Every finding on record at Ashley Manor Health & Rehabilitation

Reviewed AT Based on interview and record review, the facility failed to have adequate nursing staff available to meet the needs of the residents as determined by their facility assessment and extended call light wait times. The facility census was 45. 1. Review of the facility policy titled, Answering the Call Light, undated, showed the purpose of this procedure is to ensure timely responses to the resident's requests and needs. Staff are directed: -If the resident needs assistance, indicate the approximate time it will take for you to respond; -If the resident's task is something you can fulfill, complete the task within five minutes if possible; -If you are uncertain as to whether or not a request can be fulfilled or if you cannot fulfill the resident's request, ask the nurse supervisor for assistance. 2. Review of the Facility Assessment Tool, dated 07/26/2024, showed staff documented: -Average census of 43 residents; -Direct care staff needed for each shift (day, evening, night): -Day shift: Five Certified Nurse Aides (CNA); -Evening Shift: four CNAs; -Night shift: three CNAs. -Total CNAs needed for a 24 hour period is 12. 3. Review of the employee monthly schedule, dated 01/10/25 through 01/15/25, showed: - On Friday 01/10/25: A total of nine CNAs. - Saturday 01/11/25: A total of seven CNAs. - Sunday 01/12/25: A total of eight CNAs. - Monday 01/13/25: A total of nine CNAs. - Wednesday 01/15/25: A total of 11 CNAs. 4. Review of the facility's wireless call light report, dated 01/10/25 through 01/11/25 at 4:36 P.M., showed: - room [ROOM NUMBER] call light response times of 39 minutes; 37 minutes; 37 minutes; and 53 minutes; - room [ROOM NUMBER] call light response times of one hour 24 minutes; and 33 minutes; - room [ROOM NUMBER] call light response times of two hours 48 minutes; and 44 minutes; - room [ROOM NUMBER] call light response times of 56 minutes, one hour three minutes; three hours 47 minutes; one hour 38 minutes; and two hours 23 minutes; - room [ROOM NUMBER] call light response time of one hour 44 minutes; - room [ROOM NUMBER] call light response time of 47 minutes; - room [ROOM NUMBER] call light response times of one hour 43 minutes; and one hours and 21 min; - room [ROOM NUMBER] call light response time of one hour 35 minutes; - room [ROOM NUMBER] call light response time of one hour 3 minutes; - room [ROOM NUMBER] call light response times of 42 minutes; 33 minutes; and one hour three minutes; - room [ROOM NUMBER] call light response times of two hour 31 minutes; one hour 24 minutes; one hour 18 minutes; one hour; one hour eight minutes; one hour 10 minutes; and 44 minutes; - room [ROOM NUMBER] call light response times of 37 minutes; 37 minutes; one hour two minutes; 37 minutes; and 52 minutes; - room [ROOM NUMBER] call light response times of one hour three minutes; and 39 minutes; - room [ROOM NUMBER] call light response time of 44 minutes. 4. Review of the facility's wireless call light report, dated 01/13/25 at 4:35 P.M., showed: - room [ROOM NUMBER] call light response times of 36 minutes, and 35 minutes; - room [ROOM NUMBER] call light response times of 58 minutes; - room [ROOM NUMBER] call light response times of 40 minutes; one hour nine minutes; and 32 minutes; - room [ROOM NUMBER] call light response time of 34 minutes; - room [ROOM NUMBER] call light response times of 32 minutes; and 44 minutes; - room [ROOM NUMBER] call light response times of 31 minutes; 36 minutes; and 43 minutes; - room [ROOM NUMBER] call light response time of 52 minutes. 5. During an interview on 01/12/25 at 3:48 P.M., Resident #2 said staff does not usually get him/her out of bed until 10:00 or 11:00 A.M., even though he/she wants to get up around 8:00 or 9:00 A.M. The resident said he/she puts the call light on and it can take several hours for someone to answer it. He/she said he/she does not like sitting in his/her wet clothes or brief, and if he/she needs to be turned it hurts if he/she does not get repositioned timely. The resident said it takes three to four staff to provide cares for him/her, so often times it is almost 2:00 P.M. before he/she gets changed after lunch, because they need more staff to help him/her. During an interview on 01/13/25 at 8:43 A.M., Resident #8 said call lights are a problem, and if you fall asleep staff will come in and turn it off or say they will be right back and they do not come back. The resident said he/she does not like sitting in his/her wet clothes or brief, or if he/she needs to be repositioned it can take too long. The resident said usually it is the nursing aides that are short staffed. During an interview on 01/13/2025 at 9:01 A.M., Resident #43 said it usually takes 30 minutes or more for call lights to be answered at any time. During an interview on 01/15/25 at 8:43 A.M., Resident #20 said he/she has to wait a long time for staff to answer his/her call light, sometimes over an hour. The resident said it is hard to get any help, and there are too few staff to take care of so many residents. The resident said he/she has incontinence and sometimes he/she is left wet for long periods of time. The resident said it does not feel good. The resident said he/she wears briefs and has been sitting wet for a couple of hours. The resident said he/she had pushed his/her call lights several times. During an interview on 01/15/25 at 8:50 A.M., Resident #23 said staff leave him/her wet for long periods time, and it takes hours for staff to answer his/her call lights. During an interview on 01/15/25 at 8:55 A.M., Resident #1 said it seems like it takes a long time for staff to answer his/her call light. The resident said it takes over 30 minutes for staff to answer his/her call light. During an interview on 01/15/25 at 9:02 A.M., Resident #37 said staff take over an hour to answer his/her call light at times. The resident said staff leave him/her laying in wet clothes or a brief in his/her bed for 30 minutes to an hour. The resident said it makes him/her feel bad, laying in a cold wet bed. During an interview on 01/15/2025 at 10:04 A.M., Resident #43 said when it takes a long time for the call light to be acknowledged it makes him/her very anxious. During an interview on 01/15/25 at 10:13 A.M., Certified Nurse Aide (CNA) G said certain residents take more time than others. He/She said one resident takes 45 minutes to an hour each time they go in the room, and the resident requires two staff to provide cares. During an interview on 01/15/25 at 10:14 A.M., the Director of Nursing (DON) said the facility could use more CNAs. During an interview on 01/15/25 at 10:31 A.M., LPN C said on the evening shift the facility is short staffed. The LPN said staff are pulled away from their halls to other halls. The LPN said two, maybe three aides are being scheduled for a shift and the facility has several residents who require two people for cares. The LPN said the facility has one resident that pulls aides off their hall and the aides are in his/her room a minimum one to an hour and half at a time. The LPN said he/she has spoken to the DON about this numerous times. The LPN said it takes at least three if not four staff at a time to move a resident. During an interview on 01/15/25 at 11:22 A.M., the DON said he/she does not know why call lights are not answered timely. The DON said there is no way to tell if a CNA answered a call light, or who answered the call light. The DON said staff are pulled off their halls to answer call lights on other halls, and every staff member is responsible for answering call lights. The DON said the facility has a couple of residents that take a lot of time and staff for cares. The DON said the nurses or another staff member should answer call lights if the aides are busy. The DON said if four staff members are helping one resident the call light wait times will be longer because there is no staff answering lights on the other hall. The DON said recently, he/she has been running with minimal staff or fire code. The DON said with acuity in our facility, staffing for fire code is not appropriate. The DON said he/she has received complaints from residents about long call light wait times and one resident has complained about being left soiled for long periods of time. The DON said call light wait times get longer as the facility gets shorter staffed. The DON said he/she has not looked at the Facility Assessment. The DON said he/she has been told if he/she staffed to fire code, he/she will be alright. The DON said he/she sent emails to corporate about needing help in this building and does not even get a response. During an interview on 01/15/25 at 1:46 P.M., The Staffing Coordinator said the facility has staffing issues, and there are a lot of call-ins. The Staffing Coordinator said the facility currently only has three aides for evening shift. The Staffing Coordinator said staffing affects the call light wait times. The Staffing Coordinator said he/she has had complaints from residents about call light times being long and residents being left soiled for long periods of time. The Staffing Coordinator said he/she passes the information along to the charge nurses. The Staffing Coordinator said he/she has not read the Facility Assessment, he/she said, What's that?. The Staffing Coordinator said according to the DON, there is supposed to be two nurses each shift, five CNAs during the day, four CNAs in the evening and three CNAs on the overnight shift. The Staffing Coordinator said the facility is not meeting those numbers. The Staffing Coordinator said it takes three sometimes four aides to care for one of the residents. The Staffing Coordinator said during the evening when three to four staff care for one resident, there is no other staff to watch the residents for the rest of the building. The Staffing Coordinator said it takes 45 minutes to an hour for the three to four staff to provide care for the one resident. During an interview on 01/15/25 at 2:07 P.M., the administrator said there is a lot of holes in staffing. The administrator said typically the facility has three CNAs on the floor, one nurse and sometimes a CMT. The administrator said he/she did not know the facility did not have three CNAs and a nurse at times. The administrator said he/she looked at the Facility Assessment today and the facility is not staffing to the acuity shown in the Facility Assessment. The administrator said he/she has been made aware of the resident who takes three to four staff for care and is aware the staff are in the room for an hour. The administrator said nobody is providing care for the residents in the rest of building during the care for the one resident on evening shifts, It hurts me to say. The administrator said the care for one resident and staffing, absolutely has an impact on call light times. The administrator said corporate has been made aware of the staffing needs of the building. 45489 50361

Reviewed AT Based on interview and record review, facility staff failed to ensure the two-step purified protein derivative (PPD) (skin test for Tuberculosis (TB)) was completed for four employees (Staffing coordinator, Dietary Assistant L, Minimum Data Set (MDS) Coordinator, and Licensed practical nurse (LPN) K,) out of ten sampled employees. The facility census was 45. 1. Review of the facility's policy titled Tuberculosis (TB) Employee Screening, not dated, showed all employees are screened for Latent Tuberculosis Infection (LTBI) and active TB disease using tuberculin skin test (TST) or interferon gamma release assay (IGRA) and symptom screening prior to beginning employment. Each newly hired employee is screened for LTBI and active TB disease after an employment offer has been made but prior to the employee's duty assignment. Review of the Facility's Tuberculosis (TB) Testing Requirements, not dated, showed: -Upon hire or re-hire; -Step one: administer first TST following protocol; -Review result in 48-72 hours; -Negative induration is less than 10 millimeters (mm). Retest in 1-3 weeks after first test result date; -Document result in millimeters on TB screening record; -Step two: administer second TST; -Review result in 48-72 hours; -Document result in mm on TB screening record. Review of the Center for Disease Control and Prevention's, Clinical Testing Guidance for TB Skin Tests, dated May 14, 2024, showed: -Two-Step testing; -If the first skin test is negative, a second TB skin test should be done one to three weeks later; -The skin test reaction should be read between 48-72 hours after administration by a health care worker trained to read TB skin results. 2. Review of the staff coordinator's employee file showed a hire date of 09/05/24. Review showed the employee file did not contain documentation the second step PPD had been completed. 3. Review of Dietary Assistant L's employee file showed a hire date of 09/11/24. Review showed the employee file did not contain documentation the second step PPD had been completed. 4. Review of the MDS Coordinator's employee file showed a hire date of 10/24/24. Review showed the employee file did not contain documentation the second step PPD had been completed. 5. Review of LPN K's employee file showed a hire date of 11/27/24. Review showed the employees file did not contain documentation the two step PPD had been completed. 6. During an interview on 01/13/25 at 11:06 A.M., the business office manager said he/she is responsible for new employee screenings and the Director of nursing (DON) is responsible for ensuring the two step TBs are completed. He/She said he/she is not sure why the TBs were not completed timely and he/she believes it was an oversight. During an interview on 01/13/25 at 11:11 A.M., the DON said he/she was not aware there were employees whose two step TBs were not completed. He/She said it is the employee's responsibility to come back for their second step TB. He/She said he/she is not sure who is responsible for ensuring they are completed timely. During an interview on 01/13/25 at 02:19 P.M., the administer said it is the responsibility of both the business office manager and DON to ensure two step TBs are completed on new hires. He/She said he/she just started in December and did not know there were issues with TB's not being completed. He/She said he/she was made aware today and he/she believes there are issues with follow through in the current process.

