member and let them know they were suspended pending an investigation. During interviews on 2/1/22 at 8:20 A.M. and at 3:00 P.M., the administrator said the CNA should have been suspended that day pending the investigation. If they could not contact him/her, staff should have been notified to contact the DON for further instructions. MO 110

Based on observation and interview, the facility failed to ensure food in the walk-in freezer was dated properly and ensure staff wore hair restraints while serving food. This deficient practice had the potential to affect all residents who ate at the facility. The census was 36. Observations of the walk-in freezer, on [DATE] at 8:42 A.M., [DATE] at 7:00 A.M. and [DATE] at 6:37 A.M., showed: -One opened box, which included four, three pound boxes of breaded cream cheese stuffed jalapeno, dated [DATE]; -One opened box, which included six, one pound boxes of bone-in chicken thighs, dated [DATE]; -One sealed ten pound box, of wavy lasagna sheets, dated [DATE]; -One sealed one pound box, of blue water shrimp, dated [DATE]; -One sealed box, which included 16, one pound beef patties, dated [DATE]; -Three sealed six pound trays, of peach cobbler, dated [DATE]; -One sealed six pound tray, of peach cobbler, dated [DATE]. During an interview on [DATE] at 6:45 A.M., Sous-Chef (SC) A said the dates on the food were the manufacturer's date, not the expiration date. The dates were when the items arrived at the facility. After showing SC A the breaded cream cheese stuffed jalapenos, he/she said he/she could not locate the expiration date and threw them away. During an interview on [DATE] at 7:59 A.M., the Dietary Manager said the dates on the food were the manufacturer's date, not an expiration date. The foods did not have an expiration date listed. Once food is opened, they have seven days to use it before it is thrown away. At the moment, they did not have a system in place to track when the food was opened, and when it should be thrown away. During an interview on [DATE] at 3:20 P.M., the administrator said the facility should have a system in place to track when food is opened and expired. 2. Observations of meal services in the Glen dining room on [DATE] at 11:54 A.M. and [DATE] at 12:00 A.M., showed Dietary Aide (DA) B served food behind the steam table. His/her hair was braided down his/her back. DA B did not have on a hair restraint. During an interview on [DATE] at 11:51 A.M., the director of food and beverages said staff on Glen should wear hair restraints at all times while serving food. During an interview on [DATE] at 3:20 P.M., the administrator said staff should wear hair restraints at all times while serving food.

Based on observation and interview, the facility failed to keep floors in the kitchen, walk-in refrigeration units and dry storage area, free of dirt and debris for three of three days of observation. The census was 38. Observation of the kitchen on 7/29/19 at 10:03 A.M. and 3:57 P.M., 7/30/19 at 10:41 A.M. and 2:54 A.M. and 7/31/19 at 9:36 A.M., showed the following: -The kitchen floor, under and around preparation counters, with food particles and debris; -The walk-in refrigerator floor dirty with food debris; -The walk-in freezer floor dirty with debris and with spill stains to the left of the doorway, and to the right, in front of boxes of frozen food items; -The floor area between the stove and oven with debris and grease; -The floor area around the deep fat fryer greasy with food debris; -The floor behind the braising pan covered with a white substance, extending on approximately 15 floor tiles; -The dry storage area floor to the right of the door, under and around a shelving unit, with particles of tortilla chips. During an interview on 7/31/19 at 10:21 A.M., the Executive Chef said the staff swept and mopped the kitchen floor four times daily, twice during the day and twice at night. Three sous chefs initial the cleaning schedule when the tasks were completed. The kitchen floor was power washed and steam cleaned on 7/13/19. Deep cleaning was done on Sundays for items such as the exhaust hood and filters. There was a rotation of equipment cleaning divided up every night. They have hired a lead dishwasher to stay later to make sure little things are done. He did not know what the white substance behind the braising pan was.

