Every finding on record at Communities of Wildwood Ranch

Based on record review and interview, the facility failed to ensure all residents were free from unnecessary medications when staff administered blood pressure medication to one resident (Resident #22) when the resident's blood pressure was outside for the physician ordered parameters for administration. Review of the facility's policy titled Clinical Administering Medications, with a revised date of April 2019, showed the following: -Medications are administered in a safe and timely manner, and as prescribed; -Medications are administered in accordance with prescriber orders; -If a dosage is believed to be inappropriate or excessive for a resident, or a medication has been identified as having potential adverse consequences for the resident or is suspected of being associated with adverse consequences, the person preparing or administering the medication will contact the prescriber, the resident's attending physician, or the facility's medical director to discuss the concerns. 1. Review of Resident #22's Admission Record, located in the Profile tab of the electronic medical record (EMR), showed the following: -admitted [DATE]; -Diagnoses included personal history of transient ischemic attack (temporary interruption of blood flow to the brain) and cerebral infarction (ischemic stroke) without residual deficits, congestive heart failure (CHF - chronic condition where the heart muscle becomes weakened and cannot pump blood efficiently), unspecified atrial fibrillation (a heart rhythm disorder), and high blood pressure. Review of the resident's quarterly Minimum Data Set (MDS) assessment, located in the MDS tab in the EMR, with an Assessment Reference Date (ARD) of 01/25/25, showed the following: -Resident had severe cognitive impairment; -Resident required substantial/maximal assistance for toileting, showering, dressing, and personal hygiene. Review of the resident's EMR under Physician Orders, showed a physician order, dated 07/09/24, for hydralazine HCl (medication used to treat high blood pressure) oral tablet 50 milligrams (mg), administer one tablet by mouth two times a day for high blood pressure. Staff to hold medication if systolic blood pressure (SBP) was less than 110 millimeters of Mercury (mm/Hg). Review of the resident's December 2024 Medication Administration Record (MAR), located in the EMR Orders tab, showed the following: -The physician order for hydralazine HCl oral tablet 50 mg, give one tablet by mouth two times a day for high blood pressure. -On 12/05/24, morning, staff administered the resident's hydralazine HCL. Staff noted the resident had a SBP of 108 mm/Hg. -On 12/05/24, evening, staff administered the resident's hydralazine HCL. Staff noted the resident had a SBP of 104 mm/Hg. -On 12/06/24, morning, staff administered the resident's hydralazine HCL. Staff noted the resident had a SBP of 104 mm/Hg. -On 12/20/24, morning, staff administered the resident's hydralazine HCL. Staff noted the resident had a SBP of 105 mm/Hg. Review of the resident's January 2025 MAR, located in the EMR Orders tab, showed the following: -The physician order for hydralazine HCl oral tablet 50 mg, give one tablet by mouth two times a day for high blood pressure. -On 01/01/25, morning, staff administered the resident's hydralazine HCL. Staff noted the resident had a SBP of 109 mm/Hg. -On 01/05/25, morning, staff administered the resident's hydralazine HCL. Staff noted the resident had a SBP of 109 mm/Hg. -On 01/05/25, evening, staff administered the resident's hydralazine HCL. Staff noted the resident had a SBP of 109 mm/Hg. -On 01/08/25, morning, staff administered the resident's hydralazine HCL. Staff noted the resident had a SBP of 104 mm/Hg. Review of the February 2025 MAR, located in the EMR Orders tab, showed the following: -The physician order for hydralazine HCl oral tablet 50 mg, give one tablet by mouth two times a day for high blood pressure. -On 02/01/25, evening, staff administered the resident's hydralazine HCL. Staff noted the resident had a SBP of 109 mm/Hg. -On 02/05/25, morning, staff administered the resident's hydralazine HCL. Staff noted the resident had a SBP of 96 mm/Hg. -On 02/07/25, morning, staff administered the resident's hydralazine HCL. Staff noted the resident had a SBP of 107 mm/Hg. -On 02/10/25, morning, staff administered the resident's hydralazine HCL. Staff noted the resident had a SBP of 105 mm/Hg. Review of the resident's Progress Note, located under the EMR Progress Notes tab, dated December 2024 to February 2025, showed staff did not document why the hydralazine HCl was administered with SBP below 110 mm/Hg. During an interview on 02/13/25, at 9:46 A.M., Certified Medicine Technician (CMT) 1 said he/she would get the resident's vitals and check the parameters that were on the medication list. If a resident's blood pressure was too high or too low, she would tell the nurse. The nurse would tell him/her if he/she should give blood pressure medication or not. CMT1 confirmed the resident had received hydralazine outside of the ordered parameters, and he/she had administered some of the doses. CMT1 said there was normally a spot in the progress note where he/she would document that the nurse said to give the medication outside parameters, and did not know why there was not a note. When he/she documented the blood pressures in the EMR it would tell him/her if it was outside the parameters. If the resident's SBP was below 110 mm/Hg the hydralazine should be held. During an interview on 02/13/25, at 10:07 A.M., Licensed Practical Nurse (LPN) 1 said if a resident required a blood pressure medication, he/she would check their pulse and blood pressure. If the blood pressure was outside of ordered parameters, they would follow the parameter order. LPN1 said if the blood pressure was below parameters he/she would hold the medication and then contact the doctor to notify them. He/she would then put in a progress note, which the Medical Director and Nurse Practitioner both read. Giving blood pressure medication below parameters could cause the resident's blood pressure to go lower. During a concurrent interview on 02/13/25, at 1:17 A.M. with the Administrator, Director of Nursing (DON), and Regional Nurse Consultant showed they said if a resident's blood pressure was outside of ordered parameters, the ordered blood pressure medication should not be given. The DON said the staff would usually notify the Medical Director or Nurse Practitioner. The DON stated that the only reason to give the medication outside of parameters was if the physician had been contacted, which would then be documented. The DON said if a medication had been held below a parameter it would be on the 24-hour report.

Based on interview and record review, the facility staff failed to ensure an environment as free for accident hazards of possible for all residents, when the facility failed to ensure staff were aware of where to find care planned fall interventions and followed care planned fall intervention for one resident (Resident #1) resulting the resident falling from his/her bed, while not in the low position, and left unattended. The fall resulted in facial injuries and skin tears requiring the resident to be sent to the hospital. The facility census was 111. Review of the facility's policy Falls and Fall Risk, revised March 2018, showed the following: -Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling; -Environmental factors that contribute to the risk of falls include incorrect bed height or width; -Resident conditions that may contribute to the risk of falls include delirium and cognitive impairment; -The staff, with the input of the attending physician, will implement a resident-centered fall prevention plan to reduce the specific risk factor(s) of falls for each resident at risk or with a history of falls; -If falling recurs despite initial interventions, staff will implement additional or different interventions, or indicate why the current approach remains relevant; -If interventions have been successful in preventing falling, staff will continue the interventions or reconsider whether these measures are still needed if a problem that required the interventions has resolved. 1. Review of Resident #1's face sheet (admission data) showed the following: -admitted [DATE]; -Diagnoses included vascular dementia (problems with reasoning, planning, judgment, memory and other thought processes caused by brain damage from impaired blood flow to the brain) without behavioral disturbance, unsteadiness on feet, and muscle weakness. Review of the resident's fall risk assessment, dated 10/13/23, showed the following: -No history of falling within three months; -Ambulatory aide: None/bed rest/nurse assistance; -Gait: Impaired; -Mental status: Overestimates abilities/forgets limitations; -Resident is low risk: Implement standard fall prevention interventions. Review of the resident's care plan, revised on 10/14/23, showed the following: -The resident was at risk for falls. The resident prefers to be as independent as possible; -The resident will have no major injury related to falls. Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment tool completed by facility staff), dated 10/15/23, showed the following: -Severely impaired cognitive skills; -No behaviors; -Mobility: Roll left to right with substantial/maximum assistance; -Sit to lying: Ability to move from sitting on side of bed to lying flat on bed with substantial/maximum assistance. Review of the resident's care plan, updated 10/18/23, showed the following: -Place the resident's bed in the low position when the resident is in bed. Review of the resident's progress note dated 12/19/23, at 3:40 A.M., showed a certified nurse aide (CNA) called nurse to resident's room. The resident sat on the floor beside his/her bed. The resident said he/she just rolled off. The resident had a small skin tear to his/her left pinky finger. Review of the resident's care plan, updated 12/19/23, showed the following: -Staff to ensure the resident is positioned in the bed appropriately prior to leaving unattended. Review of the resident's nursing note dated 12/30/23, at 4:32 P.M. showed Licensed Practical Nurse (LPN) H documented staff heard the resident call for help. Staff found the resident on the floor after he/she fell out of his/her bed. The resident was noted to have multiple injuries including right facial lacerations, left eye hematoma (bruise), left hand skin tear, and right knee skin tear. The resident was alert and oriented times two per his/her baseline and conversed with the staff. Staff called emergency services to transport to the hospital. Review of the resident's care plan, dated 12/30/23, showed the following: -Staff to ensure the resident's bed in lowest position prior to leaving the resident unattended in his/her room. During interviews on 01/10/24, at 12:10 P.M. and 2:03 P.M., CNA D said the following: -On 12/30/23, at approximately 3:45 P.M., he/she changed and dressed the resident in his/her bed and placed the Hoyer sling (Hoyer lift - lift used to transfer non-weight bearing residents) under the resident; -He/she raised the resident's bed to change the resident; -He/she left the resident in bed with the bed up and went to get the Hoyer lift in another resident room; -The resident had never got out of his/her bed or tried to stand up on own; -He/she should not had left the resident's bed up in the higher position; -He/she did not know the resident was at risk for falls; -He/she thinks the resident sat up on the bed, hoisted legs over the side of the bed, and hit the metal on the bedside table which was in close proximity of the resident's bed; -He/she did not know the resident rolled out of his/her bed in a prior incident on 12/19/23; -Resident's who are fall risk should have this addressed in their care plans; -He/she did not know where to find the care plans. The care plans are probably in the charting on the computer. During interviews on 01/10/24, at 12:54 P.M. and 2:38 P.M., LPN F said the following: -The resident sometimes tried to get out of bed; -On 12/30/23, he/she found the resident face down on the floor. He/she thinks the resident hit the bedside table on the metal on the bottom of the bedside table; -He/she did not know of the incident on 12/19/23 of the resident rolling out of bed; -Staff know a resident is at risk for falls through their history, dementia, confusion or if they fell at home; -Staff should not leave a resident up in raised bed; -The care plan team consists of the department heads; -The aides should report to the Director of Nursing (DON) if the resident has a decline. Staff discuss the resident and update the care plan; -Staff communicate to the aides with charting, care plans, and the report from aides on shift to shift report; -He/she expects the nurse aides to know residents who are a fall risk; -He/she expects for staff to not leave a resident alone in a bed that is raised high. During an interview on 01/11/24, at 8:09 A.M., LPN H said the following: -Staff assisted the resident with a Hoyer lift for transfers; -The resident did not try to get out of bed; -He/she did not know of the 12/19/23 incident of the resident rolling out of bed; -On 12/30/23, CNA D left the resident's bed in a high position when he/she assisted the resident to get out of bed; -He/she found the resident on the floor with lacerations to the face and significant facial injury and multiple hematomas; -The resident's bed was in a high position; -He/she expects staff to leave the resident bed in a low position if leave the resident; -Staff knew if a resident is at risk for falls due to dementia, wandering and the resident not know own limitations; -The nurse aides have a document which contains the resident census and how the resident transfers; -The care plan should show if a resident is at risk for falls and fall interventions; -The nurse aides have access to the care plans in their documentation and the internet portal; -Nurses inform the nurse aides verbally if a resident has updated fall interventions; -Registered Nurse (RN) G updates the care plans; -He/she expects staff to leave the resident bed in a low position if leave the resident. During an interview on 01/10/24, at 2:19 P.M., RN G said the following: -On 12/19/23, the care plan intervention, positioned appropriately means the resident wiggled and the staff should make sure the resident is not on the edge of the bed and the bed was in a low position; -On 12/30/23, CNA D assisted the resident to get ready and raised up the resident's bed, left to get help for the transfer and the resident fell ; -Staff should not have the bed up and the resident unattended; -He/she updates the care plan on the hall that the resident resides on; -Staff discuss any falls in the morning meeting. He/she pulls the incident report, reads the progress notes and meets with the care plan team in the morning meeting; -The care plan team includes all the department heads; -He/she informs therapy and meets at the weekly quality assurance risk meeting with the department heads and lead nurses; -Staff inform the aides if a resident fell or a fall risk with verbal or paper communication; -Nurses pass on in the nursing shift report to the aides of any falls, updates with residents; -The aides have access to care plan and can ask for the