Reviewed AT Based on observation, interview, and record review, facility staff failed to ensure four residents (Residents #1, #30, #15 and #17) of 18 sampled residents, wheelchairs were maintained in good repair. The facility census was 45. 1. Review of the facility policy titled, Maintenance Request Policy, undated, showed: -Mainenance forms are located at the nursing desk, staff are to fill out and place on clipboard; -The request is reviewed and repairs are done; -Maintenance staff performs the work and notes repairs in the TELS Electronic Maintenance Request program. Review of the facility policy titled, TELS Wheelchair Cleaning, undated, showed; -Night shift staff will do the inspections of each residents wheelchair and clean as necessary; -Staff will inform maintenance of any issues via the TELS program or logbook at the nursing station. 3. Review of the facility's maintenance requests and TELS program for the last 30 days did not contain a request for torn wheelchair armrests. 4. Review of the facility form titled, Director of Nursing (DON) Rounds, undated, showed the DON will complete rounds for observations of wheelchairs. 5. Observation on 01/12/25 at 3:45 P.M., showed Resident #1's wheelchair armrest with multiple cracks and the vinyl peeled away. The cracked vinyl had sharp edges. During an interview on 01/12/25 at 3:46 P.M., the resident said the armrest on his/her wheelchair is cracked. The resident said staff has been made aware of his/her armrest. During an interview on 01/15/25 at 9:57 A.M., Certified Nurse Aide (CNA) E said he/she noticed the left arm rest of the resident's wheelchair cracked and peeling. The CNA said he/she filled out a maintenance for back in July, and it has not been fixed. The CNA said he/she told the charge nurse it still hasn't been fixed. The CNA said the overnight CNAs should put in maintenance request when cleaning wheelchairs. During an interview on 01/15/25 at 10:13 A.M., CNA G said he/she did not notice the damage to the resident's wheelchair. The CNA said, Obviously I should notice, I put the resident in the wheelchair. The CNA said the damaged arm rest could cause breakdown on the resident's arm, because the resident's skin is so thin. 6. Observation on 01/15/25 at 9:21 A.M., showed Resident #30's wheelchair armrests cracked with the vinyl peeled back and exposed foam. During an interview on 01/15/25 at 9:57 A.M., CNA E said he/she has not noticed the resident's armrest. The CNA said he/she had not filled out a maintenance request for the resident's wheelchair. 7. Observation on 01/15/25 at 9:28 A.M., showed Resident #15's wheelchair with the left arm rest vinyl cover torn and in disrepair. During an interview on 01/15/25 at 10:13 A.M., CNA G said he/she did notice the damage to the resident's wheelchair but did not submit a maintenance request. He/Shee said he.she did not submit a request because overnight shift aides clean the wheelchairs and submit maintenance request if they see something that needs fixed. During an interview on 01/15/25 at 10:31 A.M., Licensed Practical Nurse (LPN) C said the resident's wheelchair armrest has been reported to the DON and they were looking into it, but that has been months ago. During an interview on 01/15/25 at 10:31 A.M., LPN C said the therapy department and the maintenance director maintain the resident wheelchairs. The LPN said if he/she has an issue with the wheelchairs he/she tells therapy or the maintenance director. The LPN said there is a form staff are supposed to fill out for maintenance. The LPN said he/she had not noticed any issues with resident wheelchairs and staff have not reported any issues. The LPN said if staff reported a wheelchair issue to him/her, he/she would make a report in the TELS system. The LPN said the night shift staff clean the wheelchairs and report any issues. The LPN said if the wheelchair armrests are broken, cracked or peeling it could cause skin tears. 8. Observation on 01/15/25 at 9:35 A.M., showed Resident #17's wheelchair armrest vinyl covers torn and in poor condition. During an interview on 01/15/25 at 10:13 A.M., CNA G said he/she did notice the damage to the resident's wheelchair armrest, but did not submit a maintenance request. He/She said the wheelchair armrest have been like that since she started and thought staff had already submitted a request for it. X. During an interview on 01/15/25 at 10:13 A.M., CNA G said the maintenance director maintains resident wheelchairs. The CNA said there is a clipboard behind the desk at the Nurse's Station. The CNA said staff are supposed to write requests on the clipboard and the maintenance director checks the clip board. During an interview on 01/15/25 at 10:53 A.M., the therapy director said staff should notify the therapy department using the clipboard at the nurses station if a wheelchair requires maintenance. He/She said staff have not reported any issues with any residents armrest. He/She said the therapy department has extra armrest and can change them out. He/She said he/she wouldn't want the torn vinyl to puncture the resident's skin and cause a skin tear. During an interview on 01/15/25 at 11:08 A.M., the maintenance director said he/she maintains the wheelchairs as well as the therapy department. If something needs fixed staff should write it on a maintenance request form that he/she keeps at the nurses' station. He/She said he/she has not received any requests in the TELS system for wheelchair repair. During an interview on 01/15/25 at 11:22 A.M., The DON said therapy and maintenance maintain the resident wheelchairs. Staff should fill out a maintenance sheet so the maintenance department knows a wheelchair needs to be fixed. The DON said there are a lot of cracked and peeling armrests in the facility. The DON said he/she did not report it to anyone because he/she did not know maintenance fixed the armrests. He/She said he/she did not know if staff knew how to report broken armrests. He/She said the cracked armrests could cause skin tears, or infection due to harboring bacteria. He/She said staff should report the damages to someone. During an interview on 01/15/25 at 2:06 P.M., the administrator said the night shift CNAs maintain and care for the wheelchairs. He/She said if it is a structural problem then maintenance must maintain it. Staff should fill out a maintenance request form for damage to wheelchair arm rests and he/she does not know why staff are not reporting the issues. The administrator said a cracked and peeling arm rest could cause skin tears and is a comfort issue. He/She said the DON is responsible for ensuring the nursing staff are cleaning and maintaining the wheelchairs on a daily basis. 45489

Based on interview and record review, the facility staff failed to designate a person to serve as the Director of Food and Nutrition Services with the appropriate qualifications, when the facility did not employ a qualified dietitian or other clinically qualified nutrition professional full-time. The census was 49. 1. Review of the dietary manager's (DM) personnel records, showed a hire date of 10/15/23. Review showed the records did not contain documentation of prior dietary manager experience in a long-term care facility and certification or other education required for the director of nutritional services position. During an interview on 11/07/23 at 9:52 A.M., the DM said he/she had prior experience as a DM in a long-term care facility from 2016 to 2019 and he/she became the DM for this facility on in October 2023. The DM said he/she did not have a degree or certification related to food service management and he/she had not completed or been enrolled in any other educational courses related to food safety and management. The DM said the facility had a part-time consultant registered dietician and did not have any certified or clinically qualified nutritional staff employed full-time. During an interview on 11/07/23 at 2:52 P.M., the administrator said the DM did not have a degree or certification related to food service management and he/she had not completed or been enrolled in any other educational courses related to food safety and management. The administrator said he/she knew the DM did not meet the qualifications to be the dietary manager, but thought the facility had a month to get the DM enrolled in courses to be certified. The administrator said the facility had a part-time consultant registered dietician and did not have any certified or clinically qualified nutritional staff employed full-time.

Based on observation, interview, and record review, facility staff failed to properly propel two residents (Resident #21 and #41) in their wheelchairs in a manner to prevent accidents and failed to ensure the residents' environment remained free of accident hazards when to staff failed to properly store razors. The facility census was 49. 1. Review of the facility's policies showed the facility did not provide a policy for wheelchair safety. 2. Review of Resident #21's Quarterly Minimum Date Set (MDS), a federally mandated assessment tool dated 08/21/23, showed staff assessed resident as: -Cognitively intact; -Uses a wheelchair; -Required total dependence of staff when wheeled 150 feet; -Diagnosis of multiple sclerosis (a long-lasting disease of the central nervous system). Observation on 11/06/23 at 10:28 A.M., showed Licensed Practical Nurse (LPN) C propelled the resident through the opened shower room door, in his/her wheel chair back wards into the shower room. 3. Review of Resident #41's Quarterly MDS, dated [DATE], showed staff assessed resident as: -Severe cognitive impairment; -Uses a wheelchair; -Required total dependence of staff when wheeled 150 feet; -Diagnosis of aphasia (loss of ability to understand or express speech, caused by brain damage), dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), and Alzheimer's disease (progressive disease beginning with mild memory loss and possibly leading to loss of the ability to carry on a conversation and respond to the environment). Observation on 11/06/23 at 12:26 P.M., showed an unknown staff member propelled Resident #41 through the dining hall. The resident's right foot hung off the back of the foot pedal and the right heel rubbed the floor. 4. During an interview on 11/09/23 at 3:36 P.M., the Director of Nursing (DON) said residents should have foot pedals on their chair with their feet properly placed on top before pushing the resident. He/She said failure to have feet properly place could result in injury. During an interview on 11/09/23 at 4:13 P.M., the administrator said if a resident is not able to maneuver themselves then the resident should have foot pedals on their wheel chair before staff push them. He/She said staff should have them positioned properly with their feet on the pedals and their body a lined. He/She said he/she expects his/her staff to always push forward and never pull or push residents backwards in their wheel chairs. He/She said not propelling residents safely in wheel chairs can result in injury. 5. Review of the facility's policies showed the facility did not provide a policy for razor or chemical storage. 6. Observation on 11/06/23 at 10:18 A.M., showed the shower door unlocked with razors present. Observation on 11/07/23 at 9:51 A.M., showed the shower door unlocked with razors present. Observation on 11/08/23 at 3:35 P.M., showed the shower door unlocked with razors present. Observation on 11/09/23 at 2:39 P.M., showed the shower door unlocked with razors present. 7. During an interview on 11/09/23 at 2:39 P.M., Certified Nurse Aide (CNA) B said the shower door does lock but it sticks so it has to be pulled shut really hard. He/She said the shower door is supposed to remain shut at all times so a resident is not in there by themselves and gets hurt. He/She said razors and chemicals should always be locked up in the shower room or the supply room for resident safety. He/She said it is everyone's responsibility to make sure the shower door is closed and locked and he/she should have paid attention to that as well because he/she was here the last two days even though he/she was not on showers. During an interview on 11/09/23 at 3:36 P.M., the DON said residents should not have access to razors or chemicals and they should be locked up in cabinets. He/She said shower doors should be locked with a code to open, and should never be propped open. He/She said if shower rooms are left open there is a risk that residents could get into things that have been left out or get locked inside. During an interview on 11/09/23 at 4:13 P.M., the administrator said residents should not have access to razors of chemicals. He/She said they should be stored behind a locked cabinet. He/She said the shower room door should be locked at all times and the door should never be propped open.