Based on observation and interview, the facility failed to ensure staff used clean utensils during pureed food preparation, ensure trash receptacles were covered while not in use, ensure proper handling of bulk food storage and ensure ceiling panels and vents were free from dust and debris. These deficient practices had the potential to affect all residents who ate at the facility. The census was 32. 1. Observation on 7/20/18 at 11:20 A.M., of the lunch puree preparation, showed the following: -Cook A placed prepared peas in the blender bowl and blended; -Cook A used a metal serving spoon to scrape the pureed peas into serving pans, rinsed off the spoon in the sink next to the work station and placed the spoon on the bottom of sink; -Cook A placed prepared sweet potatoes in the blender bowl and blended; -Cook A took the spoon from the bottom of the sink and scraped out the pureed sweet potatoes into serving pans to be served to residents; -Cook A did not use a clean spoon to scrape out the contents of the blender bowl. During an interview on 7/24/18 at approximately 9:00 A.M., the DM and EC said the sink next to the work station used to prepare pureed foods is used to rinse off food and is not a sanitized area to place utensils. Cook A should have either ran the spoon through the dishwasher or used another spoon. 2. Observations of the main kitchen on 7/19/18 at 11:37 A.M., 7/20/18 at 7:08 A.M., 7/23/18 at 7:44 A.M. and 7/24/18 at 8:21 A.M., showed the following: -10 trash cans throughout the kitchen, not in use and without lids; -A large scoop left inside the bulk flour bin; -Dust and debris build up on the ceiling vents above the food prep line and coffee and juice dispensers; -Dust and debris build up on six ceiling panels above a rack of clean, dry dishes by the dishwasher; -Dust build up on an area of wall, approximately 3 feet wide, behind the sanitizing sink. During an interview on 7/24/18 at approximately 9:00 A.M., the EC and DM said the trash cans used to have lids, but the lids broke a couple of months ago. Scoops should not be kept inside the bulk bins to prevent cross contamination. The kitchen undergoes a deep cleaning every Sunday. The kitchen has had ongoing issues of dust and debris accumulating on the ceiling and approximately 15 ceiling tiles were replaced this month.

Based on observation, interview and record review, the facility failed to revise individual resident care plans timely to address pressure ulcers (injury to the skin and/or underlying tissue, usually over a bony prominence, as a result of pressure or friction) and the use of a position change alarm (A personal safety alarm, PSA, device intended to monitor a resident's movement that emits an audible signal when the resident moves in certain ways.) for two of 12 sampled residents (Residents #10 and #6). The census was 32. 1. Review of Resident #10's undated care plan, in use at the time of survey, showed the following: -Strength/Weakness: At risk for pressure ulcers and other skin impairments due to decreased mobility; coccyx (tailbone) area has reopened; -Goal: Will have no skin breakdown within next 90 days; -Approaches included: -Use specialized mattress on resident's bed (start date 3/6/18); -Staff to follow facility skin care policy (start date 3/6/18); -Use a pressure-reducing cushion for wheelchair (start date 3/6/18); -Remind and encourage resident to change positions while in bed (start date 3/7/18). Review of the resident's treatment administration record (TAR) for (MONTH) (YEAR), showed the resident refused the specialized mattress ordered by his/her physician on 9/29/16. Review of the resident's quarterly Minimum Data Set (MDS, a federally mandated instrument completed by facility staff), dated 5/17/18, showed the following; -Severe cognitive impairment; -Required extensive assistance with bed mobility, dressing and toileting; -At risk for pressure ulcers. Review of the resident's Care Conference Summary, dated 5/24/18, showed the resident's cognition declined from moderate impairment to severe impairment within the past quarter. Review of the resident's physician order [REDACTED]. -An order, dated 2/16/16, for barrier cream to buttocks and perineal area (the front and back of the hips, genitals, anal area and buttocks), topical as needed; -An order, dated 3/3/17, to lay the resident down between meals and turn every two hours; -An order, dated 4/30/18, to clean open area to sacrum (triangular bone located above the coccyx) with wound cleanser, apply [MEDICATION NAME] (antifungal medication) cream and cover with 4x4 absorbent dressing. Change every other day and as needed until