care plans; -Staff inform the aides of a resident fall and/or fall interventions through verbal report; -He/she care plans every resident as a fall risk. During interviews on 01/10/24, at 2:46 P.M. and 3:25 P.M., the Director of Nursing (DON) said the following: -On 12/19/23, the resident moved and rolled out of his/her bed; -The resident's bed was left in a high position and the resident fell from the bed; -The aide changed the resident and got the resident prepared to eat; -The aide placed the Hoyer sling (sling used with a Hoyer lift that assists with transfer non-weightbearing residents)under the resident; -The resident's bed was at the height of the aide's waist; -She expects staff to not leave residents unattended in bed in a high position. During an interview on 01/10/24, at 11:25 A.M. LPN B said the following: -He/she heard in the nursing report the resident rolled off of bed; -The resident is very confused; -The resident fell a few times in the past. During an interview on 01/10/24, at 12:39 P.M., CNA E said the following: -He/she did not understand why staff left the resident on own as staff should not leave a resident with the bed up; -The resident's bed is usually in the low position and staff should not leave the resident's bed up; -He/she did not know the resident had rolled out of his/her bed prior to this incident. -He/she did not know where to find resident care plans; -Nurses inform the nurse aides if a resident uses a Hoyer lift for transfer and if need to leave the bed in the low position. During an interview on 01/10/24, at 11:52 A.M., LPN C said the following: -The nurse aides inform the nurse if a resident falls; -The nurses assess a resident if they sustain a fall and notify the physician; -RN G completes fall investigations and updates the residents' care plans; -Staff know a resident is a fall risk from their fall history, admission information, unsteadiness on feet, confusion and mental status; -Fall interventions include bed in the lowest position, fall mat, close proximity to the nurses station and frequent rounds. During an interview on 01/10/24, at 2:46 P.M., the DON said the following: -Staff knew residents at risk for falls by the resident care plan; -RN G initiates and updates the care plans as needed and at review due dates; -Staff discuss falls in the morning meeting; -She and RN G communicate verbally to the staff of any updates to the residents' care; -The charge nurses give report to the nurse aides. The nurse aides have a paper with details of each resident care needs. Staff find out if a resident had a fall in the CNA report and communication between staff; -Staff should not leave a resident if the bed is high. Staff should make sure the bed is in the lowest position when they leave the resident; -Two staff should be in the room during a Hoyer lift transfer with a resident. During an interview on 01/10/24, at 3:25 P.M., the Administrator said the following: -Staff should know a resident at risk for falls in the residents' chart; -The nurse aides have access to residents' care plans; -Staff communicate in the morning and at the shift report of a resident fall; -Staff knew of updated fall interventions through the nursing report, word of mouth and the care plan; -The nurse aides complete shift report with each other. During an interview on 01/11/24, at 12:07 P.M., the Medical Director said the following: -He expects staff to be aware of residents at risk for falls and fall interventions; -He expects staff to not leave a resident with the bed in a high position. MO00229548, MO00229685

Based on interview and record review, the facility failed to ensure all residents were as free from accident hazards as possible when staff completed a slide transfer for one resident (Resident #1) without ensuring the area was free from potential hazards prior to completing transfer resulting in the resident's leg getting caught in a blanket while being transferred resulting in pain. The facility had a census of 109. Review of a facility policy titled, Safe Lifting and Movement of Residents, revised July 2017, showed the following information: -Nursing staff in conjunction with rehabilitation staff shall assess resident needs for transfer assistance and will document the resident transfer and lift needs in the care plan; -Manual lifting of residents shall be eliminated when feasible. Review of a facility policy titled, Lifting Safety Precautions, revised March 2005, showed the following information: -When lifting or moving residents staff are to ensure equipment is secure; -If there are mechanical devices available to assist in moving residents more safety staff are to utilize them. 1. Review of Resident #1's face sheet (basic information sheet) showed the following information: -An admitted [DATE]; -Diagnoses including multiple sclerosis (MS - a chronic, typically progressive disease involving damage to the sheaths of nerve cells in the brain and spinal cord, whose symptoms may include numbness, impairment of speech and of muscular coordination, blurred vision, and severe fatigue), morbid obesity due to excess calories, type two diabetes (DMII- a chronic condition that affects the way the body processes blood sugar) with diabetic neuropathy (a type of nerve damage that can occur with diabetes typically in the legs and feet), chronic pain, and muscle weakness. Review of the resident's Minimum Data Set (MDS- a federally mandated assessment tool completed by facility staff), dated 09/01/23, showed the following: -The resident was cognitively intact; -The resident required staff assistance with transfers. Review of the resident's care plan, current as of 12/05/23, showed staff are to utilize two staff with a Hoyer lift (mechanical lift for non-weight-bearing residents) for transfers. Review of the resident's nurses' notes showed the following information: -On 12/01/23, at 12:44 P.M., staff documented the resident was transferred from his/her bed to his/her wheelchair during a facility evacuation via slide transfer. The resident stated his/her leg was caught in a blanket during the transfer and had complaints of pain to the left knee and ankle. An x-ray was ordered and obtained at 12:40 P.M.; -On 12/01/23, at 5:05 P.M., staff documented the x-ray results were obtained and were unremarkable. During an interview on 12/05/23, at 12:25 P.M., the resident said the following: -On 12/01/23, around 11:00 A.M., staff came to his/her room to evacuate him/her from the facility; -Staff tried to wheel him/her out of the room in his/her bed; -The bed would not fit through the door; -He/She was transferred from his/her bed to his/her wheelchair by approximately five facility staff; -Staff transferred him/her by sliding him/her out of bed to the wheelchair; -During the transfer his/her left foot got caught in a blanket at the foot of his/her bed twisting his/her leg; -He/She had a sharp pain in his/her left leg and foot when his/her leg got caught and he/she said ouch; -He/She had an x-ray that was negative following the transfer; -He/She is having continued pain in the left foot and lower leg in relation to his/her leg getting caught during the transfer on top of the regular pain he/she experiences in his/her legs; -The pain is manageable when he/she is not being moved, but is a ten out of ten in pain when being moved. During an interview on 12/05/23, at 1:20 P.M., Certified Nurses Assistant (CNA) A said the resident is totally dependant on staff for transfers. During an interview on 12/05/23, at 2:10 P.M., Registered Nurse (RN) B said the following: -On 12/01/23, around 11:00 A.M., a full facility evacuation was needed; -He/She assisted with transferring the resident during the evacuation; -There were five to six total staff present assisting with the transfer of the resident; -Staff were unable to wheel the resident out of his/her room while still in bed as the bed would not fit through the door; -The resident was slide transferred from his/her bed to his/her wheelchair; -During transfer the resident's foot got wrapped in a blanket at the foot of his/her bed causing the resident's leg to be pulled slightly back; -The resident did not express pain or discomfort when being slide transferred; -An x-ray was completed that did not identify any issues; -The resident was slide transferred due to the emergency situation; -When transferring a resident staff completing the transfer are responsible for ensuring the area is clear of any hazards that may impede the transfer. During an interview on 12/05/23, at 2:23 P.M., Licensed Practical Nurse (LPN) C said the following: -On 12/01/23, around 10:00 A.M., a full resident evacuation was needed; -He/She was present and assisted with the transfer of the resident during evacuation; -Staff initially tried to evacuate the resident by pushing his/her bed out of the room, but the bed was too wide to fit through the door; -Staff then completed a slide transfer of the resident from his/her bed to his/her wheelchair; -During the transfer the resident's left leg got caught in a blanket which slightly pulled the residents leg; -The resident said, Ow, my leg, when transferred; -The resident said he/she had slight pain in his/her legs at the time of transfer; -The resident has regular pain in his/her legs and takes regular pain medication for his/her pain; -The resident was assessed with no injury, redness, or swelling noted to his/her leg that got caught during transfer; -He/She did not know the protocol for transfer during emergency and that staff present decided a slide transfer was the quickest and safest option due to the Hoyer being unavailable. During an interview on 12/05/23, at 2:33 P.M., CNA D said the following: -He/She was present when the resident was transferred during evacuation; -Five staff were present for the transfer of the resident; -The resident was slide transferred from his/her bed to his/her wheelchair; -He/She did not see any issues with the transfer; -The resident did voice pain in his/her leg (not specified) following the transfer, but leg pain is common for the resident; -He/She felt the slide transfer was appropriate given the situation. During an interview on 12/05/23, at 3:33 P.M., the Director of Nursing (DON) said the following: -He/She was unaware the resident was transferred via slide transfer until after evacuation occurred; -When the resident was transferred his/her foot got caught in a blanket that slightly pulled the residents leg; -The resident reported soreness in his/her leg following the transfer; -An assessment was completed immediately with injuries noted; -An x-ray was completed that did not identify any injury; -The resident does have regular reported pain in his/her legs and takes regular pain medication related to the pain; -All transfers are to be completed safely; -The resident had a blanket covering him/her that got caught while transferring; -Staff should ensure sheets are unattached and nothing is in the way that may get caught or impede the transfer; -Staff completing transfers are responsible for ensuring it is completed in a safe manner. During an interview on 12/05/23, at 4:13 P.M., the Administrator said the following: -The resident was slide transferred with two to three staff during the emergency evacuation; -Staff can complete alternative methods of transfer in an emergency; -Staff are to transfer residents safely; -The area of transfer should be free from hazards prior to sliding a resident if using a slide transfer; -A slide transfer could potentially be completed safely in the event of an emergency with an appropriate amount of staff to assist; -Staff completing transfers are responsible for ensuring safe and appropriate transfer. MO00228201

Based on interview and record review, the facility staff failed to implement policies and procedures to help prevent abuse when staff failed to ensure the required criminal background checks (CBC - check that searches for criminal misconduct) for three staff members (Registered Nurse (RN) B, Licensed Practical Nurse (LPN) D, and Social Services (SS) A); employee disqualification list (EDL - list maintained by the Department of Health and Senior Services of individuals who have been determined to have: abused or neglected a resident; misappropriated funds or property belonging to a resident) checks for four staff members (RN B, Office Staff C, LPN D, and Certified Occupation Therapy Assistant (COTA) F); and the CNA registry (Certified Nurse Aide - list of all nursing assistants who meet the requirements to practice under that title within their state) check for three staff members (RN B, COTA A and CNA E) were completed prior to staff beginning employment at the facility. The facility census was 103. Review of the facility provided policy titled, New Hire Checklist, dated February 2022, showed the following: -When an employee is hired, the appropriate personnel will complete the New Hire Checklist, indicating that all the necessary forms and paperwork have been received; -A CBC must be submitted by the facility prior to employment. Note on the form if the background check is completed through the Family Care Safety Registry (FCSR) or Missouri Health Care Association; -The EDL must be check must be completed prior to hire. Indicate the date the EDL was checked; -Check CNA Registry for all new hires. Complete this because some employees may have a Federal Indicator on the CNA Registry that does not show up when they apply for other positions. 1. Review of RN B's personnel record showed the following information: -Hire/start date of 11/20/21; -The facility completed a criminal background check and EDL check on 12/01/21 (eleven days after the RN's start date); -The facility did not complete a NA registry check. 2. Review of Office Staff C's personnel record showed the following information: -Hire/start date of 08/17/22; -The facility completed an EDL check on 08/22/22 (five days after the Office Staff's start date). 3. Review of LPN D's personnel record showed the following information: -Hire/start date of 02/06/21; -The facility completed a criminal background check and EDL check on 02/12/21 (six days after the LPN's start date). 4. Review of SS A's personnel record showed the following information: -Hire/start date of 04/05/21; -The facility completed a criminal background check on 04/07/21 (two days after the SS's start date). 5. Review of COTA F personnel record showed the following information: -Hire/start dated of 10/18/21; -The facility completed an EDL check on 10/19/21 (one day after the COTA's start date); -The facility did not complete a NA registry check. 6. Review of CNA E personnel record showed the following information: -Hire/start dated of 02/02/23; -The facility completed a NA registry check on 06/26/23 (four months and twenty-two days after CNA's start date). 7. During an interview on 07/28/23, at 1:00 P.M., the Administrator said that staff should complete all background checks, CBC, EDL check, and the NA Registry check prior to all new employees' dates of hire, including the housekeeping and therapy department staff. It should not wait to be done after the hire date. The therapy department did not realized they were required to check the NA registry for their staff. Staff should always complete all of the required checks prior to an employee starting work. The business office manager was responsible for completing the new hire checks.