Based on observation, interview, and record review, facility staff failed to provide reasonable accommodations to meet the needs of the residents by failing to keep the call lights within reach for three residents (Resident #5, #14, and #41) and failed to accommodate a resident with bariatric needs for one resident (Resident #6) The facility census was 49. 1. Review of facility's Call Light policy, revised March 2021, showed, when a resident is in bed or confined to a chair that the call light is within easy reach of the resident. 2. Review of Resident #5's Quarterly Minimum Data Set (MDS), a federally mandated assessment tool, dated 07/10/23, showed staff assessed resident as: -Moderately cognitively impaired; -Diagnoses of Alzheimer (progressive disease that destroys memory and other important mental functions), aphasia (trouble with speaking, understanding speech, or reading or writing as a result of damage to the part of the brain that is responsible for language processing or understanding), dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities) and traumatic brain dysfunction (TBI - Brain dysfunction caused by an outside force, usually a violent blow to the head); -Supervised or touching assistance needed with sit to stand, chair to bed transfers and toilet transfers. Review of the resident's care plan, reviewed on 12/22/22, showed the facility staff were directed to encourage the resident to use the call light. Observation on 11/06/23 at 10:18 A.M., showed the resident in bed with his/her call light wrapped around the call light box and out of his/her reach. Observation on 11/07/23 at 9:51 A.M., showed the resident in bed with his/her call light wrapped around the call light box and out of his/her reach. Observation on 11/08/23 at 1:28 P.M., showed the resident in bed with his/her call light wrapped around the call light box and out of his/her reach. Observation on 11/09/23 at 11:13 A.M., showed the resident in bed with his/her call light wrapped around the call light box and out of his/her reach. 3. Review of Resident #14's Annual MDS, dated [DATE], showed staff assessed resident as: -Moderately cognitively impaired; -Diagnoses of dementia, and cataracts (clouding of the clear lens of the eye); -Partial or moderate assistance needed with sit to stand, chair to bed transfers and toilet transfers. Review of the resident's care plan, reviewed on 01/04/23, showed the facility staff were directed to encourage the resident to use the call light. Observation on 11/06/23 at 10:29 A.M., showed the resident sat in his/her wheelchair in his/her room with the call light out of his/her reach. Observation on 11/06/23 at 10:31 A.M., showed an unknown staff entered the resident's room and did not place the call light in the residents reach when he/she left the room. Observation on 11/06/23 at 2:50 P.M., showed the resident sat in his/her wheelchair in his/her room with the call light out of his/her reach. Observation on 11/07/23 at 2:52 P.M., showed the resident sat in his/her wheelchair in his/her room with the call light out of his/her reach. Observation on 11/07/23 at 3:48 P.M., showed Licensed Practical Nurse (LPN) C in the residents room for wound care and did not place the resident's call light in reach when he/she left the room. Observation on 11/08/23 at 9:13 A.M., showed the resident sat in his/her wheelchair in his/her room with the call light out of his/her reach. 4. Review of Resident #41's Quarterly MDS, dated [DATE], showed staff assessed the resident as: -Severely cognitively impaired; -Diagnoses of Alzheimer, aphasia, dementia, and seizures; -Complete dependence on staff assistance for sit to stand, chair to bed transfers and toilet transfers. Review of the resident's care plan, reviewed on 10/14/22, showed the facility staff were directed to keep the resident's call light in reach and encourage the resident to use the call light. Observation on 11/09/23 at 11:13 A.M., showed the residentin bed with his/her call light under his/her bed and out of his/her reach. 5. During an interview on 11/09/23 at 2:39 P.M., Certified Nursing Assistant (CNA) B said call lights should always be within reach of the resident, not wrapped around anything and easily accessible, clipped on their shirt or blanket. He/She said it is important for residents to have their call lights in place so they do not fall out of bed, it is a safety issue. During an interview on 11/09/23 at 2:47 P.M., Licensed Practical Nurse (LPN) A said all resident should have call lights in place at all times, pinned to the pillow or chair so it does not fall in the floor. He/She said it should never be wrapped around the call light box or under the bed. He/She said the call light not in reach is a fall risk and it's how residents access help. During an interview on 11/09/23 at 3:27 P.M., the Director of Nursing (DON) said call lights should always be within reach of the resident, not under the bed. Call lights are the resident's means to call for help. He/She is not sure if anyone needs an accommodation for a different call light. During an interview on 11/09/23 at 4:13 P.M., the administrator said call lights need to be in resident's reach so they can get help if they need it, he/she staff are constantly in serviced on this. He/She does not know why it is not getting done. 6. Review of the facility's Bariatric Patient Policy, undated, showed: -The facility will ensure the safe handling and care of the bariatric patient/resident, including situations which may require immediate, urgent or emergent transport and evacuation; -Bariatric patients/residents are evaluated upon admission for mobility and functional status, including the use of transfer and mobility aides. These devices may include: walker, cane, hoyers, wheelchair and other devices or aides. 7. Review of Resident #6's Quarterly MDS, dated [DATE], showed staff assessed the resident as: -Cognitively intact; -Complete dependence on staff assistance for sit to stand, chair to bed transfers and toilet transfers and showering; -Electric wheelchair with pressure relieving device; -Moisture associated skin damage; -Very important to choose between a tub bath, shower, bed bath or sponge bath. Review of the resident's care plan, dated 12/20/22, showed the facility staff were directed to shower the resident twice weekly and provide a sponge bath if a full shower cannot be tolerated. During an interview on 11/06/23 at 10:31 A.M., the resident said he/she only gets bed baths because the staff told him/her that he/she is too big for the shower chair and makes it bend. During an interview on 11/08/23 at 3:28 P.M., the resident said his/her not getting a proper shower is not a one-time thing, that this has been going on for at least 6 months and he/she knows his/her weight is a problem but it makes him/her feel gross to only get a bed bath, if staff could just shower him/her one time a week it would be better. During an interview on 11/08/23 at 4:23 P.M., the administrator said that he/she does not have a manual for the current shower chair and because it is discontinued they cannot get it online but he/she called the company and the current shower chair is weight rated for 425 pounds. He/She did not realize the resident was not getting showered because he/she was too big for the chair because the resident is only 4 pounds over and is not sure how long this has been going on. During an interview on 11/09/23 at 2:47 P.M., LPN A said the resident's chair is too small for him/her and they need to try and get him/her a new one. He/She said He/She is not sure if they have a shower chair that would accommodate his/her weight. His/Her expectation is if the resident needs it then the facility should order it, if they are going to accept bariatric patients then they need bariatric accessories to keep him/her safe. His/Her concern is the resident's safety is at risk because the shower chair is made of PVC (Polyvinyl chloride) and it could break During an interview on 11/09/23 at 3:27 P.M., The DON said if the facility receives a referral for a resident that is bariatric, the facility makes sure the proper equipment is in place. If the correct proper equipment is not available at the facility we will rent and then buy the equipment. He/She said a new shower chair also needs to be ordered to make sure the resident is safe, he/she is not aware how long this has been going on. During an interview on 11/09/23 at 4:13 P.M., the administrator said the facility is ordering supplies for the resident now. He/She does not believe that the resident has only been getting bed baths for 6 months. Review of the Micro Compact Powerbase Wheelchair manual, undated, showed: -Model No: P327 4 posts weight capacity 300 lbs. Review of the residents weights showed: October 22- 338.8 lbs (pounds) [DATE] -343.5 lbs [DATE]- 392.4 lbs [DATE]- 385.6 lbs [DATE]- 385.4 lbs [DATE]- 384.5 lbs May 23- 381.9 lbs June 23- 390.1 lbs July 23- 429.0 lbs [DATE]- 433.6 lbs Sep 23- 429.2 lbs [DATE]- 429.0 lbs During an interview on 11/08/23 at 3:56 P.M., the physical therapist said he/she is aware the resident is too big for his/her chair and that is could cause issues with his/her pressure ulcers and skin issues. He/She believes the resident is in powerchair 327 with a weight limit of 300 pounds, the chair is a loaner the facility rented because the standard wheelchair they had for the resident bent the wheel and tire and was unsafe. He/She said insurance will not approve the resident for a power chair and he/she is unsure what to do next. During an interview on 11/09/23 at 2:39 P.M., CNA B said the resident's wheelchair is too small for him/her, he/she said this is a big safety concern and also a concern for the resident's skin integrity because the chair rubs and causes wounds which he/she already suffers from. During an interview on 11/09/23 at 2:47 P.M., LPN A said the resident is too large for his/her wheelchair. The resident utilizing accessories that are too small for him/her could cause skin breakdown and pressure ulcers. During an interview on 11/09/23 at 3:27 P.M., The DON said if the facility receives a referral for a resident that is bariatric, the facility makes sure the proper equipment is in place. If the correct proper equipment is not available at the facility we will rent and then buy the equipment. He/She said the owner would buy the correct wheelchair for the facility and it would be utilized by the resident if insurance denied the claim. He/She said the resident should be re-measured for a new chair if it is too small. During an interview on 11/09/23 at 4:13 P.M., the administrator said the facility is ordering supplies for the resident now. He/She said if they cannot get the resident a power wheelchair due to insurance he/she will have to use a manual. He/She has not spoken with owner ship about a new chair for the resident. Observation on 11/07/23 at 9:42 A.M., showed CNA H and CNA M performed perineal care on the resident. Staff moved the resident from side to side to place the clean brief. CNA H placed a peri pad in the front of the brief to cover the resident's front side. Further observation showed staff struggled to latch the sides of the brief and the brief just barely covered his/her back and front side. During an interview on 11/06/23 at 10:31 A.M., the resident said he/she has an issue with getting briefs that fit him/her, he/she said they use a too small brief and then a pad they usually lay under residents because they don't order him/her bariatric briefs. During a phone interview on 11/27/23 at 10:18 A.M., the administrator said that the resident has bariatric briefs and they have only had one instance to her knowledge where they ran out due to a supplier change. He/She said it was over the summer and not when state was in the building. He/She said he/she was not aware staff were not using the correct briefs on the resident. He/She said it is dangerous for him/her to wear too small of briefs because it can cause skin issues and breakdown and wont properly complete the job as its supposed too.

Based on interview and record review, facility staff failed to check the Certified Nurse Assistant (CNA) Registry for all staff prior to hire to ensure they did not have a Federal Indicator (a marker given by the federal government to individuals who have committed abuse and/or neglect) as direted by the facility policy for five employees (maintenance director, admissions coordinator, licensed practical nurse (LPN) C, housekeeper D and dietary aide E) out of a sample of six. The facility census was 49. 1. Review of the facility's Abuse Prevention Program policy, revised December 2016, showed the facility will conduct background checks and will not knowingly employ or otherwise engage any individual who has: -Been found guilty of abuse, neglect, exploitation, misappropriation of property, or mistreatment by a court of law; -Have a finding entered into the state nurse aide registry concerning abuse, neglect, exploitation, misappropriation of property; -Have a disciplinary action in effect against his/her professional license by a state licensure body as a result of a finding of abuse, neglect, exploitation, misappropriation of property. 2. Review of the Maintenance Director's employee file showed a hire date of 05/04/23. Review showed staff documented the CNA registry checked on 05/09/23(five days after hire). 3. Review of the Admission Coordinator's employee file showed a hire date of 08/18/23. Review showed staff documented the CNA registry checked on 11/06/23 (80 days after hire). 4. Review of LPN C's employee file showed a hire date of 05/02/23. Review showed of the employee file did not contain documentation of the CNA registry check. 5. Review of Housekeeper D's employee file showed a hire date of 04/10/23. Review showed of the employee file did not contain documentation of the CNA registry check. 6. Review of Dietary Aide E's employee file showed a hire date of 10/10/22. Review showed of the employee file did not contain documentation of the CNA registry check. 7. During an interview on 11/09/23 at 3:52 P.M., the human resources director said he/she is responsible for the back ground checks on all staff. He/She only runs CNA registry on the nursing department staff. He/She was not aware that all staff need the CNA registry check. During an interview on 11/6/23 at 3:50 P.M., the Director of Nursing (DON) said he/she was not aware that the CNA registry was not being checked on everyone. He/She said he/she is aware it needs to be done on all employees before hire. During an interview on 11/6/23 at 4:40 P.M., the Administrator said the business office manager (BOM) is responsible for doing the registry checks, however she does not think the BOM is aware that this was to be done on everyone. The administrator said she was also not aware this process needed to be done on every employee no matter their job.

Based on interview and record review, the facility staff failed to complete the required Minimum Data Set (MDS), a federally mandated resident assessment, within the required timeframe for four sampled residents (Residents #13, #20, #29, and #104). The facility census was 49. 1. Review of the facility's Electronic Transmission of the MDS policy, revised November 2019, showed all MDS assessments (e.g., admission, annual, significant change, quarterly review, etc.) and discharge and reentry records are completed and electronically encoded into out facility's MDS information system and transmitted to Centers for Medicare & Medicaid Services (CMS) QIES Assessment Submission and Processing (ASAP) system in accordance with currant Omnibus Budget Reconciliation Act (OBRA) regulations governing the transmission of MDS data. Review of the Resident Assessment Instrument (RAI) manual version 3.0 RAI OBRA-required Assessment Summary showed assessment time frames as follows: -Entry MDS completion date no later than the 7th calendar day from the resident's entry into the facility and submitted no later than 14 days from the date of entry into the facility; -Admission (Comprehensive) MDS completion date no later than 14th calendar day of the resident's admission and submitted no later than 14 calendar days from the care plan completion date; -Quarterly (Non-Comprehensive) MDS completion date not later than Assessment Reference Date (ARD) + 14 calendar days; -Quarterly assessment for a resident must be completed at least every 92 days following the previous OBRA assessment of any type; -Discharge Assessment for a resident must be completed no later than 14 days from the date of discharge and submitted by the MDS completion date plus 14 calendar days. 2. Review of Resident #13's MDS record showed: -Admission MDS dated [DATE]. -Did not contain a completed quarterly assessment for 04/2023. 3. Review of Resident #20's MDS record showed: -Admission MDS dated [DATE]; -Did not contain a completed quarterly assessment for 10/2023. 4. Review of Resident #29's MDS record showed: -Admission MDS dated [DATE]; -Did not contain a completed discharge assessment within the required time frame. Review of the resident's medical record showed the resident discharged on [DATE]. 5. Review of Resident #104's MDS record showed: -Entry track record 09/28/23. -Did not contain a completed admission assessment within the required time frame. 6. During an interview on 11/06/23 at 3:50 P.M., the Director of Nursing (DON) said currently he/she is responsible for MDS. He/She said the reason MDS are either late or not done is due to the previous MDS coordinator, just not doing them. The DON said the expectation is for the MDS's to be up-to-date and submitted timely. During an interview on 11/06/23 at 4:40 P.M., the Administrator said the DON role is responsible right now for MDS process. The administrator said the previous MDS coordinator was not doing their job, he/she was audited by the corporation often so she is unsure how it wasn't brought to anyone's attention that they weren't being done. The expectation is for the MDS information is up to date. 43024