healed; -An order, dated 5/28/18, for a specialized mattress. Review of the resident's Skin Evaluation records, showed the following: -Coccyx, origin date 5/24/17, healed as of 11/7/17; -Sacrum, origin date 2/27/18, healed as of 5/7/18; -Left lower buttock, origin date 5/27/18, healed as of 6/5/18; -No current wounds for July, (YEAR). Review of the resident's interdisciplinary note, dated 6/1/18, showed staff attempted to install a specialized mattress on the resident's bed for the third time. Staff noted a previous attempt made on 5/27/18. Review of the resident's TAR for (MONTH) (YEAR), showed the following: -An order dated 4/30/18, for [MEDICATION NAME] cream and absorbent dressing, discontinued on 7/22/18; -An order, dated 7/24/18, to treat open areas with Duoderm (a dressing used to protect wounds from contamination, and to provide a moist wound-healing environment). Further review of the resident's medical record, showed the following: -Staff did not update the care plan to reflect his/her refusal of the physician-ordered specialized mattress; -Staff did not update the care plan to reflect changes in the condition of pressure ulcers or state of cognitive impairment. Observation on 7/20/18 at 11:25 A.M., showed a foam dressing, dated 7/18/18, covered the resident's coccyx and contained a small amount of brown and yellow colored drainage on it. Further observation, showed the coccyx with an open circular area, measuring approximately 0.5 centimeters (cm) x 0.5 cm. During an interview on 7/24/18 at 10:15 A.M., the Director of Nursing (DON) said the care plan should reflect the resident's current condition. Updated treatment approaches should be included on the care plan. 2. Review of Resident #6's medical record, showed the following: -A physician's orders [REDACTED]. -A quarterly MDS, dated [DATE], showed the following: -Severe cognitive impairment; -Required extensive assistance with locomotion, dressing and toileting; -Used a wheelchair and walker for mobility; -[DIAGNOSES REDACTED]. -One fall without injury since last assessment; -PSA to wheelchair and bed used daily; -A care plan, last updated 2/14/18 and in use during the survey, showed staff did not include the purpose and use of a PSA for the resident. Observations of the resident on 7/19/18 at 2:07 P.M., 7/20/18 at 1:13 P.M., 7/23/18 at 7:21 A.M. and 7/24/18 at 8:03 A.M., showed the resident up in his/her wheelchair with a PSA attached to the back of the chair and a string with a clip attached to the jacket on the resident's back. During an interview on 7/24/18 at 10:15 A.M., the DON said the care plan should reflect the resident's current condition. If a resident has a PSA, it should be included on the care plan. The MDS coordinator is responsible for updating the care plan, but any nurse can revise it as well.

Based on observation, interview and record review, the facility failed to assure that a resident with a history of pressure ulcers (pressure injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure or friction), received care and monitoring to prevent the redevelopment of a pressure ulcer, for one of 12 sampled residents (Resident #10). The census was 32. Review of the facility's skin integrity, pressure ulcer prevention and treatment policy, revised on 6/29/18, showed the following: -Policy: All residents are considered to have some risk for the development of pressure ulcers/injury. Nursing staff will evaluate skin integrity and tissue tolerance, implement preventative measures as indicated and treat skin breakdown; -Purpose: Evaluate skin integrity and tissue tolerance, identify residents at risk for pressure ulcer/injury, implement pressure ulcer/injury preventative measures to maintain intact skin and initiate and implement wound treatment orders when pressure ulcer/injury and/or wounds are present or acquired; -Treatment Guidelines: Evaluate the wound and choose the appropriate dressing based on Assessment based wound dressing selection model, the resident should receive multivitamins with minerals daily for stage II injury (the skin breaks open, wears away, or forms an ulcer, which is usually tender and painful), staff should position the resident off the effected areas as much as possible and initiate weekly weights and monitor trends; -Documentation Guidelines: On date of origin, wounds will be documented on the skin evaluation form. Continued documentation on the form will occur by the nurse when there is a change in status of the wound such as the dressing not dry and intact, redness to the wound or edges or the resident complains of pain. Nurses will document daily the wound dressing status, wound assessment and pain and will be accomplished by nurses initialing on the treatment administration record (TAR) in the appropriate box and the wound dressing change; -Each resident will receive a weekly skin assessment with findings documented; -Certified nurse aides (CNAs) will inspect the resident's skin during bathing and during times of assistance when the skin is exposed. Any new or unusual findings should be reported to the nurse and documented; -Major risk factors for developing pressure ulcer/injury: Alterations in mobility, change in weight, incontinence, exposure to friction or shearing, decreased nutritional intake and general physical decline. 