Based on interview and record review, the facility failed to give written information to the resident and/or resident's representative of the facility's bed hold policy for four residents (Residents #78, #8, #19 and #51), out of four sampled residents, who were transferred out to the hospital. The facility census was 103. Review of a facility policy entitled Bed-Holds and Returns, dated October 2022, showed the following: -All residents/representatives are provided written information regarding the facility and state bed-hold policies, which address holding or reserving a resident's bed during periods of absence (hospitalization or therapeutic leave); -Residents, regardless of payer source, are provided written notice about these policies at least twice in advance of any transfer (e.g., in the admission packet) and at the time of transfer (or, if the transfer was an emergency, within 24 hours); -Multiple attempts to provide the resident representative with notice at time of discharge should be documented in cases where staff were unable to reach and notify the representative timely. Review of a facility form letter entitled Bed-Hold Notice, showed the following: -Staff to fill in resident's name, facility name, maximum number of calendar days allowed without pay during a hospitalization /therapeutic leave/vacation, room rates, facility contact person/phone number/signature, date, and time; -The resident or their representative is to sign/date/time the form, indicating whether or not they want to have the resident's bed held during the described absence from the facility. 1. Review of Resident #78's face sheet (brief information sheet about the resident) showed the following information: -admitted [DATE]; -Diagnoses included acute ischemia of the intestine (sudden loss of blood flow to the small intestine) and neuromuscular dysfunction of bladder (the nerves and muscles don't work together very well causing the bladder to not fill or empty correctly). Review of the resident's discharge Minimum Data Sheet (MDS - a federally mandated assessment tool completed by facility staff), dated 07/07/23, showed the resident discharged to the hospital with a return anticipated. Review of the resident's progress notes dated 07/07/23, at 7:32 P.M., showed the following: -The resident continued to have nausea, vomiting, and diarrhea. Emesis (vomit) mostly mucus/bile due to little to no food intake. The aides noted the resident had not urinated since before 6:00 A.M. Staff notified the physician and requested the resident be sent to the emergency room for evaluation due to bowel ileus (intestines are not moving correctly and cannot push food through the digestive system) found on KUB (kidney, ureter, and bladder X-ray performed to assess the abdominal area for causes of abdominal pain), urinalysis (UA - test of urine) results, inability to void, and continued nausea, vomiting, and diarrhea. The resident agreed to go. Staff notified the resident's family. The resident was sent with the ambulance at 7:20 P.M. with copy of face sheet, medication list, KUB and UA results. Report called to the emergency room (ER). Review of the resident's medical record showed staff did not document regarding providing the facility's bed-hold policy to the resident or resident's representative related to the transfer to the hospital. No bed-hold notice was located in the resident's admission packet. 31464 2. Review of Resident #8's face sheet showed the following: -admitted [DATE]; -Diagnoses included dependence on acute respiratory failure and pneumothorax (the presence of air or gas in the cavity between the lungs and chest wall, causing collapse of the lung). Review of the resident's discharge MDS, dated [DATE], showed the resident discharged with return anticipated. Review of the resident's progress notes dated 07/24/23, at 1:41 A.M., showed the following: -Night shift 07/23/23 - The resident was sent to the hospital for evaluation due to shortness of breath, diminished lung sounds, edema (swelling), rapid weight gain with history of kidney disease, cardiac disease, and respiratory failure. Staff notified family. Staff notified administrator and physician notified via electronic system. Review of the resident's medical record showed staff did documentation regarding the facility's bed-hold policy being provided to the resident or resident's representative related to the transfer to the hospital. A copy of a bed-hold provide to the resident or representative was not present in the record. During an interview on 07/26/23, at 3:15 P.M., the Social Services Director (SSD) said if family is in the building, he/she gives the notice to them. He/she mailed the notice to the resident's family. He/she does not send a Bed-Hold Policy with a transfer notice, but thought maybe the nurses took care of that. 3. Review of the Resident #19's face sheet showed the following: -admitted [DATE]; -Diagnoses included urinary tract infection (UTI), chronic respiratory failure with hypoxia (low oxygen in the bloodstream), dementia, muscle weakness, chronic obstructive pulmonary disease (COPD - a group of diseases that cause airflow blockage and breathing-related problems), heart failure, and high blood pressure. Review of the resident's admission packet showed the resident signed acknowledgement of the facility's Bed-Hold Policy on 09/13/16. Staff had circled the paragraph indicating the facility did not hold a Medicare patient's bed for any individual transferred to the hospital. The resident is considered discharged when they are transferred to the hospital. Review of the resident's MDS, dated [DATE], showed the resident discharged with return anticipated. Review of the resident's progress notes dated 07/23/23, at 9:07 P.M., showed staff documented the following: -The nurse practitioner gave order to send the resident to hospital emergency room (ER) for evaluation due to positive Hemoccult test (a test used to check stool samples for hidden (occult) blood), decreased level of consciousness, pallor (pale appearance), lethargy (lacking energy), and anemia (not having enough healthy red blood cells or hemoglobin to carry oxygen to the body's tissues). Staff notified family. Staff notified administration and physician via electronic system. Review of the resident's medical record showed staff did not document providing the resident or the resident's representative of the facility's bed-hold policy related to the transfer to the hospital. 48187 4. Review of Resident # 51's face sheet (gives basic profile information) showed the following: -admitted [DATE]; -Diagnoses included hemiplegia (paralysis of one side of the body) and hemiparesis (muscle weakness and or partial paralysis on one side of the body) following cerebral infarction (stroke) affecting right dominant side, and aphasia (unable to express speech). Review of the resident's MDS, dated [DATE], showed the resident discharged to the hospital with a return anticipated. Review of the resident's electronic medical record (EMR) showed a bed hold policy, dated 08/15/18, and signed by the resident's family. The form stated that the facility does not hold a Medicare bed for any individual transferred to the hospital. The individual is considered discharged when they are transferred to the hospital. The policy will be given to the resident or responsible party, in writing, at the time of transfer. Review of the resident's progress notes showed staff documented the following information: -On 04/06/23, at 10:59 A.M., the nurse documented that the resident was short of breath and left arm was twitching and shaking. The nurse notified provider and received orders to transfer resident to the hospital. -On 04/06/23, at 11:15 A.M., the nurse documented that resident left the facility via ambulance; -On 04/06/23, at 11:51 A.M., the nurse documented that the resident's family was notified of the transfer; -On 04/06/23, at 12:38 P.M., social services documented that resident was transferred to hospital, return anticipated, notice of transfer/discharge form completed. (Staff did not document regarding bed-hold policy.) Review of the resident's electronic and paper medical records showed staff did not document notification to the resident or resident's responsible party in writing of the facility's Bed Hold Policy when the resident was transferred to the hospital on 04/06/23. 5. During an interview on 07/28/23, at 12:00 P.M., Licensed Practical Nurse (LPN) H said that when a resident is transferred to the hospital that nursing staff should send a copy of the resident's face sheet, current medication list, ambulance report, and a transfer/discharge form. He/she said the ambulance takes all the forms to the hospital. He/she said that nursing would not fill out the bed hold form because nursing staff would not know what amounts to put on the form. The office staff should be filling out the bed hold form the next day. He/she was not sure who the bed hold form should be sent to. The LPN said that he/she has never filled out a bed hold form for the five years he/she has been employed at the facility. 6. During an interview on 07/26/23, at 3:00 P.M., LPN P said when sending a resident to the hospital, the nurses send a face sheet, medication list, any pertinent lab results, and a hospital transfer form with the ambulance staff. 7. During an interview on 07/28/23, at 2:42 P.M., Registered Nurse (RN) Q and LPN R said when sending a resident out to hospital, the nurse should fill out the bed-hold form using the resident's preference information obtained from the front business office. They should keep a copy for the paper chart and send the original with the resident. The nurses said they did not send the bed-hold notice to the family. 7. During an interview on 07/26/23, at 3:49 P.M., the Social Service Director (SSD) said that he/she completes a written transfer notice form and sends with the resident or family. The ombudsman is notified monthly of discharged residents. The transfer notice does not have any reference to the bed hold policy. He/she does not send a bed hold policy with the resident. 8. During an interview on 07/27/23, at 11:25 A.M., the Assistant Director of Nursing (ADON) said that the nurses should notify the ambulance and the resident's family after receiving an order to send a resident to the hospital. They should send a transform form, resident face sheet, medication list, and bed hold policy with the EMS staff.