Based on observation, interview, and record review, facility staff failed to maintain professional standards of care when they failed to have physician orders and documentation for self-care of a tracheostomy (a procedure where an opening is created in the neck so a tube can be inserted into the trachea(windpipe) from the outside of the neck to help air and oxygen reach the lungs) for one resident (Resident # 2), and failed to complete assessments after unwitnessed falls for six residents (Resident #9, #11, #15, #22, and #27). The facility census was 49. 1. Review of the facility's Tracheotomy Care policy, revised August 2013, showed tracheotomy tubes should be changed as ordered and as needed (at least monthly). 2. Review of Resident #2's Minimum Date Set (MDS), a federally mandated assessment tool, dated 10/07/23, showed staff assessed the resident as follows: -Cognitive intact; -Did not assess the resident's functional ability for self-care; -Tracheotomy care; -Diagnosis of Dementia and Cancer. Review of the resident's care plan, dated November 2023, showed the record did not contain direction on care of the tracheotomy. Review of the resident's Physician Order Sheet (POS), dated November 2023, showed the record did not contain an order for tracheotomy care. During an interview on 11/07/23 at 11:30 A.M., the Director of Nursing (DON) said the resident does their own trach care, and eats and drinks own his/her own. During an interview on 11/09/23 at 3:12 P.M., Licensed Practical Nurse (LPN) A said any time a resident self-administers a medication or care it should have an order and should be care planned. During an interview on 11/09/23 at 3:50 P.M., the DON said the expectation for a resident who provides their own care, or treatment is that there should be a physician order and be care planned. During an interview on 11/09/23 at 4:40 P.M., the Administrator said there should be a physician order for the resident to provide his/her own care and she would expect it to be care planned. 3. Review of the facility's Assessing Falls and Their Causes policy, revised March 2018, showed after a fall staff are directed to: -Obtain and record vital signs as soon as it is safe to do so; -Observe for delayed complications of a fall for approximately forty-eight (48) hours after an observed or suspected fall, and will document findings in the medical record. 4. Review of Resident #9's Quarterly MDS, dated [DATE], showed staff assessed the resident as: -Severe cognitive impairment; -Required maximal assistance with from staff with shower/bathing, and sit to stand; -Dependent on staff for toileting; -Diagnosis of Dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities) , and seizure disorder. Review of the resident's nurse's notes, dated 10/24/23 showed staff documented the resident had an unwitnessed fall. Review of the resident's medical record showed the record did not contain documentation staff assessed the resident for delayed complications of a fall for approximately fourty-eight hours after observed or suspected fall. 5. Review of Resident #11's quarterly MDS, dated [DATE], showed staff assessed the resident as follows: -Severe cognitive impairment; -Diagnosis of dementia and Alzheimer's disease (progressive disease beginning with mild memory loss and possibly leading to loss of the ability to carry on a conversation and respond to the environment). Review of the resident's 72 hour post fall assessment showed the resident had a fall on 10/16/23. Review of the resident's nurse's notes showed the record did not contain documentation the resident had a fall. Review of the resident's medical record showed the record did not contain documentation staff assessed the resident for delayed complications of a fall for approximately fourty-eight hours after observed or suspected fall. 6. Review of #15's Quarterly MDS, dated [DATE], showed staff assessed the resident as: -Cognitively impaired; -Diagnoses of dementia. Review of the resident's nurses' notes, dated 8/10/23, showed at 10:07 P.M., the resident had an unwitnessed fall. Review of the resident's medical record showed the record did not contain documentation staff assessed the resident for delayed complications of a fall for approximately fourty-eight hours after observed or suspected fall. 7. Review of #22's Quarterly MDS, dated [DATE], showed staff assessed the resident as: -Cognitively impaired; -Diagnoses of dementia. Review of the resident's nurses' notes, dated 11/02/23, showed at 7:08 P.M., the resident stated he/she hit his/her head on the side table and did not alert nurse. Staff noticed bruise on forehead at lunch today. Denies pain or discomfort. Review of the resident's medical record showed the record did not contain documentation staff assessed the resident for delayed complications of the fall for approximately fourty-eight hours after observed or suspected fall. 8. Review of Resident #27's quarterly MDS, dated [DATE], showed staff assessed the resident as follows: -Utilized a wheelchair for mobility; -Diagnoses of dementia. Review of the resident's fall report, dated 09/15/23, showed the resident had an unwitnessed fall. The resident was found on his/her back between the bed and the wall. The resident said he/she hit his/her head and was confused. The resident was transported to the hospital at 7:30 P.M Review of the resident's nurses' notes, dated 09/16/23, showed at 11:59 P.M. the resident returned from the hospital. Review of the resident's medical record showed the record did not contain documentation staff assessed the resident for delayed complications of a fall for approximately fourty-eight hours after observed or suspected fall. During an interview on 11/09/23 at 3:12 P.M., LPN A said after a fall the nurse should assess the resident, neurological assessment is done, for a head injury or if it is a unwitnessed fall. LPN A said the resident is to monitored for 72 hrs after the unwitnessed fall or head impact fall. LPN A said they have a form they fill out and it is turned into DON. During an interview on 11/09/23 at 3:50 P.M., the DON said neurological assessments are done on paper, they do them on any fall not that is unwitnessed or if the resident hit their head. The DON said there should also be a progress note, and a neurological assessment form filled out for each of those type of falls. The DON said, I'm not sure why some the assessments weren't done or they weren't able to find them. During an interview on 11/09/23 at 4:40 P.M., the Administrator said neurological assessments use to be in Point Click Care, but now they are a paper form, that gets filled out and filed in the DON's office and he/she would upload them. The administrator said care plans and progress notes should be updated for every fall. The administrator said she thought they were being done, and nothing alerted her to say they weren't. 47193

Based on observation, interview and record review, facility staff failed to accurately complete entrapment assessments for bed rails for four residents (Resident #5, #6, #41 and #103). The facility census was 49. 1. Review of the facility's Restraints: Bed Rail Safety Check, undated, directed staff as follows: -When using bed rails, close attention must be given to the design of the rails and the relationship between rails and other parts of the bed; -Seven areas in the bed system that are a potential for entrapment, entrapment may occur in flat or raised bed positions , with the rails partially or fully raised; -Regularly inspect each of the seven areas on each bed with restraints - use the bed rail safety check to determine if a resident's bed meets the safety measurement requirements suggested by the United States Food and Drug Administration (FDA). For each side, go through every zone and measure according to the FDA instructions, document each measurement and indicate whether the zone passed or failed for each resident. 2. Review of Resident #5's Quarterly Minimum Data Set (MDS), a federally mandated assessment tool, dated 10/10/23, showed staff assessed the resident as: -Cognitively impaired; -Diagnoses of Dementia (loss of cognitive functioning thinking, remembering, and reasoning), hip fracture (a break in the bone of the hip), Alzheimer's (progressive disease that destroys memory and other important mental function), aphasia (loss of ability to understand or express speech, caused by brain damage), traumatic brain injury (TBI, injury to the brain), anxiety (a feeling of fear, dread, and uneasiness), depression (low mood), psychotic disorder (loss of contact with reality), and post traumatic stress disorder (PTSD), past traumatic event that causes distress; -Required supervision for bed mobility; -Bed rails not used. Review of the resident's medical record showed the record did not contain documentation staff completed an entrapment assessment. Observation on 11/06/23 at 10:18 A.M., showed the resident in bed with the left bed rail in the upright position. Observation on 11/07/23 at 9:51 A.M., showed the resident in bed with the left bed rail in the upright position. Observation on 11/07/23 at 1:28 P.M., showed the resident in bed with the left bed rail in the upright position. 3. Review of Resident #6's Quarterly MDS, dated [DATE], showed staff assessed the resident as: -Cognitively intact; -Diagnoses of deep vein thrombosis (DVT - a medical condition that occurs when a blood clot forms in a deep vein), arthritis (inflammation of the joints), stroke (occurs when something blocks blood supply to part of the brain or when a blood vessel in the brain bursts), anxiety, depression and PTSD; -Required maximum assistance for bed mobility; -Bed rails not used. Review of the resident's medical record showed the record did not contain documentation staff completed an entrapment assessment. Observation on 11/07/23 at 9:42 A.M., showed the resident in bed with the right bed rail in the upright position. 4. Review of Resident #41's Quarterly MDS, dated [DATE], showed staff assessed the residents as: -Severely cognitively impaired; -Diagnoses of Alzheimer, aphasia, dementia, seizures (temporary abnormalities in muscle tone or movements), and malnutrition; -Required partial assistance for bed mobility; -Bed rails not used. Review of the resident's medical record showed the record did not contain documentation staff completed an entrapment assessment. Observation on 11/06/23 at 2:49 P.M., showed the resident in bed with bilateral bed rails in the upright position. 5. Review of Resident #103's medical record showed the resident with an admitted [DATE]. Review of the resident's medical record showed the record did not contain documentation staff completed an entrapment assessment. Observation on 11/06/23 at 10:45 A.M., showed the resident in bed with the left bed rail in the upright position. Observation on 11/06/23 at 2:52 P.M., showed the resident in bed with the left bed rail in the upright position. Observation on 11/07/23 at 9:56 A.M., showed the resident in bed with the left bed rail in the upright position. Observation on 11/07/23 at 2:53 P.M., showed the resident in bed with the left bed rail in the upright position. 6. During an interview on 11/08/23 at 2:33 P.M., the administrator said they can not find documentation that the assessments were completed. During an interview on 11/09/23 at 2:47 P.M., Licensed Practical Nurse (LPN) A said the facility does not use bed rails at the facility because it is an entrapment risk. During an interview on 11/09/23 at 3:14 P.M., the maintenance director said he/she is in charge of entrapment assessments. He/She says it is a form that they are required to fill out to show the entrapment assessments were done. He/She said there is not measurements required just a visual check. He/She said the checks are not required often because the resident is fitted to the bed upon admission. During an interview on 11/09/23 at 3:27 P.M., the Interim Director of Nursing (DON) said he/she believes maintenance is in charge of entrapment assessment at least quarterly and with any mattress changes. During an interview on 11/09/23 at 4:13 P.M., the administrator said entrapment measurements need to be done monthly by maintenance. He/She said he/she was shocked that entrapment assessments were not completed because he/she knows some did get completed but now the file can not be located. He/She said they need to be done because they can be considered a restraint. 47193

Based on interview and record review, facility staff failed to provide the services of a registered nurse (RN), for at least eight (8) consecutive hours per day, seven days a week. The facility census was 49. 1. Review of the facility's Staffing, Scheduling and Postings Policy, revised October 24, 2022, showed the facility must use the services of a registered nurse for eight consecutive hours a day, seven days per week, unless a wavier applies. The facility will employ sufficient nursing staff as determined by resident assessments and individual plans of care. Review of the facility's Facility Assessment Tool, Dated 5/22/23, showed staff it directed facility staff to staff the following way: -Director of Nursing (DON): 1 DON RN full-time days; -Assistant Director of Nursing (ADON): full-time days; -Registered Nurse (RN) or Licensed Practical Nurse (LPN): one for each shift. Review of the facility's Hours Worked Report, dated 09/1/23 - 11/05/23, showed the facility did not have an RN for eight consecutive hours on 9/2, 9/3, 9/09, 9/10, 9/16, 9/17, 9/23, 9/24, 9/30, 10/1, 10/7, 10/8, 10/14, 10/15, 10/21, 10/22, 10/28, 10/29, 11/4, and 11/5. During an interview on 11/07/23 at 9:18 A.M., the Director of Nursing (DON) said he/she is the interim DON. The previous DON quit on 10/27/23 and his/her first day was 10/29/23. He/She said the DON was previously the only RN in the building and took call on the weekends. He/She said they did not have the eight hours a day seven days a week coverage. He/She said he/she is now currently the only RN in the building. He/She works Monday through Friday and takes call on the weekends. During an interview on 11/07/23 at 4:55 P.M. the administrator said he/she is aware that it is a requirement to have RN coverage for eight consecutive hours seven days a week. He/She said the interim DON is the only RN they have right now and he/she only takes call on the weekends.