1. Review of Resident #10''s quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 5/17/18, showed the following: -Severe cognitive impairment; -Required extensive staff assistance with bed mobility, dressing and toileting; -Used a wheelchair for mobility; -At risk for pressure ulcers. Review of the resident's undated care plan, in use at the survey, showed the following: -Strength/Weakness: At risk for pressure ulcers and other skin impairments due to decreased mobility; -Goal: The resident will have no skin breakdown within next 90 days; -Approaches included: -Staff to follow the facility skin care policy, started on 3/6/18; -Use a pressure-reducing cushion on the wheelchair, started on 3/6/18; -Remind and encourage resident to change his/her position while in bed, started on 3/7/18. Review of the resident's physician order [REDACTED]. -An order, dated 2/16/16, to apply barrier cream to buttocks and perineal area (the front and back of the hips, genitals, anal area and buttocks) after voiding as needed; -An order dated, 3/3/17, to lie the resident down between meals and turn him/her every two hours; -An order, dated 4/30/18, to clean the open area to the tailbone with wound cleanser, apply [MEDICATION NAME] (antifungal medication) cream and cover with 4 x 4 Kerrafoam (absorbent foam) dressing. Staff to change every other day and as needed. Review of the resident's skin evaluation form, showed the following: -A wound to the coccyx, discovered on 5/24/17 and healed on 11/7/17; -A wound to the left lower buttock, discovered on 5/27/18 and healed on 6/5/18. Further review of the resident's skin evaluation forms, dated (MONTH) (YEAR), showed no current wounds. Observations on 7/19/18, showed the following: -At 10:40 A.M., the resident lay in bed on his/her back; -At 12:00 P.M., staff assisted the resident out of bed and took him/her to lunch. Staff did not reposition the resident between 10:40 A.M. and 12:00 P.M. Observation and interview on 7/20/18 at 11:25 A.M., showed the resident lay on his/her back in bed. CNAs C and D entered the resident's room and provided care to the resident. CNA C assisted the resident to turn to his/her side and exposed the resident's buttocks. A foam dressing, dated 7/18/18, covered the resident's coccyx (tail bone). CNA C said the resident's skin is very thin and on occasion he/she will get a red area on his/her tailbone area. CNAs C and D did not know if the resident had an open area under the dressing. CNA C removed the dressing from the coccyx, disposed of the dressing and provided care. The absorbent pad of the dressing contained a small amount of brown and yellow colored drainage. The resident's coccyx had an open circular area, which measured approximately 0.5 centimeters (cm) x 0.5 cm. The tissue around the wound appeared red. CNAs C and D provided care to the resident and secured a clean brief into place. CNAs C and D assisted the resident to get dressed and transferred him/her into the wheelchair. CNA C said he/she would tell the nurse he/she removed the dressing during care. CNAs C and D propelled the resident to the dining room and told the nurse they removed the dressing from the resident's coccyx but did not tell the nurse about the open coccyx wound. CNA C then said he/she should not have removed the dressing since it was not visibly soiled. He/she should have let the nurse remove the dressing. He/she should have waited to get the resident up until the nurse applied a new dressing to the area. During an interview on 7/20/18 at 11:40 A.M. Licensed Practical Nurse (LPN) E said CNAs D and D told him/her that the dressing had been removed from the resident's coccyx to provide care. He/she will reapply the dressing after the resident lies down after he/she eats. CNA C and D should have gotten him/her to reapply a new dressing before getting the resident up. He/she did not think the resident had an open area. The resident's coccyx area opens occasionally, but he/she had been