Based on observation, interview, and record review, the facility failed to provide protective oversight to all residents to prevent possible accidents/elopements when the staff did not complete checks of wander guards (wander/elopement alarm/devices) as ordered; when the facility failed to ensure the wander guard device alarms alarmed at all panels and pagers; and when staff failed to follow policy to ensure residents were accounted after one resident (Resident #14) exited the building causing the wander guard alarm to sound. The facility had a census of 103. Review of the facility's policy titled, Elopement Precautions/Missing Resident, undated, showed the following: -The facility does not have a special care unit; -In this facility, all exit doors are alarmed; -Any resident who is an elopement risk shall have a personal electronic monitoring device placed on their wrist, ankle or assistive device; -The doors that are activated by the electronic monitoring system include all dining room doors located in each community, the front door, the exit door located in the therapy office, and the exit door at the end of Pines (resident hall); -When a door alarm sounds, the charge person assigned to the area where the door is located, or their designee, will immediately investigate; -If the cause of the alarm is not immediately known, the area outside the door will be checked at the same time an accounting of the residents inside occurs; -An alarm is never to be shut off without verifying how the alarm was activated or verifying that all resident whereabouts are known. 1. Review of Resident # 14's face sheet showed the following: -admitted [DATE]; -Diagnoses included dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities) without behavioral disturbance, Alzheimer's disease (a progressive disease that destroys memory and other important mental functions), and muscle weakness. Review of the resident's physician order sheets, dated 07/27/23, showed the following: -An order, dated 03/21/23, for alarm bracelet for safety at all times, check for placement and function every shift; -An order, dated 03/21/23, staff to test wander guard every Tuesday starting 03/28/23. Review of the resident's Elopement Risk Tool, dated 04/09/23, showed the following: -The resident displays cognitive deficits, disorientation, and intermittent confusion; -The resident has a diagnosis of dementia which may increase the risk of elopement; -The resident has never left the facility without notifying staff; -The resident's wandering behaviors have affected his/her safety and well-being; -Elopement Risk Summary states that the resident has been found to be at risk for elopement and wander guard is currently in use. Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment tool completed by facility staff), dated 04/30/23, showed the following: -The resident had a cognition that was severely impaired; -The resident required one person to assist with bed mobility and transfers; -The resident did not walk in corridor; -The resident used a wheelchair for mobility; -The resident used a wander/elopement alarm. Review of the resident's electronic Medication Administration Record (eMAR) showed the following: -On 06/12/23, at 9:00 A.M., staff documented the wander guard was not checked by staff. Staff did not document the reason the check did not occur. -On 07/01/23, at 9:00 P.M., staff documented the wander guard was not checked by staff. Staff did not document the reason the check did not occur; -On 07/11/23, at 12:00 P.M., staff documented the wander guard was not tested by staff. Staff did not document the reason the test did not occur. Review of the resident's progress notes on 07/23/23, at 07:00 P.M., showed resident was found exit seeking in parking lot. Wander guard was in place and working. During an interview on 07/27/23, at 07:02 P.M., Certified Nurses Aide (CNA) L said the following: -They currently have two residents on the [NAME] hall that are elopement risk residents; -He/she redirects them with snacks or turns on the television; -He/she said that on the evening (07/23/23) the resident was found in the parking lot by CNA M, it was around 6:30 P.M. or 07:00 P.M.; -CNA M told CNA L that he/she heard the front doors alarm, but didn't see anyone right away; -CNA M then seen the resident in the parking lot next to the flag pole sitting in his/her wheelchair; -CNA L said that the resident was off the floor less than ten minutes; -CNA L said the nurses had been sitting at the nurses' station giving report when it all happened; -CNA L said the alarms are loud and can be heard in the halls and on the pagers that all staff have; -CNA L said he/she does not remember hearing the alarms the evening (07/23/23) of the incident; -CNA L said maintenance checks the alarms but not sure how often it gets done. During an interview on 07/27/23, at 7:23 P.M., CNA M said the following: -On the evening that the resident attempted to leave the facility, he/she was working on Pines hall, which is closest to the front doors; -CNA M said that he/she heard the front door alarm, went and checked the front entrance area, but only saw family and no residents so he/she turned the alarm off; -CNA M said the door alarmed again and he/she again did not see any residents outside, only family; -CNA M said he/she turned the alarm off again, then went to [NAME] hall to ask if they were missing any residents; -CNA M and CNA L went to the front entrance and found the resident in the front parking lot next to the flag pole sitting in his/her wheelchair; -CNA M said that if any resident sets off the front door alarm that it would not be heard on [NAME] or [NAME] halls; -He/she said staff have to constantly be listening for the alarms because they are not very loud and there are not any pagers that work on the Pines hall. Review of the resident's care plan, dated 07/27/23, showed the following: -The resident wanders, exit seeks and intrudes on other residents' privacy; -Staff will provide diversional activities and redirect when resident is wandering into other resident's rooms; -Staff will monitor and document behaviors; -Resident will be monitored with a wander guard device that sounds an alarm when the resident leaves the building; -Staff reminded to be aware of resident's location and risk for exit seeking behaviors. During observation on 07/27/23, between 7:30 P.M. to 7:45 P.M., the wander guard and doors were tested throughout the facility. When the front door was tested with a wander guard, the alarm sounded at the front entrance, however, the alarm was not heard on [NAME] or [NAME] halls. The alarm boards did not alarm and the pagers did not alarm. During an interview on 07/27/23, at 6:57 P.M., Certified Medication Technician (CMT) S said that the resident is the only resident he/she is aware of that is an elopement risk and wears a wander guard on [NAME] hall. He/she said that if the resident gets close to the doors the doors lock and the alarms sound loudly. During an interview on 07/27/23, at 6:59 P.M., Certified Nurses Aid (CNA) K said he/she tries to keep the elopement risk residents busy and redirect them when they start exit seeking. He/she said the doors will lock and alarm loudly when the wander guard device gets close to the doors. During an interview on 07/27/23, at 7:14 P.M., Licensed Practical Nurse (LPN) O said there are currently four residents on [NAME] hall that wear wander guard devices. There is a resident that attempts to exit seek out the door every other day. During an interview on 07/28/23, at 4:16 P.M., the Administrator and Director of Nurses (DON) said that if staff hear an alarm all staff should respond to it. All staff are responsible to answer wander guard alarms. Staff are to look for who triggered the alarm. Staff are expected to go outside and look for residents before turning off the alarm. The Administrator and DON said that the alarms show on the boards at the end of the halls and on all the pagers. The nurse and all the aides should have pagers on every hall.

Based on record review and interview, the facility failed to protect residents from misappropriation when tablets of one resident's (Resident #1) Belsomra (a schedule IV controlled substance used for adults who have trouble falling asleep) went missing while in possession of the facility. The facility census was 104. Record review of the facility's policy titled Abuse, Neglect, Misappropriation of Property, undated, showed the following: -The resident has the right to be free from abuse, neglect, misappropriation of property, and exploitation; -Misappropriation of resident property is the deliberate misplacement, exploitation, or wrongful temporary or permanent use of a resident's belongings or money without the resident's consent. Record review of the facility's policy titled Storage of Medications, revised November 2020, showed the following: -Schedule II to V controlled medications are stored in separately locked, permanently affixed compartments. Access to controlled medication is separate from access to non-controlled medications. Record review of the facility's policy titled Controlled Substances, revised April 2019, showed the following: -Controlled substances are stored in the medication room in a locked container, separate from containers for any non-controlled medications; -Controlled substances are reconciled upon receipt, administration, disposition, and at the end of each shift; -Upon receipt, nurse receiving the medication and the individual delivering the medication verify the name, dose, and quantity of each controlled substance being delivered. Both sign the controlled substance record of receipt; -Controlled medications are counted at the end of each shift. The nurse coming on duty and the nurse going off duty determine the count together; -The Director of Nursing (DON) shall investigate any discrepancies in narcotics reconciliation to determine the cause and identify any responsible parties, and give the Administrator a written report of such findings. 1. Record review of Resident #1's face sheet (a brief resident profile sheet) showed the following: -An date of 11/23/2022 with latest return date 12/08/2022; -Diagnoses included unspecified symbolic dysfunctions (symptoms and signs involving speech), muscle weakness, sepsis (bodies response to an infection), urinary tract infection (infection in the urinary system), heart failure (heart's inability to pump enough blood to meet the body's needs), and type 2 diabetes (impairment in the way the body regulates and uses sugar). Record review of the resident's November Physician Order Sheet (POS), showed the following: -An order, dated 11/23/22, for Belsomra 10 milligram (mg), one tablet at bedtime for insomnia. Record review of the resident's November 2022 Medication Administration Record (MAR) showed the following regarding the Belsomra order: -On 11/23/22, staff entered an N on the MAR indicating the medication was not administered. Staff noted the resident refused the medication; -On 11/24/22, staff entered an N on the MAR indicating the medication was not administered. Staff noted the medication was missing. Record review of the resident's care plan, with a start date of 11/25/22, showed the following: -Resident takes hypnotic medication (sleep aide). Staff to monitor sleep patterns and administer medications as ordered. Record review of the resident's November 2022 MAR showed the following regarding the Belsomra order: -On 11/25/22, staff entered a checkmark on the MAR indicating the medication was administered. During an interview on 12/12/2022, at 12:55 P.M., DON said the medication was not at the facility on 11/25/22 so it could not have been administered. Record review of the resident's November 2022 MAR showed the following regarding the Belsomra order: -On 11/26/22, staff entered an N on the MAR indicating the medication was not administered. Staff noted the reason was medication not available; -On 11/27/22, staff entered an N on the MAR indicating the medication was not administered. Staff noted the reason was medication not available. Record review of the pharmacy delivery manifest sheet showed the following: -Belsomra 10 mg tablets, delivered to the facility on [DATE]. Licensed Practical Nurse (LPN) D's signature was on the sheet as the person receiving the delivery. Record review of the resident's November 2022 MAR showed the following regarding the Belsomra order: -On 11/28/22, staff entered an N on the MAR indicating the medication was not administered. Staff noted special requirement not met; -On 11/29/22, staff entered an N on the MAR indicating the medication was not administered. Staff noted medication was held due to sombulance. Record review of the resident's admission Minimum Data Set (MDS - a federally mandated assessment tool completed by facility staff), dated 11/29/2022, showed the following: -The resident had cognitive impairments; -No behaviors. Record review of the resident's November 2022 MAR showed the following regarding the Belsomra order: -On 11/30/22, staff entered an N on the MAR indicating the medication was not administered. Staff noted resident asleep. During an interview on 12/12/22, at 2:25 P.M., a pharmacy employee said the following: -Prior to the medication being sent to the facility the pharmacy technician checks and counts the medications, and then the pharmacist checks and counts the medications; -The delivery driver is also a pharmacy technician; -The medications being sent to the facility are placed in a tote that has a red zipper tag that's removed by the facility employee; -Once the driver is at the facility and the red tag is removed by the facility employee, the employee verifies all medications are present and the correct count of each and the facility employee signs the delivery manifest sheet; -Confirmed that 14 tablets of Belsomra were delivered to facility on 11/28/22 and LPN D signed the delivery manifest sheet; -Controlled medications have a C on the med card. Belsomra is a controlled medications, but due to the type of packaging, it did not have a C on the package. Record review of the resident's December 2022 POS showed the following: -An order, dated 11/23/22, for Belsomra 10 milligram (mg), 1 tablet at bedtime for insomnia. Record review of the resident's December 2022 MAR, showed the following: -On 12/01/22, staff entered an N on the MAR indicating the medication was not administered. Staff noted other special requirement not met; -On 12/02/22, staff entered an N on the MAR indicating the medication was not administered. Staff noted resident refused; -On 12/03/22, staff entered an N on the MAR indicating the medication was not administered. Staff noted the medication was not available; -On 12/04/22, staff entered an N on the MAR indicating the medication was not administered. Staff noted the resident refused. Record review of the facility's Resident Abuse Investigation Report Form, completed on 12/08/22, showed the following: -LPN C wrote he/she and LPN E were reviewing P.M. meds and noticed that Belsomra was not being administered. The LPNs began searching the medication cart and medication room and found the medication in a clear labeled bag with only four pills in the bag. The hard box was empty. The bag was sitting in the overhead cabinet. Record review of the facility's investigation staff interviews, completed on 12/08/22, showed the following: -LPN D said he/she signed in the medication from the pharmacy, but did not realize it was a controlled substance so he/she put it