Based on observation, interview and record review, facility staff failed to use appropriate infection control procedures to prevent the spread of bacteria or other infectious causing contaminants when staff failed to wash or sanitize their hands in between glove changes during perineal care for two residents (Resident #6 and #7), failed to wash or sanitize their hands in between gloves changes, did not wash or sanitize their hands before preparing wound dressing supplies, and did not provide a barrier for wound care suppplies for one resident (Resident #4). Facility staff failed to wash or sanitize their hands or wear gloves during wound care for one resident (Resident #21), failed to maintain transmission based precautions to prevent the transmission of ESCHERICHIA COLI- Extended Spectrum Beta-Lactamase ([E.Coli-ESBL] (E. coli that produces the enzyme ESBL, which makes the germ harder to treat and resistant to antibiotics) for one residents (Resident #27) . Facility staff failed to ensure all residents were screened for Tuberculosis (TB) (a potentially serious infectious bacterial disease that mainly affects the lungs) when staff failed to ensure a two-step purified protein derivative (PPD) (skin test for TB) and/or annual PPD tests were completed and documented as per the facility policy for three residents (#21, #43, and #47). The facility census was 49. 1. Review of the facility's Handwashing/Hand Hygiene policy, revised August of 2019, showed staff were directed as follows: -All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents and visitors; -Wash hands with soap (antimicrobial or non-antimicrobial) and water for the following situations: i.When hands are visibly soiled; -Use alcohol-based hand rub containing at least 62% alcohol, or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: i.Before and after direct contact with the residents; ii.Before moving from a contaminated body site to a clean body site during resident care; iii.after contact with a resident's skin; iv.After removing gloves; -Hand hygiene is the final step after removing and disposing if personal protective equipment; -Single use disposable gloves should be used: i.When anticipating contact with blood or body fluids; ii.When in contact with a resident, or the equipment or environment of a resident, who is on contact precautions. Review of the facility's Personal Protective Equipment-Gloves policy, revised July 2009, showed staff were directed to the following: -All employees must wear gloves when touching blood, bodily fluids, secretions, excretions, mucous membranes and/or non-intact skin; -The use of disposable gloves is indicated: i.When it is likely that the employee's hands will come in contact with blood, bodily fluids, secretions, excretions, mucous membranes, and/or non-intact skin while performing the procedure; ii.When handling soiled linen or items that may be contaminated; iii.When examining abraded or non-intact skin or patients with active bleeding; iv.During all cleaning of blood, bodily fluids, and decontaminating procedures -Wash your hands after removing gloves. Review of the facility's Perineal Care policy, revised February 2018, showed staff were directed as follows: -Wash and dry hands thoroughly; -Put on gloves; -Wash perineal area; -Remove gloves and discard into designated containers; -Wash and dry hands thoroughly; -Reposition the bed covers. Make resident comfortable; -Wash and dry hands thoroughly. 2. Review of Resident #6's Quarterly Minimum Date Set (MDS), a federally mandated assessment tool, dated 9/23/23, showed staff assessed the resident as: -Cognitively intact; -Required total dependence on staff for toileting, showing, bathing, and lower body dressing; -Required substantial maximal assistance with upper body dressing; -Always incontinent of bowel and bladder. Observation on 11/07/23 at 9:42 A.M., showed certified nurse aide (CNA) M and CNA H entered the resident's room to provide perineal care. CNA M cleaned the resident's front side, removed gloves and did not perform hand hygiene before he/she replaced his/her gloves. CNA H assisted the resident to roll to his/her right side and held the resident there while CNA M cleaned the resident's back side. CNA M did not perform hand hygeine in between glove changes after his/her right glove became soiled. CNA M then wiped the resident multiple times before he/she changed his/her gloves and did not perform hand hygiene. CNA H touched his/her face with gloved hands and rolled the resident to his/her left side. CNA M and CNA H removed their gloves and did not perform hand hygiene before they applied new gloves. CNA H placed the clean brief to the backside of the resident and assisted the resident to roll over flat. CNA H observed bowel movement on the resident's inner thighs. CNA M did not perform hand hygeine in between glove changes after he/she cleaned the resident's soiled legs or before he/she and CNA M placed the resident's clean brief. CNA H and CNA M removed their gloves and did not wash his/her hands before they applied new gloves. CNA M and CNA H assisted the resident with dressing and his/her glasses, removed thier gloves and did not perform hand hygiene. CNA H and CNA M did not perform hand hygiene before they left the residents room. 3. Review of Resident #7's Quarterly MDS dated [DATE], showed staff assessed the resident as: -Severe cognitive impairment; -Dependent on staff for mobility and toileting; -Always incontinent of bowel and bladder. Observation on 11/7/23 at 2:50 P.M., showed Nurse Aid (NA) G and CNA F entered the resident's room to provide perineal care. CNA G and CNA F performed hand hygiene and applied gloves. CNA F wiped the resident's front perineal area and continued to wear the same gloves and rolled the resident to his/her left side. NA G wiped the resident's back side multiple times with the same area of the wipe and applied barrier cream to the resident's bottom. With the same gloves NA G and CNA F placed a clean brief on the resident and placed a blanket on the resident. Observation showed NA G and CNA F did not perform hand hygiene before they left the residents room. During an interview on 11/07/23 at 2:50 P.M., CNA F said he/she should have changed their gloves between dirty and clean tasks. He/She said when you are in the flow of things, it is not something you always think about. CNA F said he/she knows after care is provided, staff should wash their hands before they leave the room. 4. During an interview on 11/09/23 at 2:58 P.M., Licensed Practical Nurse (LPN) A said he/she expects staff to perform hand hygiene when entering and exiting a resident room, any time staff change their gloves, in-between clean and dirty tasks, and any time their gloves become soiled. He/She said staff are allowed to sanitize but are expected to wash their hands with soap after the third time. During an interview on 11/09/23 at 3:36 P.M., the Director of Nurse (DON) said he/she expects staff to remove their gloves and wash hands when they enter and exit a resident room, when their gloves become soiled, and when they move from dirty to clean tasks. He/She said any time staff remove their gloves they should perform hand hygiene. During an interview on 11/09/23 at 4:13 P.M., the administrator said he/she expects staff to use hand hygiene when they enter or exit a resident's room, before they put on gloves, and any time their gloves become soiled or they change their gloves. 5. Review of the facility's Wound care policy, revised October 2010, showed staff were directed to the following: -Use disposable cloth (paper towel is adequate) to establish clean field on resident's overbead table. Place all items to be used during procedure on the clean field; -Wash and dry your hands thoroughly; -Put on exam gloves. Loosen tape and remove dressing; -Pull glove over dressing and discard into appropriate receptacle. Wash and dry hand thoroughly. 6. Review of Resident #4's Admission MDS, dated [DATE], showed staff assessed the resident as follows: -Moderate cognitive impairment; -Required substantial maximal assistance with upper body dressing, showering, and bathing; -Has moisture associated skin damage; -Diagnosis of fractures. Observation on 11/07/23 at 10:43 A.M., showed LPN C did not perform hand hygiene or apply gloves before he/she opened the bandages and placed them on top of the medication cart in the 300 hallway. LPN C took the opened bandages into the resident's room and placed the bandage on the residents bed without a barrier. LPN C cleaned the resident's wound, removed his/her gloves and did not perform hand hygiene before he/she replaced his/her gloves or before he/she applied the new bandages. 7. Review of Resident #21's Admission MDS, dated [DATE], showed staff assessed the resident as follows: -Cognitively intact; -Required substantial maximal assistance with upper body dressing, lower body dressing, toileting, showering, and bathing; -Diagnosis of multiple sclerosis (disease in which the immune system eats away at the protective covering of nerves, resulting nerve damage disrupts communication between the brain and the body). Observation on 11/06/23 at 10:25 A.M., showed LPN C did not perform hand hygiene or apply gloves before he/she removed the resident's bandage on his/her left wrist. 8. During an interview on 11/09/23 at 2:58 P.M., LPN A said when nursing staff are performing wound care he/she expects them to perform hand hygiene when they enter and exit the room. He/she said they should remove gloves, perform hand hygiene, and reapply gloves after they remove the old bandage, after they clean the wound, after they apply the treatment, and then remove gloves and perform hand hygiene after they apply the new bandage. During an interview on 11/09/23 at 3:36 P.M., the DON said he/she expects staff to wash their hands and put on gloves when they enter the residents room to perform wound care. He/She expects staff to change gloves and perform hand hygiene after removing the dressing, if they become soiled, and before they apply the clean bandages. He/She expects opened wound care supplies to be placed on a barrier, and not directly on top of medication carts or beds. He/She said not performing appropriate infection control practices like washing hands, changing gloves and using barriers could result in passing germs to open wounds causing infections. During an interview on 11/09/23 at 4:13 P.M., the administrator said when providing wound care he/she expects his/her nursing staff to use hand hygiene when they enter the residents room, before applying gloves, after removing the dressing and changing gloves, before applying the new dressing, and before exiting the residents room. He/She said she expects nursing staff to try and keep as much of a sterile environment as possible and he/she would expect staff to have barriers under all supplies after they are opened. He/She said residents are at risk for infections when staff do not properly perform hand hygiene, glove changes, and handle supplies in a way that prevents cross contamination. 9. Review of the facility's policies showed the facility did not provide a policy for isolation. Review of the facility's Work Practices policy, revised August 2019, showed staff were directed as follows: -Employees shall wash their hands as soon as possible after removing gloves or other personal protective equipment and after contact with blood or other potentially infectious materials; -All personal protective equipment (PPE) shall be removed in the area where contamination occurred, or as soon as possible if overly contaminated, and placed in an appropriately designated area or container for storage, washing, decontaminating or disposal; -All procedures involving blood or other potentially infectious materials, shall be performed in such a manner as to minimize splashing, spraying, and aerosolization of these substances. 10. Review of Resident #27's Quarterly MDS, dated [DATE], showed staff assessed the resident as follows: -Moderate cognitive impairment; -Has an indwelling catheter; -Always incontinent of bowel and bladder; -Diagnosis of urinary tract infection (UTI) bladder infection) and dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities). Review of the resident's electronic medical record, dated 11/06/23, showed the residents urinalysis results came back positivie for E.Coli-ESBL. Review of the resident's progress notes, dated 11/07/23, showed the an order for the resident antibiotics for a UTI with ESBL. Observation on 11/08/23 at 1:35 P.M., showed the residents room did not contain PPE or PPE not available outside the resident's room and the resident's door did not contain a sign to alert staff or visitors the resident was on precautions or any instructions on the type of PPE needed. Observation on 11/08/23 at 2:50 P.M., showed two biohazard boxes in the resident's room, one with resident's laundry and the other with used briefs and gloves. Observation on 11/08/23 at 3:02 P.M., showed the resident flushed the toilet and came out of the shared bathroom. Further observation showed he/she did not wash his/her hands before he/she came out of his/her room in his/her wheelchair. Observation on 11/09/23 at 9:14 A.M., showed the residents room did not contain PPE or PPE not available outside the resident's room and the resident's door did not contain a sign to alert staff or visitors the resident was on precautions or any instructions on the type of PPE needed. During an interview on 11/08/23 at 1:45 P.M., LPN A said the resident is on contact precautions for ESBL. He/She said he/she should have a commode in his/her room and a sign on his/her door that alerts staff that he/she is on precautions. He/She said the resident has an indwelling catheter, the urine culture came back the previous night and is only in the resident's urine so gloves and gowns are not needed to care for the resident. During an interview on 11/08/23 at 1:50 P.M., CNA F said to his/her knowledge there is not any residents on precautions. During an interview on 11/09/23 at 9:40 A.M., CNA J said he/she had just gave the resident a shower. He/She said he/she only used gloves and not a gown because staff are not required to wear a gown to shower residents. He/She said to his/her knowledge the resident is not on precautions. He/She said he/she was unsure why the resident had the biohazard bags in his/her room. During an interview on 11/09/23 at 9:45 A.M., laundry aide K said to his/her knowledge there is not currently anyone on precautions. He/She said if there were anyone on transmission based precautions there would be a sign on the resident's door to alert staff and visitors. He/She said if a resident was on precautions he/she would wear a gown and gloves to go in their room. He/She said their laundry comes in a separate laundry bag that alerts staff to wash it separate from everyone else. During an interview on 11/09/23 at 9:48 A.M., the house keeping supervisor said resident #27 is the only one on precautions. He/She said there was not a sign on the door because he/she was told the infection was contained. He/She said his/her staff always wear gloves to clean resident rooms but are not required to wear gowns. He/She said rooms that have precautions are cleaned the same as other rooms, except the pay special attention to frequently touched areas. During an interview on 11/09/23 at 11:40 A.M., the DON said the only resident he/she has on precautions is Resident #27. He/She said the resident has ESBL, which means he/she is on contact precautions and should have biohazard cans in his/her room, a precaution sign on his/her door, a commode since he/she shares a room with his/her spouse, and a box outside the room that contains PPE with gowns and gloves. He/She said it is his/her expectation that staff wear gowns and gloves when they are performing perineal care or giving the resident a shower. He/She said it is the DON's responsibility to ensure the precaution signs are up and the appropriate precautions are in place. He/She was not aware that the resident did not have a precaution sign up, a commode, or PPE outside the door. He/She said he/she was out of office when the resident was diagnosed on the 7th and that he/she just returned this morning. During an interview on 11/09/23 at 11:57 A.M., the administrator said he/she expects the nurses who received the orders to give a good report to the oncoming shift, with education on the precaution. He/She expects there to be a sign on the resident's door to alert staff and visitors, a cart outside the door with the appropriate PPE inside, and biohazard boxes for laundry and trash. He/She said it is usually the infection preventionists responsibility to put out the precaution signs and PPE, but there is a folder with extras that the charge nurses have access to in case the precaution is set when the infection preventionist is not in the building. Currently the intrum DON is their infection preventionist, who just started last week. He/She said he/she was not aware that anyone in the building was on precautions. He/She said with ESBL it is his/her expectation that staff be wearing gowns and gloves and goggles if there was a risk of splatter. He/She said it was the responsibility of the charge nurse who took the report, to put out the precautions and notify all staff who were working the floor. He/She said he/she should have been made aware of what was going on in the building. During an interview on 11/09/23 at 2:58 P.M., LPN A said housekeeping was responsible for putting up the isolation signs and putting out the PPE cart. He/She said he/she thought it should be nursing's responsibility to handle the precautions. He/she said he/she was not aware the resident should have been on contact precautions. He/She said the nurse who took the orders should have put out the sign and PPE cart right away and notified staff in his/her change of shift report. He/She said that staff were not made aware that gowns and gloves were needed to care for the resident. 11. Review of the facility's policies showed staff did not provide a policy on the administration of PPD. 12. Review of Resident #21's medical record showed admitted on [DATE]. Review showed the immunization record did not contain documentation a first or second step TB test administered. 13. Review of Resident #43's medical record showed admitted on [DATE]. Review showed the immunization record did not contain documentation a first or second step TB test administered. 14. Review of Resident #47's medical record showed: -admitted on [DATE]; -Immunization record showed the resident received the first step TB test on 9/13/23; -Immunization record did not contain the results of the resident's first step TB test; -Immunization record did not contain documentation a second step TB test administered. During an interview on 11/09/23 at 2:58 P.M., LPN A said the nurse who admits the resident is responsible for administering the first step TB. He/She said any LPN can read the TB results and then two weeks later the resident should receive the second step TB, and then annually after. He/She said he/she was unaware there were residents who had not received their two step TB's. He/She said that he/she knows they were out of the TB solution and he/she just ordered more. During an interview on 11/09/23 at 11:40 A.M., the DON said residents should receive two step TB's, the first one upon admission and the second two weeks after. He/She said it is the charge nurse's responsibility to ensure they get them upon admission and the DON's job to audit them and make sure they are completed. He/She said he/she was not sure why they were not done because he/she is the interim DON and had been there less than a week. During an interview on 11/09/23 at 4:13 P.M., the administrator said residents should have the two step TB's done upon admission. He/She said he/she is not sure what the acceptable amount of time between the first and second step is. He/She said it is a collaborative effort between the MDS coordinator/infection preventionist, DON, and charge nurses to ensure the two step TB's are done. He/She said he/she was not aware that they were not being done or completed. He/She said as far as he/she was being told, they were done and up to date. 43024 47193