told the area had been healed and a foam dressing is used for protection only. Observation and interview on 7/20/18 at 1:34 P.M., showed the resident lay in bed with a brief fastened in place. LPN E removed the resident's brief, turned the resident onto his/her side and exposed the resident's buttocks. LPN E said the area to the resident's coccyx appeared to be open and caused from pressure and he/she said it was a stage II (a partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed without slough, may also present as an intact or open/ruptured blister). The resident is thin and had a history of [REDACTED]. He/she did not know the area had reopened. The wound did not have a dressing on it since the aides removed the dressing. The CNAs did not tell him/her the area was open before getting the resident up. He/she applied the ordered treatment to the wound. He/she said the current treatment is not appropriate for an open wound and he/she would need to call the doctor for a new order. He/she had suggested in the past to apply a Duoderm (used to reduce the risk of further skin breakdown due to friction, aides in protection) dressing to the coccyx but the facility declined the Duoderm because the dressing was not in the facility's formulary. LPN E did not obtain wound measurements of the open wound. During an interview on 7/20/18 at 1:35 P.M., CNA H said skin assessments are completed during resident showers. Further review of the resident's TAR, reviewed on 7/24/18 at 8:38 A.M., showed the following: -An order, dated 7/22/18, to discontinue [MEDICATION NAME] ointment to coccyx area; -A hand written order, dated 7/22/18, to clean the wound to the resident's coccyx with wound cleanser and apply Duoderm, to begin on 7/24/18. During an interview on 7/23/18 at 7:20 A.M., LPN E said he/she contacted the resident's physician on 7/22/18 and got a new order for a Duoderm dressing. The facility does not carry the Duoderm and the dressing will come from the pharmacy. He/she did not know when the Duoderm will be delivered. Until the Duoderm is delivered, a dry dressing had been applied to the open area for protection. Observations on 7/23/18, showed the following: -At 8:56 A.M., the resident lay in bed, on his/her back; -At 9:20 A.M., staff entered the resident's room and did not reposition the resident; -At 10:06 A.M., staff entered the resident's room and administered medication. Staff did not reposition the resident; -At 10:54 A.M., the resident lay in bed on his/her back. During an interview on 7/24/18 at 10:15 A.M., the Assistant Director of Nursing (ADON) said the resident is scheduled to receive skin assessments on Saturday evenings. The Director of Nursing (DON) said the current schedule for skin assessments was put in place on 7/12/18. Skin assessments should be completed by the charge nurse. At the time a wound is observed, it should be measured and documented in the medical record. The physician should be notified for changes in condition of pressure ulcers. This should be done the same day the change is identified. Waiting two days to notifiy the physician and get new orders is too long. Staff are expected to follow physician orders. Any changes in condition, including the resolution of prior issues, should be updated on the resident's care plan. The care plan coordinator should update the care plan and charge nurses can update the care plan if they are available to them.

Based on observation, interview and record review, the facility failed to ensure medication parameters, physician orders [REDACTED].#2, #3 and #6). The census was 33. 1. Review of Resident #2's medical record, showed the following: -A quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 7/1/17, showed the following: -[DIAGNOSES REDACTED]. -A Brief Interview for Mental Status (BIMS, a screening tool to assess cognitive impairment) score of 13 (a score of 13-15 shows cognitively intact); -Extensive to total assist of staff for activities of daily living; -A July 2017 physician's orders [REDACTED]. Hold the medication if the systolic blood pressure (SBP, top number of the blood pressure reading) is less than 140 and call physician. Review of the resident's July 2017 Medication Administration Record [REDACTED] -Staff recorded the resident's SBP as less than 140 on 22 of 31 days; -Staff documented the administration of [MEDICATION NAME] 5 mg on all 22 days with a SBP less than 140. Review of the resident's 8/1/17 through 8/17/17 MAR, showed the following: -An order, dated 12/5/16, for [MEDICATION NAME] 5 mg every morning; -Staff recorded the resident's SBP as less than 140 on nine of 17 days; -Staff documented the administration of [MEDICATION NAME] 5 mg on all nine days with a SBP less than 140. During an interview on 8/17/17 at 11:00 A.M., the Director of Nursing (DON) said staff should follow the parameters of medication administration. The parameter for the resident's [MEDICATION NAME] administration seemed high and she would need to verify the order to hold for SBP less than 140. During an interview on 8/17/17 at 1:35 P.M., the DON said she verified the resident's [MEDICATION NAME] order with the physician. The physician did want the [MEDICATION NAME] 5 mg given daily and hold the medication when the SBP is less than 140. Staffs should follow the order as written. 