in the cabinet in the locked med room with the rest of the overflow medications. During interviews on 12/12/2022, at 3:50 P.M., and 12/14/22 at 3:05 P.M., LPN D said the following: -Medications are delivered by the pharmacy on the evening shift, the pharmacy employee opens the box in front of the facility employee; -The list of meds are read and staff verify. If it's a narcotic, it's put in a different stack so the count can be verified. Once this is completed, staff sign the form and get a copy and they (the pharmacy) keeps a copy; -Check the narcotics and write the count name and count in the narcotic's book, the other medications are put in the med room; -He/she accepted the medications on the night of 11/28/22. He/she wasn't aware that Belsomra was a narcotic, and the medication was in a case and there were also four loose in the bottom of the bag; -When narcotic meds are received from the pharmacy, they're counted and signed into the green book, and they're locked in the med cart; -Staff write down the narcotics every shift change, the nurse coming on would go to the cart and you would count from the book, once confirmed and matches, you both sign in the green book; -The Belsomra was supposed to have 14, but there were only four tablets; -Upon receiving the Belsomra from the pharmacy driver, he/she put it in the overflow cabinet; -Misappropriation would be taking someone's medications, or medications being stolen or missing, or giving meds to someone that you shouldn't, that isn't ordered; -Missing medications, or a discrepancy in the count, are reported to the DON. Record review of the facility's investigation staff interviews, completed on 12/08/22, showed the following: -Certified Medication Technician (CMT) B said he/she saw the medication Sunday in the med room. He/she was looking for it to offer to the resident . The resident refused it and he/she had seen where the resident had not been taking the medication so he/she put it back in the cabinet. He/she did not realize it was a controlled substance. He/she did not look in the case for the insert at that time. During an interview on 12/12/2022, at 11:30 A.M., CMT B said the following: -Pharmacy delivers the medications to the facility, usually at night, and any nurse can accept the medications; -When the medications are received from the pharmacy, the nurse signs off on receiving them; -The nurse puts the medications in the baskets in the med room. If it is a controlled substance the medication is put in a medication case in lock box; -Med techs administer controlled substances; -Controlled substances are counted at each shift change by both parties. The count is documented in the green narcotics book and both parties sign off on the count; -An N marked on the MAR would indicated the medication was not administered; -He/she has offered the Belsomra to the resident in the past, but the resident refused due to it making him/her sleepy; -He/she found the medication, it was in a cartridge that was enclosed in a zipped bag. There were 3 or 4 loose pills in the bag with the cartridge. The medication was in the cabinet in the med room. The cabinet is not locked; -The controlled substance medication cards have a C on them indicating they're a controlled substance; -When verifying the controlled med cards, staff know how many cards they should have by verifying and it's written on the count sheet in the controlled substance book. Record review of the facility's investigation staff interviews, completed on 12/08/22, showed the following: -LPN E said he/she hadn't seen the medication come in and asked LPN C to check on it since we had been waiting for it. During an interview on 12/12/2022, at 4:20 P.M., LPN E said the following: -On 12/3/22 he/she did not give Belsomra as he/she was not able to locate the medication; -LPN C contacted the pharmacy to verify it had been delivered, and it had been on 11/28/22; -The medication was found in the med room. During an interview on 12/12/2022, at 11:40 A.M., LPN C said the following: -Pharmacy brings the medication to the nurse at the facility and the nurse counts each medication. Staff pour them all out of the bag and go through one by one for each medication; -The driver has a sheet with the list of all medications being delivered and the facility nurse signs off on that sheet as receiving all the medications; -Believes it the facility policy to verify each medication that's delivered; -Once medications brought to the med room, the controlled substances are written down on a new sheet. This includes the number of medications, the starting number, in the green book. Then they're transferred to the lock box in the med cart. Controlled medications have a C on the card; -LPN E told him/her the medication was missing, they began looking for the Belsomra and located it in the over the counter cabinet, that's not locked. There were only four pills in the bottom of the bag in a bubble pack, the container was to hold 10 tablets and there were none in the plastic container; The N marked on the MAR may mean the medication was not administered, or refused, there is a comment section that goes along with the MARs that would explain why it was not administered; -Didn't realize it was a controlled medication; -When it's a controlled medication the staff create a count sheet and it's locked in the narcotics box, these are counted at each shift change. Would know if something is missing as it would be torn out of the narcotic book; -Non controlled substances are put in the med room, they could be stacked up and sit in the med room or put in the individual boxes depending on the residents; -Med room meds may be put up the next morning, Belsomra could have been put up in the med room and sat there as there was not a sheet created for it since staff didn't know it was a controlled medication. During an interview on 12/12/2022, at 12:35 P.M., CMT A said the following: -Employee of the pharmacy drops off the medications to the facility at night; -Facility employee checks the invoice from the pharmacy employee, to make sure the medication count is correct and matches the invoice; -If the medication is a controlled substance, they're double locked. If not controlled, they're put in the med room; -If controlled substance they're written down in the green book; -No specific person puts the medications away, it's whoever has time to put the medications away; -When medications are administered they're marked off on the MAR, this includes the initials and if the resident refuses, staff mark refused. Not sure what and N stands for on the MAR; -Controlled substances are counted each shift or person change, they're counted together and the count is written in the narcotic book; -If medications are a controlled substance, there will be a C on the med card. During an interview on 12/12/2022, at 12:45 P.M., Registered Nurse (RN) F said the following: -Pretty sure the pharmacy has an invoice that lists the medications and the medications are supposed to be counted by the facility; -Controlled substances have to be signed into the green book, along with the count of how many were received, don't know if it one or two nurses that counts; -The medications are looked over and put in the med cart if the med cart is empty, or in the storage bins. Don't usually put in the med room or overflow, its usually in the resident's storage; -Controlled substances are signed off in the green book each time they're administered; -Controlled substances are counted each shift by the oncoming and off-going nurse, they count them together and this is documented in the green book; -Don't know what the letter N means on the MAR; -Don't know if there is an indicator on the medications that would tell staff if the medication is a controlled substance; -Belsomra is controlled and would need to be double locked and counted. During an interview on 12/12/2022, at 4:30 P.M., the DON and Administrator said the following: -When facility employees receive medications from the pharmacy, they should be verifying each medication, including counting the pills to make sure they're all present. Once they're verified, the form is signed by the facility staff and the pharmacy staff; -When the meds are brought from the facility, they're brought in a bin; -Staff check the med cart to see if it needs to be replenished, and the extras go into the cabinet; -If the medications are narcotics, they're added to the narcotic count in the green book; -Narcotics are counted each shift and this is documented in the green book; -Typically narcotics have a C on the med card. Belsomra came in a plastic container and did not have a C on it; -It was LPN D's responsibility to count the Belsomra to make sure all the medications were present. During interviews on 12/12/2022, at 12:55 P.M., and on 12/14/2022, at 10:30 A.M., the DON said the following: -The letter N on the MAR means the med was not administered, there are comments on another sheet that explain the reason the med was not administered; -Misappropriation would be any mishandling of medications or whatever's lost or stolen, or property that's lost or stolen; -Report missing medications to the supervisor, administration and staff report to the DON. The DON files a police report, calls the family, and notifies Department of Health and Senior Services (DHSS) in 24 hours. During an interview on 12/15/2022, at 10:15 A.M., the Administrator said the following: -If something goes missing, staff notify administrator, DON and a investigations is started; -Staff report misappropriation to ombudsman, families, law enforcement and DHSS within 24 hours. MO00210816

Based on interview and record review, the facility staff failed to ensure 100% of staff had been fully vaccinated for COVID-19 (a highly contagious virus that causes serious illness or death), or granted a qualifying exemption, when one staff member (Employee A) had a medical exemption for a medical reason not recognized as a medical contraindication by the Centers for Disease Control (CDC) and failed to ensure one staff member (Employee B) received the second dose of a two-dose COVID-19 vaccine in a timely manner. The facility census was 98. Record review of the facility's policy, COVID-19 Mandatory Vaccination, dated 11/15/21 and updated 01/22/22, showed the following: -All staff are required to have received at least one dose of the FDA-authorized COVID-19 vaccine by 02/14/2022, or have an approved religious or medical exemption; -Under federal law, staff may be eligible for a medical or religious exemption but must meet the criteria for the exemption to qualify; -Medical Exemption: If the immunization is medically contraindicated per CDC's Summary Document for Interim Clinical Considerations for the use of COVID-19 Vaccines Currently Authorized in the United States. 1. Record review of the facility's undated COVID-19 Staff Vaccination Status for Providers forms, showed the following: -Total staff: 164; -Staff with completed vaccination: 93; -Staff with granted exemption: 65; -Staff partially vaccinated: 6; -Staff pending exemptions: 0; -Temporary delay on new hires: 0. Record review of the facility's COVID-19 resident outbreak documentation showed one resident tested positive for COVID-19 in the prior four weeks. No residents who tested positive for COVID were hospitalized , and there were no resident deaths due to COVID 19. 2. Record review of Employee B's Vaccination Immunization record showed on 08/10/21 the employee received the first dose of a two-dose COVID-19 vaccine. Staff did not document the employee received the required second COVID-19 vaccine shot to complete the initial vaccination and did not have an exemption. During an interview on 05/12/22, at 9:00 A.M., the Administrator said five of the six partially vaccinated staff members had only received their first COVID-19 vaccine and were all scheduled to take the second COVID-19 vaccine. One staff member, Employee B, had taken the first COVID-19 vaccine on 08/10/21 and was not sure why the staff member had not taken the second COVID-19 vaccine by now. Employee B should have taken the second COVID-19 vaccine and this had been overlooked. 2. Record review of Employee A's Medical Exemption/Accommodation Request related to COVID-19 vaccination, dated 11/29/21, showed the following: -The exemption listed severe cardiac dysfunction; -On 11/30/21, the physician signed the request form. Record review of the CDC Summary of Document for Interim Clinical Considerations, dated 03/07/22, showed the CDC did not recognize severe cardiac dysfunction as a medical exemption to not receive a COVID-19 vaccination. During an interview on 05/12/22, at 9:20 A.M. the Administrator said the following: -She did not know of the approved CMS recognized clinical reasons for the contraindications to COVID-19 vaccines; -The facility should follow CMS and CDC guidelines for all medical exemptions to be in compliance.

Based on observation, interview, and record review, the facility failed to ensure all residents were treated with dignity and respect when one staff (Certified Medication Technician (CMT) H) interacted with four residents (Resident #4, Resident #5, Resident #6, and Resident #7) in a manner that made them uncomfortable. The facility census was 91. Record review of the facility's policy titled Dignity, dated February 2021, showed the following: -Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem; -Residents are treated with dignity and respect at all times; -Staff speak respectfully to residents at all times, including addressing the resident by his or her name of choice and not labeling or referring to the resident by his or her room number, diagnosis, or care needs. 1. Record review of Resident #4's face sheet (a document that gives a resident's information at a quick glance) showed the following information: -admitted [DATE] with readmitted [DATE]; -diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Record review of the resident's quarterly Minimum Data Set (MDS - a federally mandated comprehensive assessment instrument completed by facility staff), dated 06/30/21, showed the resident was cognitively intact. During interviews on 8/25/21, at 10:10 A.M., and on 8/30/21, at 10:03 A.M. and 11:20 A.M., the resident said the following: -Approximately three weeks ago, CMT H patted the resident's stomach and asked the resident if he/she was pregnant; -CMT H has tried to hug and kiss him/her before; -The resident does not like to be touched, and CMT H said he/she does it to make the resident mad; -CMT H said to the resident that he/she would like to have intercourse with his/her child in order to give the resident a grandchild; -CMT H told the resident he/she was going to borrow the facility van and take the resident to the movies; -CMT H has asked the resident if he/she thinks he/she is good looking; -CMT H watches him/her eat from the doorway, and he/she has told CMT H to stop; -The resident does not want CMT H in his/her room as he/she has made the resident feel uncomfortable. 2. Record review of Resident #5's face sheet showed the following information: - admitted [DATE] and readmitted [DATE]; -diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the resident's quarterly MDS, dated [DATE], showed the resident was cognitively intact. During interviews on 8/25/21, at 10:19 A.M., and on 8/30/21, at 10:17 A.M., and 11:18 A.M., the resident said the following: -Last summer, CMT H said to the resident that he/she must have been a hot momma back in the day; -CMT H will stand in the door and watch Resident #4 and Resident #5; -Resident #5 heard Resident #4 (Resident #5's roommate) tell CMT H to get away, stop and leave him/her alone. 