Based on observation, interview, and record review, facility staff failed to maintain residents' dignity and privacy when staff failed to close the privacy curtains and left the door open during care for two resident's (Resident #4 and #7) and failed to recognize one resident (Resident #43) who was exposed to the hallway while in their room with their door open. The facility census was 49. 1. Review of the facility's Resident Rights Policy, revised December 2016, showed: -Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: -Be treated with respect, kindness, and dignity; -Privacy and confidentiality. 2. Review of Resident #4's Admission Minimum Date Set (MDS), a federally mandated assessment tool, , dated 10/02/23, showed staff assessed the resident as follows: -Moderate cognitive impairment; -Required substantial maximal assistance with upper body dressing, showering, and bathing; -Has moisture associated skin damage. Observation on 11/07/23 at 10:43 A.M., showed Licensed Practical Nurse (LPN) C and the activities director went in to the residents room to perform wound care and did not pull the privacy curtain. The resident's shirt was pulled up under his/her arms to expose his/her back. The resident's roommate entered the room during the care which exposed the resident's abdomen to the hallway. 3. Review of Resident #7's Quarterly MDS dated [DATE], showed staff assessed the resident as: -Severe cognitive impairment; -Dependent on staff for mobility and toileting; -Always incontinent of bowel and bladder. Observation on 11/7/23 at 2:50 P.M., showed Nurse Aide (NA) G and Certified Nurse Aide (CNA) F entered the resident 's room to provide perineal care, NA G or CNA F did not pull the privacy curtain. NA G and CNA F undressed the resident from the waist down. CNA F rolled and held the resident on their left side, with their buttock and back towards the door, CNA H opened the resident's door and stood with the door open which exposed the resident to the hallway. 4. Review of Resident #43's Admission MDS, dated [DATE], showed staff assessed the resident as: -Severe cognitive impairment; -Moderate assistance with transfers and toileting; -Diagnosis of vascular dementia(changes to memory, thinking, and behavior resulting from conditions that affect the blood vessels in the brain). Observation on 11/07/23 at 1:46 P.M., showed the resident sat in his/her bed with his/her chest exposed. Observation showed the residents door open where staff and residents could view the resident. Observation on 11/07/23 at 1:48 P.M., showed the resident sat in his/her bed with his/her chest exposed. Observation showed the residents door open where staff and residents could view the resident. Observation showed CNA F walked by, looked in the resident's room and did not stop or assist the resident to cover himself/herself. Observation on 11/07/23 at 1:55 P.M., showed the resident sat in his/her bed with his/her chest exposed. Observation showed the residents door open where staff and residents could view the resident. Observation showed CNA H walked by, looked in the resident's room and did not stop or assist the resident to cover himself/herself. 5. During an interview on 11/09/23 at 3:00 P.M., CNA I said staff are expected to pull the privacy curtain before they provide care and close the door behind them. He/She said staff should not open door or curtain during care to avoid the resident being exposed. CNA I said if a residents body parts are exposed staff should assist them, and pull the curtain or door closed while they assist them. During an interview on 11/06/23 at 3:12 P.M., LPN A said a resident's curtain needs to pull closed and the window blinds before staff provide care for a resident. He/She said you should never open a door during resident care, you should wait until the staff are done before you enter, unless it's an emergency then the resident should be covered or curtain drawn so the resident is not exposed. LPN A said staff should never ignore a resident if they are exposed, they should cover them up or close the door. During an interview on 11/06/23 at 3:50 P.M., the Director of Nursing (DON) said staff are expected to pull the privacy curtain, blinds or curtains on the window and shut the door before they start care for a resident. The DON said staff should never stand with the door open while care of a resident is being done, the staff member should either go in the room and close the door behind them or wait until it is done. He/She said if a staff member sees that a resident is exposed, they would be expected to pull the curtain and close the door. During an interview on 11/06/23 at 4:40 P.M., the Administrator said the expectation for staff when they provide care for a resident, is to shut the door and pull the privacy curtain. The administrator said it is not okay to open the door during care of a resident, staff should wait until the task is done. The administrator said if a resident is observed to be exposed he/she would expect staff to take care it it, not ignore the resident. 47193

Based on observation, interview, and record review, facility staff failed to maintain a clean, comfortable, homelike environment for three resident (Resident #6, #47 and #102) rooms when facility staff did not ensure resident's rooms were in good repair. The facility census was 49. 1. Review of the facility's Homelike Environment policy, revised February 2021, showed the facility staff and management maximizes, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include a clean, sanitary and orderly environment. 2. Observation on 11/06/23 at 9:46 A.M., showed the bathroom ceiling in room [ROOM NUMBER] had patch work started but was unfinished. The tiled floors were broken and had rust colored stains. 3. Observation on 11/06/23 at 10:23 A.M., showed a large unpainted patched area above Resident #6's bed. 4. Observation on 11/06/23 at 10:09 A.M., showed the shared bathroom between room [ROOM NUMBER] and 302 wall with dark colored specs, exposed pipes and missing trim. base trim missing. Observation showed the floor tiles around the toilet with black and rust colors, the dry wall around the vent in the ceiling covered in an unknown substance. Observation showed the bathroom with multiple patched white areas. During an interview on 11/09/23 at 9:35 A.M., Resident #47 said the pipe was leaking. He/She said maintenance removed the trim but there was mold behind it so they needed to let it dry out before they repaired it. During an interview on 11/09/23 at 3:15 P.M., the maintenance director said there are places like Resident #47's bathroom, all around the building. He/She said it was like that when he/she started and he/she has just been trying to catch up. 5. Observation on 11/06/23 at 1:00 P.M., showed Resident #102's room did not have floor trim. During an interview on 11/09/23 at 9:32 A.M., Resident #102 said his/her room has not had trim along the bottom for several months. He/She said he/she thinks it was pulled off due to a leak. During an interview on 11/09/23 at 3:15 P.M., the maintenance director said room [ROOM NUMBER] does not have trim in his/her room because he/she had to re-do the boiler heater, but then the resident was admitted to the room so it's just a work in progress. 6. During an interview on 11/09/23 at 2:41 P.M., Certified nurse aide (CNA) L said he/she notifies maintenance by writing on the clip board at the nurse's station. He/She said maintenance usually gets things fixed the same day. During an interview on 11/09/23 at 2:58 P.M., Licensed Practical Nurse (LPN) A said he/she notifies maintenance by writing it on the clip board at the nurse's station or if it is urgent he/she get him/her. During an interview on 11/09/23 at 3:15 P.M., the maintenance director said staff are supposed to notify him/her through a program called TELS (a system used for maintenance that keeps track of their work orders and due dates) He/She said there is something wrong with the program and staff have not been able to get in. He/She said staff notify him/her by writing down issues on the clip board at the nurse's station. He/She said resident rooms are checked when they leave and on a monthly basis he/she looks at the lights and faucets. He/She said when he/she does the walk through he/she takes notes on repairs that are needed. He/She said he/she has been bad about spackling the holes in the walls and not finishing them. He/She said he/she is just trying to catch up. During an interview on 11/09/23 at 11:40 A.M., the Director of Nursing (DON) said they just started using a program that tracks works orders. He/She said staff who do not have access to the program can fill out a work order sheet on the clip board at the nurse's station. He/She said maintenance checks the clip board daily. He/She said he/she would expect maintenance to fix and paint holes in the wall and have the project completed within a few days. He/She said maintenance should be doing a regular walk through of the building. During an interview on 11/09/23 at 4:13 P.M., the administrator said the facility has a program where staff can go in and add a work order. He/She said for those who do not have access, there is a form they can fill out at the nurse's station. He/She said maintenance should be doing a daily walk through of the building. He/She said he/she was unaware of the unfinished work. He/She said sometimes there is issues with getting funding right away but he/she would expect projects most projects to be finished in just a few days.

Based on interview and record review, facility staff failed to accurately update a new diagnosis within the Pre-Admission Screening and Resident Review (PASARR) documentation to incorporate the recommendations into resident assessment and care plan for two residents (Resident #5 and #14) out of four sampled residents. The facility census was 49. 1. Review of the facility's policy titled, Admission Criteria, revised March 2019, showed staff are directed to do the following: -All new admissions and readmissions are screened for mental disorders (MD), intellectual disabilities (ID), or related disorders (RD) per the PASARR process: -The facility conducts a level I PASARR screen for all potential admissions, regardless of payer source, to determine if the individual meets the criteria for a MD, ID or RD. -If the level I screen indicates the individual may meet the criteria for a MD, ID or RD, he or she is referred to the state PASARR representative for the Level II (evaluation and determination) screening process, the admitting nurse notifies the social services department when a resident is identified as having a possible (or evident) MD, ID or RD, the social worker is responsible for making referrals to the appropriate state-designated authority. 2. Review of Resident #5's Quarterly Minimum Data Set (MDS), a federally mandated assessment tool, dated 07/10/23, showed staff assessed resident as: -Moderately cognitively impaired; -Diagnoses of anxiety (feeling of fear, dread, and uneasiness), depression, psychotic disorder (a collection of symptoms that affect the mind, where there has been some loss of contact with reality) and post-traumatic stress disorder (PTSD) (disorder that develops in some people who have experienced a shocking, scary, or dangerous event). Review of the resident's PASARR Level I, dated 2018, showed the resident did not trigger for a level II screening. Review of the resident's medical diagnoses showed the resident diagnosed with major depressive disorder on 01/12/23 and obsessive compulsive disorder on 03/10/2023. Review of the resident's medical record showed the record did not contain a updated Level 1 screening with a new diagnosis of a serious mental illness. 3. Review of Resident #14's Annual MDS, dated [DATE], showed staff assessed resident as: -Moderately cognitively impaired; -Diagnoses of depression and psychotic disorder. Review of the resident's PASARR Level I, dated 08/10/16, showed the resident did not trigger for a Level II screening. Review of the resident's medical diagnoses, showed the resident was diagnosed with bipolar disorder on 08/04/23. Review of the resident's medical record showed the record did not contain a updated Level I screening with a new diagnosis of a serious mental illness. 4. During an interview on 11/09/23 at 2:59 P.M., the Social Services Director (SSD) said he/she is told by the MDS coordinator if there is a new diagnoses that would require a change to the PASSAR. He/She was not aware that there are residents with new diagnoses that affect the PASSAR's. He/She said they have not had a MDS coordinator for a while and will have to communicate with the new one to make sure there is a process for new diagnoses. During an interview on 11/09/23 at 3:27 P.M., the interim director of nursing (DON) said the nurse or the DON would be responsible to let the SSD know there is new diagnoses that affects the PASSAR. He/She said he/she does not know why new diagnoses are not reported besides a lack in communication prior to his/her arrival. During an interview on 11/09/23 at 4:13 P.M., the administrator said it is the responsibility of the DON to alert SSD of new diagnoses that affect the residents PASSAR. He/She does not know why it was not communicated that way.

Based on interview and record review, facility staff failed to provide an ongoing program of activities designed to meet the residents' interest on the weekends. The facility census was 49. 1. Review of the facility's records showed the facility did not have a policy for activities. 2. Review of the facility's Activity Calendar, dated October 2023, showed the following: -Saturday, 10/04/23: Bingo; -Sunday, 10/05/23: Resident #6's Bible Study; -Saturday, 10/11/23: Bingo; -Sunday, 10/12/23: Resident #6's Bible Study; -Saturday, 10/18/23: Bingo; -Sunday, 10/19/23: Resident #6's Bible Study; -Saturday, 10/25/23: Bingo; -Sunday, 10/26/23: Resident #6's Bible Study. 2. Review of Resident #6's Quarterly Minimum Data Set (MDS), a federally mandated assessment tool, dated 09/23/23, showed the resident thinks it is somewhat important to do his/her favorite activities and very important to do things with groups of people. During an interview on 11/07/23 at 10:31 A.M., the resident said he/she does bingo on the weekends and church on Sundays because there isn't enough staff to run activities and they get bored. 3. Review of Resident #30's Quarterly Minimum Data Set (MDS), a federally mandated assessment tool, dated 07/06/23, showed the resident thinks it is very important to do his/her favorite activities and very important to do things with groups of people. During an interview on 11/06/23 at 9:46 A.M., the resident said there is not many options for activities on the weekends. He/She said they sometimes get the one scheduled activity on Saturdays, but it depends if staff have time. He/She said there is the option of church on Sundays if you want to do that. He/She said he/she wishes there were more consistent options for weekend activities. 4. During an interview on 11/09/23 at 2:39 P.M., Certified Nursing Assistant (CNA) B said staff do not run activities on the weekends, Resident #6 does church and bingo. During an interview on 11/09/23 at 2:47 P.M., Licensed Practical Nurse (LPN) A said Resident #6 runs activities on the weekends, church and bingo, because there is not activity aide and the nursing aides are too busy. The other resident's get sad if Resident #6 is sick or does not want to get out of bed. During an interview on 11/09/23 at 3:27 P.M., the director of nursing (DON) said he/she does not know if there is staff here to run the activities on the weekends, but know it is a regulation. During an interview on 11/09/23 at 4:13 P.M., the administrator said activities are usually ran by the residents on the weekends, there is not a designated staff here to help them. He/She said He/She is aware that they are required to have a staff designated for activities. During a phone interview on 11/27/23 at 3:14 P.M., the activities director (AD) said he/she does not have an activity aide but has CNA's assist. He/She said CNA's assist residents with acitvities if they have time. Resident #6's does BINGO and bible study for the facility, anyone is allowed to participate, if the resident is sick there is other resident's he/she can ask to conduct activities. 47193