2. Review of #3's POS, dated 7/13/17, showed: -An order dated 7/13/17 for a personal safety alarm (PSA, loud sounding alarm attached to clothing and allow staff to intervene and prevent a fall) on at all times; -An order dated 8/14/17 to check pulse every shift for three days, if below 55 report to physician. Review of the resident's admission MDS, dated [DATE], showed: -admission date of [DATE]; -Diagnoses: [REDACTED]. -BIMS score of 6 out of a possible score of 15. A BIMS score of 0-7 shows severe cognitive impairment; -Extensive assistance needed for toileting and hygiene; -Frequently incontinent of bowel and bladder; -One fall since admission. Review of the resident's care plan, dated 8/2/17, showed: -Falls: keep his/her wheelchair in reach and keep the resident's PSA on when he/she is in the chair or his/her bed. Observation during each day of the survey, from 8/15/17 through 8/17/17, showed the resident in his/her wheelchair. Staff failed to attach the PSA to the resident's wheel chair. Review of the resident's August, 2017 treatment administration record (TAR), showed: -An order, dated 7/13/17, for PSA on at all times and nurse aide check every shift on 7:00 A.M. to 3:00 P.M., 3:00 to 11:00 P.M. and 11:00 P.M. to 7:00 A.M., showed staff initialed for all listed times as task completed each day through 8/17/17; -An order, dated 8/14/17, to check pulse every shift for three days and call physician if pulse below 55. Staff failed to document a pulse reading result for five out of nine opportunities. Further review of the resident's TAR, showed: -On 8/14/17, on evening shift, a pulse reading result of 50. Staff failed to document if they notified the resident's physician; -On 8/16/17, on day shift, a pulse reading result of 54. Staff failed to document if they notified the resident's physician. During an interview on 8/17/17 at 11:00 A.M., the DON said she expected staff to follow physician orders. PSAs are usually ordered for residents who are a high fall risk or have a history of falling. Staff should not document an alarm is applied on a resident if the alarm is not attached. 3. Review of Resident #6's medical record, showed the following: -[DIAGNOSES REDACTED].>-An order, dated 8/8/17, to serve prune juice every day at breakfast. Observations of the resident on 8/16/17 at 8:22 A.M. and 8/17/17 at 8:21 A.M., showed the resident eat breakfast in the West dining room. Staff failed to provide prune juice at breakfast as ordered. During an interview on 8/17/17 at 8:50 A.M., Certified Nurse's Aide (CNA) A and CNA B said there are no residents in the West dining room who have an order for [REDACTED].>Review of the resident's meal ticket, showed Prune juice daily at breakfast. During an interview on 8/17/17 at 11:00 A.M., the DON said she expected staff to follow physician orders. She would expect nursing staff to lay eyes on the resident during the mealtime to insure staff provided prune juice.

Based on interview and record review, the facility failed to ensure the admission agreement did not require residents to waive potential facility liability for losses of personal property. The census was 33. Review of the facility's undated admission agreement, showed the facility advised residents not to retain or take possession of valuables or money while in residence and the facility would not be liable or responsible for such valuables or money retained or left in the possession of the resident. It is agreed by all parties that money, jewelry, documents, furs and other personal articles of significant monetary value which are brought into the facility by the resident and third parties are in violation of the paragraph and shall not be the responsibility of the facility. During an interview on 8/17/17 at 11:00 A.M., the administrator said she was aware of the requirement for facilities not to waive potential liability for loss of personal property and thought the admission agreement had been updated to reflect that.