3. Record review of Resident #6's face sheet showed the following information: - admitted [DATE], readmitted [DATE]; -diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the resident's annual MDS, dated [DATE], showed the resident was cognitively intact. During interviews on 8/25/21, at 1:00 P.M., and 8/30/21, at 12:47 P.M., the resident said the following: -CMT H has asked the resident out to a steak dinner. CMT H has also asked Resident #7 to go out to a steak dinner; -The resident has asked CMT H to leave him/her alone; -On 08/06/21, CMT H took Resident #6 and Resident #7 to a drive thru restaurant for food/drinks. CMT H became upset with Resident #7 over a receipt, and Resident #6 observed CMT H yell at Resident #7. CMT H told Resident #7 that he/she could not ride in the van again. CMT H then advised all the residents he/she was going to keep all the residents on the van until Resident #7 provided CMT H with his/her receipt. 4. Record review of Resident #7's face sheet showed the following information: -admitted [DATE] and readmitted [DATE]; -diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the resident's annual MDS, dated [DATE], showed the resident was cognitively intact. During an interview on 8/30/21, at 10:32 A.M., the resident said the following: -During a resident outing, CMT H requested the resident's phone number. The resident refused. CMT H became upset and followed the resident around the store; -After shopping, CMT H took Resident #6 and Resident #7 to a drive-thru restaurant; -Resident #6 paid for Resident #7; -CMT H requested to see the receipt; -Resident #7 told CMT H that he/she did not need to see the receipt; -CMT H yelled at the Resident #7 and accused him/her of ripping up the receipt and throwing it away; -CMT H said Resident #7 could not get off the bus until he/she gave CMT H the receipt and that he/she not welcome on the bus again if he/she is driving; -Resident #7 heard CMT H ask Resident #6 out on a date; -Resident #7 is nervous about CMT H being in his/her room and passing his/her medications, as he/she does not trust him/her. 5. During an interview on 8/25/21, at 10:43 A.M., Certified Nurse Aide (CNA) I said the following: -CNA I was been aware of CMT H teasing and being inappropriate with Resident #4; -CNA I has heard from residents that CMT H has made them uncomfortable; -CNA I felt CMT H's perceived the comments as teasing. 6. During an interview on 8/25/21, at 11:05 A.M., CNA R said the following: -CMT H has been inappropriate with residents; -CNA R is aware that Resident #5 does not like CMT H and does not want him/her in his/her room. 7. During an interview on 8/26/21, at 1:55 P.M., CNA P said the following: -While providing cares, Resident #4 told CNA P that CMT H came in and patted Resident #4's belly and said he/she looked pregnant; -Resident #4 said CMT H had said him/her that he/she dreamed of them being married to Resident #4 and running through a meadow together. 8. During an interview on 8/30/21, at 1:04 P.M., Social Services (SS) said the following: -Resident #7 reported to him/her that he/she was going to get into trouble for something that he/she did not do; -Resident #7 was afraid he/she would be in trouble for not having the receipt from the trip; -Resident #7 did not tell him/her that CMT H had yelled at him/her; -SS interviewed Resident #4 last week regarding CMT H touching the resident and making inappropriate comments; -Resident #4 confirmed the information in the allegations, which was CMT H was in his/her room, patted his/her stomach and asked if he/she was pregnant; -Resident #4 also told SS that CMT H made inappropriate comments. Resident #4 said he/she is always flirting and saying he/she would take Resident #4 to dinner; -Resident #5 said CMT H flirts with everyone. 9. During interviews on 8/30/21, at 2:05 P.M. and 2:27 P.M., CNA Q said the following: -CNA Q said comments such as staff dreaming of running in a meadow together with a resident or staff asking a resident if he/she is pretty/[NAME] are inappropriate. 10. During an interview on 8/30/21, at 3/12 P.M., Licensed Practical Nurse (LPN) O said the following: -He/she did not think is it appropriate for staff to say things like am I [NAME]/pretty to residents or to ask residents to dinner or ice cream. 11. During an interview on 8/30/21, at 3:41 P.M., LPN S said the following: -He/she did not think comments about staff dreaming of running through a meadow with a resident or asking if a resident thinks a staff member is [NAME]/pretty was appropriate and would report to the on call the registered nurse (RN), Director of Nursing (DON) or Administrator immediately. 12. During an interview on 8/30/21, at 3:51 P.M., CNA T said the following: -Investigations of abuse, inappropriate comments, respect/dignity are handled by his/her superiors; -He/she found comments about staff asking residents to dinner or ice cream, asking residents if staff is attractive, and dreaming about walking through a meadow together (staff to resident) is inappropriate and would report to charge nurse. 13. During an interview on 08/30/31, at 4:57 P.M., with the Corporate Nurse, DON, and the Administrator, the following was said: -Staff are expected to treatment residents with dignity and respect; -If staff observe or are notified that a staff member had said something inappropriate to a resident, they should report it to their charge nurse immediately. MO 869, MO 949, and MO 977

Based on observation, record review, and interview, the facility failed to provide incontinent care in a manner to help prevent possible infection for three residents (Resident #1, Resident #2, and Resident #3) when staff failed to perform hand hygiene before and during incontinent care. The facility census was 91. Record review of the facility's policy, titled Perineal (genital) Care, dated October 2010, showed the following information: -The purposes of this procedure are to provide cleanliness and comfort to the resident, prevent infections and skin irritation, and to observe the resident's skin condition; -Place the equipment on the bedside stand. Arrange the supplies so they can be easily reached; -Wash and dry hands thoroughly; -Wash perineal area, wiping from front to back; -Rinse and dry thoroughly; -Wash and rinse the rectal area thoroughly, including the buttocks; -Dry the area thoroughly; -Remove gloves and discard into designated container; -Wash and dry hands thoroughly. (The policy did not address hand hygiene when going from a soiled area to a clean area.) Record review of the facility's policy, titled Handwashing/Hand Hygiene, dated August 2019, showed the following information: -This facility considers hand hygiene the primary means to prevent the spread of infections; -All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors; -Use an alcohol-based hand rub containing at least 62% alcohol or soap and water before moving from a contaminated body site to a clean body site during resident. 1. Record review of Resident #1's face sheet (a brief resident profile sheet) showed the following: -admitted [DATE]; -diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the resident's care plan, dated 7/7/2021, showed the following: -Occasionally incontinent of bladder and bowel; -Staff should assist the resident with incontinent care as needed. Record review of the resident's significant change Minimum Data Set (MDS - a federally mandated assessment tool completed by facility staff), dated 7/15/2021, showed the following: -Severely cognitively impaired; -Required two persons to assist with toileting; -Always incontinent of bowel and bladder. Observations on 8/30/2021, at 11:20 A.M., showed the following: -Certified Nursing Assistant (CNA) A entered the resident's room from the hallway to perform incontinent care. The CNA applied gloves without performing hand hygiene; -The CNA removed his/her gloves to get an item from the hallway that he/she forgot to bring in; -The CNA returned to the room from the hallway and put on gloves without performing hand hygiene; -The CNA pulled a paper from his/her pocket and looked at it. He/she adjusted his/her face mask, moved the trash can close to the bed, and moved the resident's barrier cream (a cream used to prevent skin damage from moisture) on the bedside table; -The CNA performed incontinent care on the resident. He/she changed gloves without performing hand hygiene between contaminated body sites; -The CNA changed gloves without performing hand hygiene and applied barrier cream to resident's inner thighs; -The CNA changed gloves and applied barrier cream to the resident's bottom and removed his/her gloves without performing hand hygiene; -The CNA placed a brief on the resident without performing hand hygiene. During an interview on 8/30/2021, at 11:45 A.M., CNA A said the following: -Staff should perform hand hygiene before resident care; -Staff should change gloves between contaminated and clean body sites. 2. Record review of Resident #2's face sheet showed the following: -admitted [DATE]; -diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the resident's quarterly MDS, dated [DATE], showed the following: -Severely cognitively impaired; -Required two persons to assist with toileting; -Always incontinent of bladder and bowel. Record review of the resident's care plan, updated 8/21/2021, showed the following: -Incontinent of bowel and bladder; -Staff should assist the resident with incontinence care as needed. Observations on 8/30/2021, at 2:45 P.M., showed the following: -CNA B entered the resident's room from the hallway to perform incontinent care and applied gloves without performing hand hygiene; -The CNA assisted the resident to bed, utilizing the Sit-to-Stand machine (a lift device that assists a person to stand from a seated position) and removed his/her gloves; -The CNA gathered equipment and put new gloves on without performing hand hygiene; -The CNA removed the resident's wet brief and performed incontinent care; -The CNA removed his/her gloves and applied new gloves without performing hand hygiene; -The CNA applied barrier cream to the resident's buttocks and rolled the resident back to his/her back. During an interview on 8/30/2021, at 3:05 P.M., CNA B said when he/she does incontinent care, he/she does hand hygiene before going in to the resident's room and after the care is completed. 3. Record review of Resident #3's face sheet showed the following: -admitted [DATE]; -diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the resident's significant change MDS, dated [DATE], showed the following: -Severely cognitively impaired; -Required two persons to assist with toileting; -Frequently incontinent of bowel and bladder. Record review of the resident's care plan, dated 7/15/2021, showed the following: -Occasionally incontinent of bladder and incontinent of bowel; -Staff should assist the resident with incontinent care as needed. Observations on 8/30/2021, at 3:20 P.M., showed the following: -CNA C entered the resident's room from the hallway and put on gloves without performing hand hygiene; -The CNA removed the resident's blankets, his/her pants, and brief; -The CNA performed incontinent care on the resident without removing his/her gloves or performing hand hygiene. During an interview on 8/30/2021, at 3:30 P.M., CNA C said staff should use sanitizer before starting cares. He/she was never trained to do hand hygiene in the middle of incontinent care, between contaminated and clean body parts. 4. During an interview on 8/30/2021, at 11:50 A.M., CNA G said staff should perform hand hygiene before beginning resident care and should change gloves between contaminated and clean body sites. If his/her hands were visibly soiled during cares, he/she would perform hand hygiene. During an interview on 8/30/2021, at 1:05 P.M., CNA D said staff should do hand hygiene before any resident care and when going from a contaminated body part to a clean body part. During an interview on 8/30/2021, at 1:55 P.M., Licensed Practical Nurse (LPN) E said staff should perform hand hygiene before any resident care and between contaminated and clean body sites. If staff touch any surfaces that could be contaminated they should perform hand hygiene. During an interview on 8/30/2021, at 2:05 P.M., Registered Nurse (RN) F said staff should perform hand hygiene before entering any resident room, before performing resident care and between a contaminated and clean body site. Staff should use a alcohol based hand rub if their hands are not visibly soiled, and should wash with soap and water if they are visibly soiled. During the exit interview on 8/30/2021, at 5:00 P.M., the Administrator, Director of Nursing (DON) and corporate compliance nurse said they expect the staff to perform hand hygiene when entering a resident's room to begin the care and between the contaminated and clean body site. They said it was never appropriate to wear the same gloves throughout the care, and never appropriate to not perform hand hygiene before applying gloves. MO 977

Based on observation, interview and record review, the facility failed to use appropriate infection control procedures to prevent the possible spread of bacteria or other infectious carrying contaminants when staff failed to use appropriate hand hygiene after performing incontinent care for three residents (Resident #1, Resident #2, and Resident #3). The facility census was 91. Record review of the facility's policy titled Handwashing/Hand Hygiene, dated August 2019, showed the following information: -The facility considered hand hygiene the primary means to prevent the spread of infections; -All personnel shall be trained and regularly in-serviced on the importance of hand hygiene in preventing the transmission of healthcare associated infections; -Use an alcohol based hand rub containing at least 62% alcohol or alternatively soap and water before and after coming on duty; before and after direct contact with residents; before moving from a contaminated body site to a clean body site during resident care; before applying non-sterile gloves; and after removing gloves. 