Based on interview and record review, facility staff failed to keep records of the monthly Medication Regimen Review (MRR) conducted by the pharmacy and the recommendations of the resident's psychotropic gradual dose reduction (GDR's) signed by the physician with rational for four residents (Resident #6, #14, #15 and #41). The facility census was 49. 1. Review of the facility's policy titled, Medication Regimen Review, revised February 2020, showed staff were directed to do the following: -Recommendations and apparent irregularities will be reported timely to ensure the safe and appropriate medication utilization to meet the individual needs of the residents; -A hard copy of the recommendation will be addressed to the attending physician as part of the consultant's regular monthly report with a timely response; -The consultant's comprehensive monthly report will be provided to the facility either electronically and/or in written hard copy within 5 business days or monthly consulting rounds. If provided electronically, the DON or designee shall print out the report to facilitate follow up and required notification of the attending physician and medical director within a professional standard of timely response. Clinical justification will be documented on the recommendation response, which will remain as part of the clinical chart. Recommendations that are declined without clinical justification may be rewritten with a request for further clarification or required documentation. Review of the facility's policy titled, Antipsychotic Medication use, revised December 2016, showed Antipsychotic medications will be prescribed at the lowest possible dose for the shortest period of time and are subject to gradual dose reduction and re-review. 2. Review of Resident #6's Quarterly Minimum Data Set (MDS), a federally mandated assessment tool, dated 09/23/23, showed staff assessed resident as: -Cognitively intact; -Diagnoses of anxiety ([NAME] feeling of worry and fear), depression (serious medical illness that negatively affects how you feel, the way you think and how you act) and Post traumatic stress disorder (PTSD - real disorder that develops when a person has experienced or witnessed a scary, shocking, terrifying, or dangerous event); -Received antipsychotics on a routine basis, a GDR has not been attempted or contraindicated by a physician. Review of the resident's Physician Order Sheets (POS), dated November 2023, showed the following orders: -12/10/22: Buspirone HCI (antianxiety medication) 7.5 milligrams (mg) twice a day (BID); -04/14/22: Bupropion (antidepressant medication) 300 mg once daily (QD); -12/10/22: Trazadone (antidepressant medication) 100 mg BID; -12/10/22: Sertraline (antidepressant medication) 100 mg BID; -05/30/23: No GDR to psychotropic medications due to risk for resident decompensation. Review of the resident's medical record showed the record did not contain documentation a MRR or an attempt of a GDR or clinical rationale for the resident's continued use of psychotropic medications. 3. Review of Resident #14's Annual MDS, dated [DATE], showed staff assessed resident as: -Moderately cognitively impaired; -Diagnoses of depression, psychotic disorder (mental disorder characterized by the disconnection from reality), dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities),; -Received antipsychotics on a routine basis, a GDR has not been attempted. Review of the resident's POS, dated November 2023, showed the following orders: -09/04/22: Divalproex (used to treat bipolar disorder) 125 MG BID; -09/08/22: Fluvoxamine (used to treat obsessive compulsive disorder) 100 MG QD; -04/11/23: Mirtazapine (used to treat depression) 15 MG QD; -04/11/23: Aripiprazole (used to treat bipolar disorder) 15 MG QD; -05/30/23: No GDR to psychotropic medications due to risk for resident decompensation. Review of the resident's medical record showed the record did not conatin documentation a MRR or an attempt of a GDR or clinical rationale for the resident's continued use of psychotropic medications. 4. Review of Resident #15's Quarterly MDS, dated [DATE], showed staff assessed resident as: -Moderately cognitively impaired; -Diagnoses of alzheimers (a progressive disease that destroys memory and other important mental functions), dementia, depression, schizophrenia (A disorder that affects a person's ability to think, feel, and behave clearly), and PTSD. -Received antipsychotics on a routine basis, a GDR has not been attempted. Review of the resident's POS dated November 2023, showed the following orders: -06/13/23: Vraylar (used to treat atypical antipsychotic disorders) 3 MG QD; -04/14/22: Duloxtine (used to treat depression) 30 MG and 60 MG QD; -04/14/23: No GDR to psychotropic medications due to risk for resident decompensation. Review of the resident's medical record showed the record did not conatin documentation a MRR or an attempt of a GDR or clinical rationale for the resident's continued use of psychotropic medications. 5. Review of Resident #41's Quarterly MDS, dated [DATE], showed staff assessed the resident as: -Severely cognitively impaired; -Diagnoses of alzheimers, dementia, behaviors and psychotic disorder; -Received antipsychotics on a routine basis, a GDR has not been attempted. Review of the resident's POS dated November 2023, showed the following orders: -12/20/22: Celexa (used to treat depression) 10 MG QD; -01/13/23: No GDR to psychotropic medications due to risk for resident decompensation. Review of the resident's medical record showed the record did not contain documentation a MRR or an attempt of a GDR or clinical rationale for the resident's continued use of psychotropic medications. 6. During an interview on 11/09/23 at 11:17 A.M., the Director of Nursing (DON) said they could not provide reports for the residents MMR's or GDR's because the facility has new owner ship and they do not have access to the emails, he/she cannot be sure if the residents have GDR's or that medications were or weren't properly stopped and added. He/She said this is an organizational and documentation issue. During an interview on 11/09/23 at 4:13 P.M., the administrator said he/she expects to keep all the documentation on the monthly pharmacist reviews and GDR's. He/She does not know why the documentation is not there for the MMR's or the GDR's but it is not acceptable, there is a documentation issue. He/She is aware that they must keep documentation on MMR's and GDR's so they can track the resident's medication use. He/She said the resident having too many medications or medications that contradict themselves is a danger and could be toxic to the resident. Additionally, he/she said it is not acceptable for resident's to have a standing order for no GDR's, the physician needs to review and sign the reports with each recommendation.

Based on record review and interview, facility staff failed to maintain a Quality Assessment and Assurance (QAA), (identification, assessment, correction and monitoring of important aspects of resident care to enhance quality) committee consisted of the minimum required members. The facility census was 49. 1. Review of the facility's Quality Assurance and Performance Improvement (QAPI) Program Policy, revised March 2020, showed: -The following individuals serve on the committee; Administrator or designee, Director of nursing, Medical Director, Infection Perfectionist; -The following departments, as required by the administrator; Pharmacy, Social Services, activity services, environmental services, human resources and medical records; -The committee meets at least quarterly (or more often as necessary). Review of the facility's QAA/QAPI plan, dated 07/2023 through 10/2023, showed the Medical Director (MD) did not attend the meetings. Review of the QAA/QAPI plan did not contain sigantures by the MD or the committee as being reviewed. During an interview on 11/6/23 at 4:40 P.M., the Administrator said she is aware the Medical Director or designee should attended the QAA/QAPI meeting at least quarterly. She said the MD is invited quarterly but does not always come to the meetings.

Reviewed Based on interview and record review, facility staff failed to implement an Antibiotic Stewardship Program with antibiotic use protocols and a system to monitor antibiotic use. The facility census was 49. 1. Review of the facility's policy titled, Antibiotic Stewardship Program, revised December 2016, showed: -Antibiotics will be prescribed and administered to residents under the guidance of the facility's antibiotic stewwardship program, if antibiotics are indicated the antibiotic stewardship will include; -Drug name; -Dose; -Frequency of administration; -Duration of treatment (start and stop date) or (number of days of therapy); -Route of administration; -Indication of use. Review of the facility's antibiotic stewardship book showed facility staff did not track antibiotic usage from January 2023 to July 2023. During an interview on 11/09/23 at 10:46 A.M., the Director of Nursing (DON) said the MDS coordinator was in charge of the antibiotic stewardship before he/she was here and he/she can not speak for what happened prior to that, if the infection control and antibiotic stewardship monitoring was in place or not, they just do not have the documentation for the programs. During an interview on 11/09/23 at 2:47 P.M., Licensed Practical Nurse (LPN) A said he/she believes the DON is in charge of the antibiotic stewardship. During an interview on 11/09/23 at 3:35 P.M., the DON said between new owners and the old DON leaving there is poor documentation and records. The new staff are starting the process over because they do not where they are with it. During an interview on 11/09/23 at 4:13 P.M., the administrator said he/she thought antibiotic stewardship was being completed on a monthly basis. He/She said he/she expects it done every month, the concern with it not completed is increased infection and sickness.

Based on observation, interview, and record review, facility staff failed to provide appropriate care and services to assist residents with Activities of Daily Living (ADLs), for six residents (Resident #1, #6, #7, #8, #9 and #10) when staff failed to assist residents to brush their hair before taking them to the dining room, get them dressed, and change their soiled clothes. The facility census was 47. 1. Review of the facility ADLs Supporting policy, revised March 2018, showed residents will be provided with care, treatment, and services as appropriate to maintain or improve their ability to carry out ADLs. Residents who are unable to carry out ADLs independently will receive the services necessary to maintain good nutrition, grooming, and personal and oral hygiene. 2. Review of Resident #1's Admission Minimum Data Set (MDS), a federally mandated assessment tool, dated 8/31/22, showed staff assessed the resident as: -Mild Cognitive Impairment; -Required supervision with set up assist for eating; -Required limited assistance from one staff members with dressing; -Required limited assistance from two staff members for bed mobility; -Required extensive assistance from one staff members for bathing, and dressing; -Required extensive assistance from two staff members for toileting; -Dependent on two staff for transfers; -Did not reject care. Observation on 11/2/22 at 11:45 A.M., showed the resident had on a gown, had multiple chin hairs, and his/her hair was unkempt. During an interview on 11/2/22 at 11:46 A.M., the resident said Yes it bothers me to have long chin hair, be in a gown, and not have my hair brushed, but what am I supposed to do? I can't get any one to do it, but I would sure like more care than I get. He/She said, Of course I have asked them to do it but they just disappear and don't come back. I am actually up out of bed today more than most days, usually they just leave me in bed. During an interview on 11/2/22 at 12:57 P.M., Certified Nurse Assistant (CNA) C said the resident was assisted up but since he/she would not eat in the dining room they focused on those residents first. During an interview on 11/2/22 at 1:20 P.M., Certified Nurse Assistant (CNA) D said they focus on residents that will be in the dining room for the meals and today has just been crazy with so many people in the facility. It had put them off their routine. 3. Review of Resident #6's Admission MDS, dated [DATE], showed staff assessed the resident as: -Mild cognitive impairment; -Required supervision of one staff member for eating; -Required limited assistance of one staff member for personal hygiene; -Required extensive assistance from two staff members for bed mobility, dressing, and bathing; -Was dependent on two staff members for transfers, and toileting; -Did not reject care. Observation on 11/2/22 at 11:57 A.M., showed staff propelled the resident to the dining room with his/her hair unkempt. 4. Review of Resident # 7's Quarterly MDS, dated [DATE], showed the staff assessed the resident as: -Cognitively intact; -Independent with eating; -Required supervision of two staff members for personal hygiene; -Required extensive assistance from two staff members for bed mobility, dressing, and bathing; -Dependent on two staff members for transfers, and toileting; -Did not reject care. Observation on 11/2/22 at 12:30 P.M. showed the resident at the dining room with other residents. Further observation showed the resident with multiple chin hairs and unkempt hair. During an interview on 11/2/22 at 12:31 P.M. the resident said he/she would like his/her hair brushed and chin hair shaved before he/she goes to the dining room because it is embarrassing but he/she doesn't remember the last time it was done. 5. Review of Resident #8's Quarterly MDS, dated [DATE], showed staff assessed the resident as: -Mild Cognitive Impairment; -Independent with set up assistance only for eating; -Required limited assistance from one staff member for transfers; -Required limited assistance from two staff members for personal hygiene; -Required extensive assistance from one staff member for bed mobility, toileting, and bathing; -Did not reject care. Observation on 11/2/22 at 12:16 P.M., showed the resident left the dining room in his/her wheelchair with food debris from breakfast on his/her pants and unkept hair. 6. Review of Resident #9's Quarterly MDS, dated [DATE], showed staff assessed the resident as: -Severe Cognitive Impairment; -Required supervision of one staff member for bed mobility; -Required limited assistance of one staff member for transfers, dressing, and eating; -Required extensive assistance from one staff member for bathing, toileting, and personal hygiene; -Did not reject care. Observation on 11/2/22 at 12:21 P.M., showed the resident in a wheelchair at the dining room table. Further observation showed he/she had unkempt hair. Observation on 11/2/22 at 1:25 P.M., showed the resident outside with family. Further observation showed his/her hair was unkempt and his/her black pants contained food debris. 7. Review of Resident #10's Quarterly MDS, dated [DATE], showed staff assessed the resident as: -Mild Cognitive Impairment; -Independent for transfers; -Required supervision with set up assistance for eating; -Required limited assistance of one staff member for bed mobility, toileting, and personal hygiene -Required extensive assistance from one staff member for bathing, and dressing; -Did not reject care. Observation on 11/2/22 at 12:56 P.M., showed the resident propelled out of the dining room in in his/her wheelchair with unkempt hair. 8. During an interview on 11/2/22 at 12:42 P.M., Registered Nurse (RN) A said that staff are expected to make sure residents are presentable before they wheel them to the dining room to include their clothes are clean, hair is brushed, and clean clothes on. During an interview on 11/2/22 at 12:46 P.M., Certified Medication Tech (CMT) B said that when he/she worked the floor they were to make sure residents are presentable before they take them to the dining room. He/She said they should have on clean clothes and staff should brush their hair. During an interview on 11/2/22 at 12:57 P.M., CNA C said that residents should always have clean clothes on and their hair brushed before they are taken to the dining room. He/She said they have been behind today and some things are just not done. During an interview on 11/2/22 at 1:20 P.M., CNA D said residents should always have their hair brushed, clean clothes, and their feet covered when they are taken to the dining room. He/She said today has just been crazy with so many people in the facility it has put us off our routine and some things are just not done. During an interview on 11/2/22 at 1:30 P.M., the Administrator said before residents go to the dining room that staff are expected to make sure residents have clean clothes on and are not in a gown, their hair should be brushed, and they should have something on their feet. He/She said staff are expected to do their job the same way no matter who is in the facility or what is going on. MO00208997