Based on observation, interview and record review, the facility failed to follow their policy as well as state and federal regulations by not notifying the Department of Health and Senior Services (DHSS) about an allegation of sexual abuse, immediately, but no later than 2 hours after the allegation was made, by one of four sampled residents. (Resident #1) The census was 31. Review of the facility's Abuse Prohibition Policy, dated 3/21/17, showed the following: -Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidations or punishment with resulting physical harm, pain or mental anguish, or deprivation by an individual, including a caretaker of good or services that are necessary to attain or maintain physical, mental and psychological well being. Also, verbal abuse, sexual abuse, physical abuse and mental abuse facilitated or enabled through use of technology/social media. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. Abuse may be resident to resident, staff to resident or visitor to resident. -Sexual abuse includes, but is not limited to sexual harassment, sexual coercion or sexual assault (non-consensual sexual contact of any type with a resident). -Reporting: The executive director or designee and health services director or designee is promptly notified of suspected or actual abuse, regardless of the time of day or day of week. The executive director or designee, in conjunction with the health services director or designee, notifies the following of a suspected abuse occurrence: -State licensing/certification agency; -All alleged violations involving abuse, neglect exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property are reported immediately and no later than 2 hours after allegation is made if the events that cause the allegation involve abuse or result in serious bodily injury. Review of Resident #1's quarterly Minimum Data Set (MDS), a federally mandated resident assessment instrument completed by facility staff, dated 5/26/17, showed the following: -[DIAGNOSES REDACTED]. -Cognitive loss with patterns of inattention and disorganized thinking; -Extensive assistance with care and transfers; -Incontinent of bowel and bladder. Review of the resident's interdisciplinary notes, dated 7/9/17, showed the following: -At approximately 7:15 A.M., Nurse A entered the resident's room to perform a treatment on his/her roommate. The resident was lying supine in bed underneath a blanket and appeared asleep with eyes closed and not speaking; -When Nurse A completed the treatment, he/she exited the room. The resident called out to Nurse A and said he/she needed to talk with him/her; -The resident reported he/she had bad news and was assaulted and raped this morning at 10:00 A.M. When Nurse A asked who assaulted him/her, the resident said it was an employee, the guy that cleans during the day. The resident was holding eyeglasses in his/her hands on top of the covers; -Nurse A lifted the side of the resident's blanket to observe the resident's state of dress. The resident was wearing a button down shirt and an incontinence brief while resting in bed; -Nurse A went to the central nurse's station and spoke with night Nurse B about the resident's report of assault/rape. Nurse B confirmed that no male employee worked on the night shift and the two CNAs worked together in the resident rooms; -At 7:25 A.M., Nurse A left a telephone message with the Director of Nurses (DON) to notify him/her; -At 7:27 A.M., the DON returned the call and was informed by Nurse A of the complaint by the resident of being assaulted/raped that morning at 10:00 A.M., by the guy that cleans during the day. The DON said to notify the administrator and the DON will let Nurse A know what actions need to be taken. Will notify staff to only care for resident with a second staff member present; -At 7:48 A.M., entered resident's room with Nurse C. Resident resting in bed and agreed to have vital signs done, which were stable. Asked if resident was experiencing any pain and resident replied no, that's a good thing. No further complaints of assault/rape; -At 9:09 A.M., the DON called and reported he/she is notifying the administrator of the resident's complaint of assault and will call Nurse A back with further instructions after speaking with the administrator; -At 9:25 A.M., DON returned call and reports spoke with administrator, who instructed the DON to have Nurse A examine the resident's genitalia for redness and bruising and notify the physician to see if he/she wants to send the resident to the emergency room for examination. The DON also reports he/she is notifying the social worker, who is manager on duty, to come and speak with the resident. Nurse A did not feel comfortable doing a genitalia exam on the resident until he/she spoke with the physician. Nurse A did not want to open resident's brief and compromise any evidence; -At 9:33 A.M., Nurse A put a call out to the physician, who returned the call at 9:39 A.M. The physician said Nurse A would be unable to do a thorough genitalia exam at the facility and the resident needed to be sent to the emergency room . During an interview on 7/10/17 at 11:30 A.M., the administrator and DON said the following: -They talked with the police detective that morning and just called the DHSS hotline; -The resident had a history of [REDACTED]. -They felt the resident's allegation of sexual abuse on 7/9/17, should be investigated; -The day shift nurse called 911. The Emergency Medical Service called the police, who said they would see the resident at the hospital; -The