1. Record review of Resident #1's face sheet (a brief resident profile sheet) showed the following: -admitted [DATE]; -diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the resident's care plan, dated 7/7/2021, showed the following: -Occasionally incontinent of bladder and bowel; -Staff should assist the resident with incontinent care as needed. Record review of the resident's significant change Minimum Data Set (MDS - a federally mandated assessment tool completed by facility staff), dated 7/15/2021, showed the following: -Severely cognitively impaired; -Required two persons to assist with toileting; -Always incontinent of bowel and bladder. Observation on 8/30/2021 at 11:20 A.M., showed the following: -Certified Nursing Assistant (CNA) A entered the resident's room from the hallway to perform incontinent care; -The CNA performed incontinent care on the resident without performing hand hygiene; -The CNA applied barrier cream without performing hand hygiene; -The CNA placed a brief on the resident without performing hand hygiene; -The CNA covered the resident with a blanket, placed the call light within reach, removed the resident's trash bag from the trash can, and carried it to the hallway to the dirty utility room without performing hand hygiene. During an interview on 8/30/2021 at 11:45 A.M., CNA A said staff should perform hand hygiene after performing resident care. 2. Record review of Resident #2's face sheet showed the following: -admitted [DATE]; -diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the resident's quarterly MDS, dated [DATE], showed the following: -Severely cognitively impaired; -Required two persons to assist with toileting; -Always incontinent of bladder and bowel. Record review of the resident's care plan, updated 8/21/2021, showed the following: -Incontinent of bowel and bladder; -Staff should assist the resident with incontinence care as needed. Observation on 8/30/2021 at 2:45 P.M., showed the following: -CNA B entered the resident's room from the hallway to perform incontinent care; -The CNA removed the resident's wet brief and performed incontinent care without performing hand hygiene; -The CNA applied barrier cream without performing hand hygiene; -The CNA touched the resident's linens, then removed his/her gloves; -The CNA changed gloves, without performing hand hygiene, positioned the resident in bed, put a pillow under the resident's legs, and adjusted the resident's bed with the hand controller; -The CNA changed gloves, without performing hand hygiene, and changed the resident's trash, and took the trash bag to the soiled linen room. During an interview on 8/30/2021 at 3:05 P.M., CNA B said when he/she does incontinent care, he/she does hand hygiene before going in to the resident's room and after the care is completed. 3. Record review of Resident #3's face sheet showed the following: -admitted [DATE]; -His/her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the resident's significant change MDS, dated [DATE], showed the following: -Severely cognitively impaired; -Required two persons to assist with toileting; -Frequently incontinent of bowel and bladder. Record review of the resident's care plan, dated 7/15/2021, showed the following: -Occasionally incontinent of bladder and incontinent of bowel; -Staff should assist the resident with incontinent care as needed. Observation on 8/30/2021 at 3:20 P.M., showed the following: -CNA C entered the resident's room from the hallway and performed incontinent care on the resident without performing hand hygiene; -The CNA C removed the resident's brief. The CNA put a clean brief on the resident and pulled his/her pants up without performing hand hygiene; -The CNA covered the resident with three blankets, moved the packet of cleaning wipes, and adjusted the bed using the controller without performing hand hygiene; -The CNA emptied the resident's trash can, walked out the door to the trash barrel, lifted the lid and placed the trash bag in the barrel without performing hand hygiene; -The aide went to the spa room, punched a code to enter the room, and washed his/her hands. During an interview on 8/30/2021 at 3:30 P.M., CNA C said staff should use sanitizer after finishing cares. 4. During an interview on 8/30/2021 at 11:50 A.M., CNA G said staff should perform hand hygiene after completing resident care. During an interview on 8/30/2021 at 1:05 P.M., CNA D said staff should do hand hygiene after resident care is completed. During an interview on 8/30/2021 at 1:55 P.M., Licensed Practical Nurse (LPN) E said staff should perform hand hygiene after resident care. If staff touch any surface that could be contaminated they should perform hand hygiene. During an interview on 8/30/2021 at 2:05 P.M., Registered Nurse (RN) F said staff should perform hand hygiene after finishing resident care. Staff should use a alcohol based hand rub if their hands are not visibly soiled, and should wash with soap and water if they are visibly soiled. During an interview on 8/30/2021 at 5:00 P.M., the Administrator, Director of Nursing (DON) and corporate compliance nurse said they expect staff to perform hand hygiene when the care is completed. It is never appropriate to exit a resident's room and not immediately perform hand hygiene. MO 006

Based on record review and interview, the facility failed to administer wound care as ordered and failed to monitor and fully assess the resident's wound, which was showing signs of infection, per orders for one resident's (Resident #8) provide wound care as ordered by the physician. The facility census was 91. Record review of a facility's policy titled Wounds, revised October 2010, showed the following information: -Verify that there is a physician's order for procedure; -The following information should be recorded in the resident's medical record: the type of wound care given, the date and time the wound care was given, the name and title of the individual performing the wound care, all assessment data obtain when inspecting the wound, if the resident refused the treatment and the reason why, and the signature of title of the person recording the data. 1. Record review of Resident #8's face sheet (a document that gives a resident's information at a quick glance) showed the following information: -admitted [DATE]; -diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of resident's care plan, dated 07/29/21, showed the following: -Resident has potential for skin breakdown and skin tears; -Educate resident and family regarding wound prevention care; -Provide skin audit per schedule and as needed; -Wound care consult as needed. Record review of the resident's nurse's note dated 07/29/21, at 12:12 A.M., showed the following: -Resident arrived from the hospital with a right distal tibial (one of the lower leg bones) fracture that was repaired on 07/27/21, with an external fixator (a metal frame that holds bones in place). Record review of the resident's nurse's note dated 07/29/21, at 2:20 P.M., showed the following: -Resident on back with heels floated; -Right foot is in pin traction, moderately soiled bandages with blood and serosanguinous (blood and the liquid part of blood) drainage; -No odor, no redness, or tenderness noted. Record review of the resident's skin inspection report, dated 07/29/21, showed skin not intact-existing. Record review of the resident's Physician's Order Sheet, dated August 2021, showed the following: -An order, dated 07/29/21 with start date of 07/30/21, for right lower extremity (RLE) - clean pin sites daily using 50/50 peroxide/NS (normal saline) and sterile Q-tip. Push down under the skin with Q-tip to fully cleanse the pin site. Apply split sponges around pin sites, then wrap with Kerlix (a bandage that provides wicking action, aeration and absorbency) around pins only. Do not use ace wraps. Record review of the resident's nurse's note, dated 07/30/21, showed the external fixator on lower left leg with no redness or drainage noted from pin sites. Record review of the resident's Medicare skilled daily note, dated 7/31/21, showed an existing wound/skin condition to the external fixator to the right lower extremity (leg). Record review of the resident's nurse's note, dated 07/31/21, showed the following: -RLE with an external fixator present; -Dressings to pin sites clean and dry; -[CONDITION(S)] (swelling) to RLE; -Right foot and ankle elevated on a pillow. Record review of the resident's nurse's note, dated 08/01/21, showed the following: -Right foot elevated on pillow with external fixator in place; -Some non-pitting (if the skin is pressed upon, it does not indent) [CONDITION(S)] noted to right lower extremity (RLE). Record review of the resident's Medicare skilled daily note, dated 08/02/21, showed an existing wound/skin condition. Record review of the resident's skin inspection report, dated 08/03/21, showed skin not intact-existing. Record review of the resident's nurse's note, dated 08/03/21, showed the following: -Resident returned from appointment with new orders received; -Remain non-weight bearing and continue to elevate right ankle; -Discontinue [MEDICATION(S)] (an anticoagulant medication used to treat and prevent blood clots and to prevent stroke) 24 hours prior to surgery; -Surgery on 08/06/21 to remove external fixator. Record review of the resident's Treatment Administration Record (TAR), dated August 2021, showed the following: -An order, dated 07/29/21 with a start date of 07/30/21, for RLE - clean pin sites daily using 50/50 peroxide/NS with sterile Q-tip. Push down under the skin with Q-tip to fully cleanse the pin site. Apply split sponges around pin sites, then wrap with kerlix around pins only. Do not use ace wraps; -On 08/03/21, staff documented the treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] -On 08/04/21, staff documented the treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . (Staff did not document attempting the treatment at a different time.); -On 08/05/21, staff documented the treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the resident's nurse's note, dated 08/06/21, showed the following: -Resident returned from hospital with new orders; -[MEDICATION(S)] (antibiotic medication) 100 milligrams (mg) tablet, twice a day for 10 days; -[MEDICATION(S)] (pain medication) 10/325 mg tablet, every 4 to 6 hours for pain; -[MEDICATION(S)] (anti-nausea medication) 4 mg, one tablet every 4 to 6 hours for nausea/vomiting; -Ice and elevate continuously for 72 hours; -Controlled ankle movement boot at all times; -Change dressing in five days, do not get wet; -Follow up appointment in two weeks. Record review of the resident's Medicare skilled daily note, dated 08/10/21, showed the following: -An existing wound/skin condition; -Surgical incision on right foot. Record review of resident's Physician's Order Sheet, dated August 2021, showed the following: -An order, dated 08/10/21 with start date of 08/11/21, for surgical wound site right foot. Staff to change dressing daily. Cleanse area with wound cleanser, pat dry apply ABD (a highly absorbent sterile dressing) and wrap with Kerlix. Observe area daily. Record review of resident's TAR, dated August 2021, showed the following: -An order, dated 08/10/21 with a start date of 08/11/21, for surgical wound site right foot. Staff to change dressing daily, cleanse area with wound cleanser, pat dry, apply ABD and wrap with Kerlix. Observe area daily. Record review of the resident's Medicare skilled daily note, dated 08/11/21, showed the following: -An existing wound/skin condition; -Surgical incision on right foot. Record review of the resident's medical records showed staff did not document assessing or observing the wound per orders on 8/11/21 and 8/12/21. Record review of the resident's Medicare skilled daily note, dated 08/13/21, indicated no skin conditions. Record review of the resident's medical records showed staff did not document assessing or observing the wound per orders on 8/13/21. Record review of the resident's Medicare skilled daily note, dated 08/14/21, showed an existing wound/skin condition. Record review of the resident's medical records showed staff did not document assessing or observing the wound per orders on 8/13/21. Record review of resident's TAR, dated August 2021, showed the following: -On 08/14/21 and 08/15/21, staff documented surgical site dressing change as not administered. Staff did not document a reason. Record review of the resident's Medicare skilled daily note, dated 08/15/21, showed the following: -An existing wound/skin condition; -Surgical incision on right foot. Record review of the resident's medical records showed staff did not document assessing or observing the wound per orders on 8/15/21. Record review of the resident's Medicare skilled daily note, dated 08/16/21, showed the following: -An existing wound/skin condition; -Surgical incision on right foot. Record review of the resident's nurse's note, dated 8/16/21, showed the following: -Nurse performed wound care on 8/16/21; -Nurse was unable to sign off as floor nurse marked not administered to the order on the TAR; -Wound care complete, resident tolerated well. (The nurse did not document a full assessment of the surgical site.) Record review of the resident's skin inspection report, dated 08/16/21, showed skin not intact-existing. Record review of the resident's medical records showed staff did not document assessing wound on 8/17/21. Record review of the resident's nurse's note, dated 08/18/21, showed the following: -The nurse called the physician's office to request antibiotics for RLE wound; -Periwound (the skin extending beyond the wound edge) is red and edematous (swollen) indicating possible start of infection; -The nurse left a message at physician's office as they were out of the office; -The nurse will continue to monitor. (Staff did not document follow-up with the physician.) Record review of resident's TAR, dated August 2021, showed the following: -On 08/19/21, staff documented the surgical dressing change was not administered. Staff noted refused by resident. Record review of the resident's medical record, dated 8/19/21, showed staff did not document a full assessment of the surgical site, or follow-up with the physician regarding the signs of possible infection. Record review of resident's TAR, dated August 2021, showed the following: -On 08/20/21, staff documented the dressing change was not administered. Staff did not document a reason why. Record review of the medical record, dated 8/20/21 and 8/21/21, showed staff did not document a full assessment of the surgical site, or follow-up with the physician regarding the signs of possible infection. Record review of the resident's nurse's note dated 8/22/21, at 12:36 A.M., showed the following: -The nurse spoke to the physician regarding possible infection in the wound on RLE (four days after initial message left regarding possible infection); -Orders obtained for a wound culture to be obtained on morning of 08/22/21; -After wound culture is obtained, start [MEDICATION(S)] (antibiotic medication) 500 mg, three times a day for seven days; -Notify surgeon of infection on Monday. Record review of the resident's nurse's note dated 8/22/21, at 12:45 P.M., showed the following: -Unable to obtain wound culture with dressing change; -No culture kits available in facility; -Contacted the laboratory and left message for delivery in the morning. (Staff did not document notifying physician of inability to complete wound culture.) Record review of the medical record, dated 8/22/21, showed staff did not document a full assessment of the surgical site, or follow-up with the physician regarding the signs of possible infection. Record review of the resident's nurse's note dated 08/23/21, at 8:58 A.M. and 10:00 A.M., showed the following: -The nurse contacted the orthopedic physician and notified then of possible infection; -The physician's office said they would collect the wound culture that day in the office; -The facility will start antibiotic therapy after wound culture collected. Record review of the resident's Medicare skilled daily note, dated 08/23/21, showed the following: -An existing wound/skin condition -Surgical incision on right foot; -Dry gauze dressing; -Drainage present; -Resident is scheduled to see orthopedic for follow up this day. Record review of the resident's skin inspection report, dated 08/23/21, showed skin not intact-existing. Record review of the resident's nurse's note dated 8/23/21, at 5:26 P.M., showed resident was admitted to hospital from orthopedic appointment. Record review of resident's orthopedic progress note, dated 08/23/21, showed the following: -admitted to hospital on 08/23/21; -Right ankle infection; -Wound VAC (vacuum assisted wound therapy) to right ankle. Record review of resident's