Based on observation, record review and interview, the facility staff failed to provide appropriate assistance and foot support during wheelchair transport, to prevent avoidable accidents, for four dependent residents (Residents #1, #2, #3 and #4), out of four sampled residents. Facility staff failed to apply wheelchair foot rests to one resident's (Resident #1) wheelchair prior to wheeling the resident from the dining room, which resulted in the resident falling forward, striking his/her head on the floor, and receiving a hematoma on his/her forehead, two fractures in his/her cervical spine and numerous skin tears. The resident expired at the hospital two days later. The facility census was 38. 1. Review of Resident #1's Minimum Data Set (MDS), a federally mandated assessment instrument, dated [DATE], showed staff assessed the resident as follows: - Unable to recall three out of three words on the Brief Interview for Mental Status; - Inattention and disorganized thinking, continuously present; - Experienced delusions; - Totally dependent on two plus persons for transfers and toilet use; - Totally dependent on one person for locomotion off unit and bathing activity; - Required extensive assistance and one person physical assistance for dressing and hygiene; - Used a wheelchair; - Always incontinent of bowel and bladder; - [DIAGNOSES REDACTED]. Review of the resident's plan of care, updated [DATE], showed staff planned the following interventions: - Encourage the resident to make basic care decisions within his/her ability and safety; - Re-orient as needed to his/her surroundings; - Utilize a two person transfer with use of a gait belt for transfers; - Utilized a wheelchair for mode of transportation. Staff to help him/her with mobility while in chair; - Encourage resident to use his/her legs to propel himself/herself in his/her wheelchair; - No foot pedals to wheelchair per family request to encourage self propelling; - Assist to bed as soon as able after meals unless staying up for an activity; - Assist him/her back to his/her room if he/she wanted to rest. Review of the resident's plan of care showed staff did not document interventions directing staff regarding the application of foot rests when staff wheeled the resident in his/her wheelchair. Review of the resident's nurse's notes, dated [DATE], 9:00 P.M., showed staff documented the following: - At 7:30 P.M., staff propelled the resident to his/her room in the wheelchair; -Staff observed the resident with his/her head on the floor and the wheelchair behind him/her; - The resident had multiple skin tears on both hands and his/her left forearm; a large, deep wound on his/her right forehead with skin tear to cheek and skin tear to left side of nose; - Emergency Medical Services (EMS) arrived and transported resident to hospital emergency room . Review of the resident's 72-Hour Fall Monitoring sheet, dated [DATE] at 9:00 P.M., showed staff recorded the following: - Description of incident- "Resident propelling in hallway found on floor with head on floor"; - Bruises/Swelling- "Multiple"; - Pain- "Complaint of pain to head"; - Other injuries- "Multiple skin tears, large deep laceration to forehead"; - Resident sent to hospital emergency room for evaluation and treatment. Review of Certified Nurse Aide (CNA) B's written statement, dated [DATE] at 9:00 A.M., showed the CNA recorded as he/she wheeled the resident down the hallway on [DATE], the resident put his/her feet down, and fell out of the wheelchair. During an interview on [DATE] at 10:30 A.M., CNA B said the incident occurred after supper on [DATE]. He/She said he/she directed the resident to lift his/her feet up and he/she wheeled him/her away from the dining room. CNA B said the resident would "usually keep putting his/her feet up and down," but this time the resident "fell out" of the wheelchair. CNA B said the resident hit his/her head on the floor and had "a gash" in his/her head, skin tears on his/her right arm, fingers and knee. Review of the facility's Final Incident Investigation Report Incident/Abuse report, undated, showed the Director of Nursing (DON) documented staff wheeled the resident down the hall of the facility when the resident "fell forward out of wheelchair after putting feet down. Struck head on right side of body on floor". During an interview on [DATE] at 11:38 A.M., the DON said the resident frequently put his/her feet down while staff wheeled the resident in his/her wheelchair. During an interview on [DATE] at 12:02 P.M., the social service director (SSD) said the resident put his/her feet "up and down all the time" while staff wheeled him/her in the wheelchair, and put his/her "feet down and locked" his/her legs. During an interview on [DATE] at 1:55 P.M., CNA A said the resident could propel himself/herself, but recently had a decline and put his/her feet "up and down" while staff wheeled him/her. During an interview on [DATE] at 10:30 A.M., the administrator said on [DATE], as staff wheeled the resident from the dining room without first applying foot rests on the wheelchair, the resident placed his/her feet on the floor causing him/her to fall forward out of the chair onto the floor. The resident suffered a head laceration and they sent him/her to the local emergency room for evaluation and treatment. Review of the resident's Physician order [REDACTED]. Review of the Computerized Topography (CT) report from the hospital, dated [DATE] at 8:44 P.M., showed the resident suffered a C1 and C2 (cervical spine) fractures, a forehead laceration, and a hematoma (collection of blood under the skin). The CT scan report showed there was no evidence of a brain bleed at that time. Review of the hospital Physician's Progress Notes, dated [DATE], 2:00 A.M., showed hospital staff documented the following: - "Fit patient with Miami collar (cervical collar), fit and function as prescribed, no problems at this time. Miami provides support to cervical spine. Patient to follow physician wearing schedule, gave areas to watch for pressures, also put on/take off instructions. Staff to call if any questions." Review of the Admissions/Emergency Medical Services Prehospital First Care Form, dated [DATE], showed the following: - Referring facility- hospital; - Destination- Facility; - 5:30 A.M.- Blood Pressure ,[DATE], Pulse 97; - 5:50 A.M.- Blood Pressure ,[DATE], Pulse 104. Review of the resident's 72-Hour Fall Monitoring sheet, dated [DATE] at 9:30 P.M., showed staff recorded the resident's physician called the facility and stated they would send the resident back to the facility upon completion of the treatment. Review of the nurse's notes, dated [DATE] at 6:00 A.M., showed staff recorded the resident returned to the facility from the hospital. Staff recorded the resident's blood pressure was ,[DATE] (normal is ,[DATE]), heart rate 96 and irregular (normal is ,[DATE] and regular). Review of the nurse's notes, dated [DATE] at 7:40 A.M., showed staff recorded the following: - Resident's vital signs "unstable"; - Vital signs at 6:00 A.M.- Blood Pressure ,[DATE], Pulse 97; - Vital signs at 7:30 A.M.- Blood Pressure ,[DATE], Pulse 98; - Resident "very" lethargic, unable to test grip; - Vital signs at 8:30 A.M.- Blood Pressure ,[DATE], Pulse 95; - Resident unable to eat or drink; - Vital signs at 9:00 A.M.- Blood Pressure ,[DATE], Pulse 92; - Injuries sustained from fall; - Right forehead 2.2 centimeters (cm) in length by 3 cm in width laceration; - Right cheek laceration approximately 3 cm; - Also sustained bruise 1 cm on left side of nose; - 2.5 cm skin tear on right hand; - 4 cm by 4 cm bruise on right shoulder; - 2 cm in length by 1.7 cm in width bruise on upper left arm; - 4 bruises (red) approximately 1 cm each on upper left arm; - 1 cm bruise on right forearm; - 3 cm in length by 1.5 cm in length skin tear right hand; - 4 cm in length by .5 cm in width skin tear right forearm; - Left hand, middle and fourth fingers have 1 cm lacerations which were sutured at hospital; - The middle, fourth and fifth fingers on left hand are bruised from bases to tips; - 1.5 cm skin tear on left knee surrounded by 10 cm in diameter bruise; - Blister noted on back of right upper leg. Review of the resident's POS, dated [DATE] (no time), showed the resident's physician directed staff to send the resident to the hospital per ambulance for observation. Review of the resident's 72-Hour Fall Monitoring sheet, dated [DATE] at 4:00 P.M. showed staff recorded the resident remained at the hospital. Review of the nurse's notes, dated [DATE] at 11:00 A.M., showed staff documented the resident's family member notified facility staff, the resident expired at 12:05 P.M. During an interview on [DATE] at 1:45 P.M., the administrator said the resident expired at the hospital on [DATE]. The administrator said she did not know the cause of the resident's death. On [DATE] at 10:18 A.M., the DHSS surveyor left a message for the hospital attending physician. As of [DATE], the hospital attending physician had not returned the phone call. 2. Review of Resident #2's Minimum Data Set (MDS), a federally mandated assessment instrument, dated [DATE], showed staff assessed the resident as follows: - Unable to recall three out of three words on the Brief Interview for Mental Status; - Inattention continuously present; - Totally dependent on one person physical assistance for hygiene and bathing activity; - Required limited assistance and one person physical assistance for transfers, dressing and toilet use; - Used a wheelchair; - Frequently incontinent of bladder; - Always continent of bowel; - [DIAGNOSES REDACTED]. - Had a fall since admission or prior assessment; - Two or more falls with no injury; - Two or more falls with injury (except major). Review of the resident's plan of care, updated [DATE], showed staff planned the following interventions: - Wheelchair was primary mode of locomotion; - Auto lock breaks on his/her wheelchair for safety; - Fallen leaf protocol to alert all staff that resident is a fall risk. Review of the facility's Report Sheet, undated, showed staff assessed the resident as "sometimes propels". Observation on [DATE] at 10:40 A.M., showed Housekeeper C wheeled the resident in his/her wheelchair. Observation showed there were no foot rests on the resident's wheelchair. During an interview on [DATE] at 1:38 P.M., Housekeeper C said he/she attended an inservice regarding foot rests. He/she said staff only needed to place one hand on a resident's shoulder as they wheeled the resident in their wheelchair. He/she said staff needed to apply foot rests to resident's wheelchairs before wheeling the resident, only if the resident never self propelled himself/herself in the wheelchair. 3. Review of Resident #3's Minimum Data Set (MDS), a federally mandated assessment instrument, dated [DATE], showed staff assessed the resident as follows: - Able to recall three out of three words on the Brief Interview for Mental Status; - Required extensive assistance and one person physical assistance for dressing, toilet use and hygiene; - Required physical help and one person physical assistance with bathing activity; - Impairment on one side, upper and lower extremities; - Used a wheelchair. Review of the resident's plan of care, updated [DATE], showed staff planned the following intervention: - Utilized a wheelchair for locomotion. Review of the facility's Report Sheet, undated, showed staff assessed the resident as "sometimes propels". Observation on [DATE] at 11:30 A.M., showed Certified Nurse Aide (CNA) D wheeled the resident in his/her wheelchair. Observation showed the resident's wheelchair only had a right-sided foot rest. During an interview on [DATE] at 1:52 P.M., CNA D said he/she attended an inservice regarding the need to apply foot rests to resident's wheelchairs. CNA D said they only applied foot rests to residents who did not self propel their wheelchairs. 4. Review of Resident #4's Minimum Data Set (MDS), a federally mandated assessment instrument, dated [DATE], showed staff assessed the resident as follows: - Able to recall three out of three words on the Brief Interview for Mental Status; - Required extensive assistance and one person physical assistance for transfers, dressing and toilet use; - Used a wheelchair. Review of the resident's plan of care, updated [DATE], showed staff planned the following interventions: - Independent with mobility when up in wheelchair; - Monitor for safety and whereabouts when resident took wheelchair rides outdoors. Review of the facility's Report Sheet, undated, showed staff assessed the resident as "sometimes propels". Observation on [DATE] at 11:40 A.M., showed Certified Nurse Aide (CNA) A wheeled the resident in his/her wheelchair. Observation showed there were no foot rests on the resident's wheelchair. During an interview on [DATE] at 1:50 P.M., CNA A said he/she attended an inservice regarding foot rests on resident's wheelchairs. CNA A said they were directed to hold their hand on the resident's shoulders and apply foot rests if the resident was not self-propelling their wheelchair. 5. During an interview on [DATE] at 2:30 P.M., the administrator said they inserviced all staff regarding the need to apply foot rests to all residents' wheelchairs when wheeling the residents in the chairs. MO 548 MO 567 Note: At the time of the abbreviated survey exit on [DATE], the violation was determined to be at the immediate and serious jeopardy level J. Based on observation, interview and record review during the onsite visit, it was determined the facility had implemented corrective action to address and lower the violation at the time. During the onsite visit, the Director of Nursing inserviced staff regarding policies and procedures related to application of foot rests to all residents' wheelchairs when wheeling the resident in his/her wheelchair. Staff continued to assess each resident who used a wheelchair, to determine each resident's level of assistance needed. At the time of the exit, inservice training was ongoing until all staff are addressed. A final revisit will be conducted to determine if the facility is in substantial compliance with participation requirements. At the time of exit, the severity of the deficiency was lowered to a D grid level. This statement does not denote that the facility has complied with State law (Section 198.026.1 RSMo.) requiring that prompt remedial action be taken to address the Class I violation.