resident's children did not believe any sexual abuse happened and asked why the resident was sent to the hospital; -The resident told the police detective that the person who sexually abused him/her looked like his/her first spouse; -The resident had an upper gastrointestinal tract series (a diagnostic x-ray examination of the tract) done on 7/6/17; -They watched the facility videos that morning with the police detective; -No staff entered the resident's room from 5:00 A.M. to 7:00 A.M.; -There was no male staff who worked at the facility, as described by the resident. During an interview on 7/24/17 at 9:00 A.M., the social worker said the following: -He/She started the investigation regarding the resident's allegation of sexual abuse on 7/9/17; -He/She was not aware that the DHSS should have been notified with-in 2 hours. During an interview on 7/25/17 at 11:45 A.M., the administrator said the facility policy/procedure should have been followed to notify the DHSS within 2 hours after an allegation of abuse was made by the resident on 7/9/17. MO 135

Based on observation and interview, the facility failed to date and discard outdated food and beverages, increasing the risk of cross-contamination and food-borne illness, potentially affecting all residents served from the main kitchen or unit kitchenettes on three of three days of observation. The census was 38. 1. Observation of the facility's main kitchen on 7/6/16 at 10:52 A.M., showed the following: -A reach-in refrigerator contained a steam pan of undated meat and sauce; -The large walk-in cooler (refrigerator) contained the following: -A steam pan of unidentifiable substance with mold on the top. The pan was marked use by 3/19; -An undated steam pan of diced tomatoes; -An undated block of ham, approximately 2 pounds; -An undated bag of shredded cheese, approximately 2 pounds; -Three undated cases plus three 5 pound cartons of liquid egg product with instructions to use within three days of thawing; -An undated bag of shredded cabbage, approximately 1 pound; -A block of bulk sausage, approximately 3 pounds, dated 6/31; -Two large undated bags of chicken pieces, approximately 10 pounds each; -An undated block of ham, approximately 1 pound; -An undated block of turkey, approximately 10 pounds. Observation of the walk-in cooler in the facility's main kitchen on 7/7/16 at 8:07 A.M., showed the following: -An undated block of ham, approximately 2 pounds; -An undated bag of shredded cheese, approximately 2 pounds; -Three undated cases plus three 5 pound cartons of the same liquid egg product from 7/6/16 with instructions to use within three days of thawing; -A block of bulk sausage, approximately 3 pounds, dated 6/31; -Two undated large bags of chicken pieces, approximately 20 pounds each; -Seven undated large roasts, approximately 20 pounds each. Observation of the walk-in cooler in the facility's main kitchen on 7/8/16 at 6:05 A.M., showed the following: -An undated block of ham, approximately 2 pounds; -Two cases plus three 5 pound cartons of the same liquid egg product from 7/6/16, with instructions to use within three days of thawing; -Two undated large bags of chicken pieces, approximately 20 pounds each; -Seven undated large roasts, approximately 20 pounds each. 2. Observation of the East kitchenette on 7/7/16 at 7:00 A.M., showed the following: -One pitcher of lemonade with a use by 7/3 label; -One pitcher of lemonade with a use by 7/4 label; -A bowl of lemon slices with a use by 7/5 label. Observation of the East kitchette on 7/8/16 at 5:40 A.M., showed the following: -One pitcher of lemonade with a use by 7/3 label; -One pitcher of lemonade with a use by 7/4 label. 3. Observation of the North kitchenette on 7/7/16 at 7:23 A.M. and 7/8/16 at 5:43 A.M., showed an approximately 12 inch by 12 inch cardboard box of brownies, partially covered with no date. 4. During an interview on 7/8/16 at 1:15 P.M., the administrator said she would expect the kitchen and unit kitchenette staff to properly label and date the food products.

Based on observation, interview and record review, the facility failed to keep equipment and vents in the main kitchen and two of three unit kitchenettes clean and free of debris on three of three days of observation. The census was 38. 1. Observations of the main kitchen on 7/6/16 at 10:52 A.M., 7/7/16 at 8:07 A.M. and 7/8/16 at 6:05 A.M., showed the following: -On the stove, a thick layer of baked on carbon that extended approximately 12 inches down the side; -The fronts and sides of the three warmers and the fryer soiled with dried spills and food debris; -A reach-in refrigerator contained dried spills and food debris in the bottom; -Three of nine ceiling exhaust vents contained a dust build-up. Review of the kitchen cleaning schedule, showed the following: -Range and oven cleaned on Monday; -Fryer cleaned on Wednesday; -Two burner range cleaned on Thursday; -Grill cleaned on Friday; -Warmers cleaned on Saturday. 2. Observations of the North unit kitchenette on 7/7/16 at 7:23 A.M. and 7/8/16 at 5:43 A.M., showed the inside of the freezer contained food spills and debris. 3. Observations of the West unit kitchenette on 7/7/16 at 7:23 A.M. and 7/8/16 at 5:50 A.M., showed the inside of the freezer contained food spills and debris. 4. During an interview on 7/8/16 at 1:15 P.M., the administrator said she would expect the kitchen and kitchenettes to be clean. Vents in the kitchen should be cleaned by maintenance staff and on a cleaning schedule. Dietary staff who are assigned the kitchenettes should keep them clean.