hospitalist history and physical, dated 08/23/21, showed the following; -admitted to hospital on 08/23/21; -Postoperative (post-surgery) right ankle wound infection; -Resident reportedly had some weeping from dressing and facility was concerned about infection; -Resident has quite a bit of [CONDITION(S)] (redness) around the sutures on his/her right medial ankle; -One small open area with some slight amount of exudate (fluid), and some swelling [CONDITION(S)]. During an interview on 08/25/21, at 12:31 P.M., Licensed Practical Nurse (LPN) E said the following: -When conducting wound care, he/she follows the physician's orders; -He/she is able to complete all wound treatments as ordered; -After a resident's dressing has been changed, staff should date the dressing and document in the TAR that the treatment has been complete; -If he/she observes a dressing that has not been dated, he/she will check the TAR. LPN will then perform wound treatment and assess the wound; -If he/she is aware the prior shift did not complete the wound treatment, he/she would do the treatment; -Skin assessments are completed by the admitting nurse or sometimes the wound nurse; -Skin assessments are completed weekly, which consists of a head to toe assessment; -If a wound is present, he/she would describe the wound, including location of wound, what the wound bed and edging of the wound looked like, and he/she would measure the wound. During an interview on 08/25/21, at 1:25 P.M., LPN K said the following: -He/shecompletes wound care as ordered; -He/she has observed dressings that have not been changed as ordered; -After a wound treatment has been complete, it should be dated and documented in the TAR as complete. During an interview on 08/25/21, at 1:36 P.M., Registered Nurse (RN) L said the following: -On 08/18/21, he/she performed the resident's wound treatment; -On 08/19/21, he/she was unable to perform the resident's wound treatment until later in his/her shift and the resident refused treatment as he/she prefers the treatment complete in the morning; -On 08/21/21, a nurse passing morning medications advised him/her that the resident's wound had an odor; -He/she observed the resident's dressing and noted it had not been changed since 08/18/21; -The resident's dressing was saturated through with fluid, and the wound smelled; -He/she cleaned the wound and changed the dressing; -Around 6:00 P.M., he/she notified the wound nurse of the condition of the resident's wound that that he may require antibiotics; -The physician was notified, and an order was received for an antibiotic, but only to administer after a wound culture had been collected at the next dressing change; -The wound culture was not collected as the facility was out of kits; -He/she performed the wound treatment without obtaining the culture; -He/she contacted the wound nurse that evening due to the resident's wound seeping through the dressing; -A second wound treatment was performed that evening; -The resident was scheduled for an orthopedic follow up the next day, 08/23/21. -RN L is unsure if the resident's dressing was changed prior to his/her appointment. During an interview on 08/26/21, at 12:42 P.M., LPN M said the following: -If a wound treatment is unable to be complete during his/her shift, the next shift will complete the treatment; -If a resident refuses a treatment, there is an option in the TAR to mark resident refusal. During an interview on 08/27/21, at 1:29 P.M., RN N said the following: -He/she only completes wound treatments if the treatment is ordered twice a day, or if the treatment has not been complete during the prior shift; -He/she does not always complete all the required wound treatments due to medication passes taking too long; -If he/she does not complete a treatment, he/she will enter not complete in the TAR and report to the next shift; -He/she has not completed a wound treatment on the resident; -The resident does not have an order for [MEDICAL RECORD OR PHYSICIAN ORDER] -The resident has an order to verify his/her dressing is intact; -The RN has observed that his/her treatment has not been signed as complete, but he/she is unsure if the treatment was administered. During an interview on 8/30/2021, at 11:50 A.M., Certified Nurse Aide (CNA) A said the following: -If he/she found a wound on a resident, he/she would tell the nurse immediately; -The nurse would look at the wound and do measurements and start a treatment. During an interview on 08/30/21, at 1:00 P.M., the Assistant Director of Nursing (ADON) said the following: -Dressing changes should be dated; -The ADON has observed dressings without a date noted on the dressing; -Approximately two weeks ago, around 08/19/21, a nurse asked the ADON to observe the resident's dressing as the nurse did not believe it had been changed as ordered. The ADON did not observe a date on the dressing, and the dressing appeared to have been previously saturated with blood. The resident had a boot over the dressing. The dressing was removed, and the surgical incision looked okay. The ADON looked in the TAR and observed that some of the resident's treatments/dressing changes had not been completed. The ADON reported to the Director of Nursing (DON) his/her concerns that the dressing had not been changed. No concerns had been reported to the ADON regarding treatments not being complete as ordered; -If staff cannot complete treatments/dressing changes during their shift, they should advise the ADON or DON, who will offer to help. Staff should also report this information to the next shift, as they would be expected to complete the treatment/dressing change; -Staff should report all concerns regarding wound treatments/dressing changes to the ADON or DON; -Weekly skin assessments are completed by the wound nurse. The assessments document if the skin is intact. Wound assessments are also completed by the wound nurse and include details like measurements and description, including appearance of the wound, odor, or drainage. During an interview on 8/30/2021, at 1:05 P.M., CNA D said the following: -If he/she found a wound on a resident, he/she would report it immediately; -The nurse would call the wound nurse who would do an assessment and start treatments; - If the wound nurse was not available, the nurse would start the treatment. During an interview on 08/30/21, at 1:30 P.M., LPN O said the following: -He/she completes wound care on his/her shift; -In the morning, he/she checks the TAR to find out which residents need wound treatments; -He/she does not always have time to complete wound treatments during his/her shift; -He/she has observed wound treatment to be not signed off in the TAR and the dressing not dated; -If staff do not sign off on the treatment in the TAR or date the dressing, LPN O is unsure if the wound/dressing change has been complete; -He/she will report to the nurse on the next shift if he/she observes a dressing that is not dated. He/she will report to department heads if the wound that was not dated looks like it has worsened; -Nurses conduct skin assessments weekly. LPN O does not obtain measurements of wounds, but if he/she observes something, he/she will make and estimate and document in the TAR, which will also populate in the nurses' notes; -Aides are to monitor skin and notify the charge nurse if they notice any change. If deemed necessary, the nurse will notify the wound nurse, and if he/she is not available, the wound physician would be contacted. During an interview on 08/30/21, at 2:15 P.M., RN F (wound nurse) said the following: -When he/she is unable to complete wound care, the charge nurses are to perform wound care/dressing changes; -If he/she is not available, skin and wound assessments are not completed; -The skin assessment only indicates if the resident's skin is intact or not intact, and if the wound is new or existing. No detail is given on the skin assessment; -The wound assessment contains details including measurements, and description of the wound, including wound bed appearance; -Wound assessments are completed on those who have a wound that would take several weeks to heal; -He/she has been unable to complete wound treatments due to being on-call during nights; -When he/she is unable to complete a wound treatment, he/she hopes the charge nurse on the next shift will complete the treatment; -Wound dressings are not always dated. He/she will check the TAR to see if the treatment was complete. He/she would report to the DON any wound treatments that had not been complete, but has not reported any dressings that have not been dated; -On 08/16/21, he/she checked the resident's wound. It had an odor and the dressing was black, with the boot over the dressing; -The boot and dressing were removed. The wound looked okay, and there were no signs of infection; -He/she showed the dressing and wound to the ADON and reported the issue to the DON; -On 08/18/21, the RN observed the resident's wound and noted it to be red. He/she called the physician and left a message with the physician's nurse requesting an antibiotic; -The RN did not get a response from the physician. On 08/22/21, he/she text the physician to obtain an order for [MEDICAL RECORD OR PHYSICIAN ORDER] -The physician said antibiotics could be started after a wound culture was obtained during the next dressing change; -He/she read in the nurse's note that a wound culture was not collected; -The physician's office was contacted on 08/23/21, and informed a wound culture had not been collected. The physician's office said they could collect the culture during his scheduled appointment that day; -The physician sent the resident to the hospital from his appointment due to his wound being infected. During an interview on 08/30/21, at 4:57 P.M., with the Corporate Nurse, DON, and the Administrator, the following was said: -Completed wound treatments are documented on the TAR and the wound dressing should be dated; -Nursing staff is expected to follow the physician's orders in regard to wound treatment; -Nurses should complete as many wound treatments as they can on their shift, and should notify the oncoming nurse of any outstanding wound treatments; -On 08/20/21, the wound nurse advised management that a dressing change had not been complete for the resident; -The ADON advised the DON that he/she observed the wound on 08/20/21. The DON did not observe the wound; -The initial skin assessment is completed by the admitting nurse. These assessments are not completed on a regular basis; -The wound nurse or the charge nurse completes weekly wound assessments, which include measurements and description of the wound; -Weekly skin assessments document if skin is intact or not intact. Details regarding the condition of the skin are not documented on this assessment. MO 087

Based on observation, interview, and record review, the facility failed to implement CDC and CMS recommendations in order to prevent the spread of COVID-19 among the residents of the facility. The facility failed to prevent one staff person who reported possible signs or symptoms of COVID-19 from working their scheduled shift at the screening station. Additionally, the facility failed to ensure that staff working on COVID-19 positive units wore appropriate PPE while on the unit. Findings include: - Review of the facility's employee screening logs, titled COVID-19 Screening Checklist- for Visitors and Staff documented that people entering the facility must document their name, the date, and the reason for visiting. They must then answer if they had a cough, shortness of breath, fever, shaking with chills, new loss of taste or smell, diarrhea, chills, muscle pain, sore throat, vomiting, and exposure to someone with confirmed or suspected COVID-19. The person's temperature would be documented. Further review of the facility's screening forms documented that on 8/25/20, Medication Aide (MA1) reported presence of headache and muscle pain during the screening process. The form lacked any documented follow-up. Review of timeclock records documented that MA1 worked their scheduled shift at the front desk that day, and did not work with residents. On 11/4/20 at 3:50pm, the Administrator indicated that the expectation of staff was to notify administration about the presence of any symptoms, and that if possible symptoms of COVID-19 were present, the employee was to be sent home and tested . The Administrator indicated that she was not aware that MA1 reported possible signs and symptoms of COVID-19 on 8/25/20. The Administrator indicated that the screening forms were reviewed daily by herself or by other administrative staff. The facility failed to provide a policy regarding the testing of staff and residents for COVID-19. The Administrator indicated that the facility utilized CDC and CMS guidelines regarding the testing of staff for COVID-19. - On 11/4/20 at 9:30am, the Admissions Coordinator indicated that the facility had one unit that was for COVID-19 negative residents, and three units for COVID-19 positive residents. The positive units were the Oaks, the Maples, and the Willows units. The negative unit was the Pines unit. The Admissions Coordinator indicated that the facility accepted COVID-19 positive residents from a local hospital, that was nearing it's capacity. On 11/4/20 at 12:45pm, on the Oaks unit, Registered Nurse (RN1) sat at the nursing station, wearing an N95 respirator (a specialized facemask) and a face shield, and no other personal protective equipment (PPE). The double doors to the resident hallway were open, leaving the hallway, dining room, and nursing station open to the contaminated area of the hallway. RN1 indicated that 22 residents were housed on the Oaks unit, and that staff were to don full PPE (disposable gown, gloves, face shield, and N95 respirator) if they were to leave the nursing station and go down the hallway. If staff were not in the hallway, they didn't have to wear full PPE, only an N95 and a face shield. Once staff began their shifts on the unit, including staff such as housekeepers, they did not leave the unit. On 11/4/20 at 12:55pm, on the Oaks unit, Maintenance Staff (M1) walked down the hallway. M1 wore only an N95 and a face shield, and did not wear any other PPE. Other staff in the hallway wore the full PPE. M1 indicated that full PPE needed to be worn only when entering a resident's room. On 11/4/20 at 1:06pm, on the Maples unit, Licensed Practical Nurse (LPN1) sat at the nursing station, wearing an N95 respirator, a face shield, and a gown. LPN1 indicated that if staff were to enter the unit, they must wear full PPE at all times, because the unit was considered contaminated. Staff could remove gloves after leaving a resident's room, but must put on a new pair if they were entering a resident's room. On 11/4/20 at approximately 1:23pm, in the Willows unit, M2 cleaned the resident spa. M2 wore only a face shield and N95. M2 indicated that staff only had to wear the full PPE if they were going into resident's rooms. On 11/4/20 at 3:50pm, the Administrator indicated that the expectation of staff who were working on the COVID-19 positive units was to wear full PPE at all times while on the unit. The facility policy, dated 04/2020, titled Coronavirus Disease (COVID-19) Prevention and Control measures, documented the following: 13. If there are COVID-19 cases in the facility: a. Staff wear all recommended PPE (i.e., gloves, gown, eye protection and respirator or facemask) for the care of all residents on the unit (or facility-wide based on the location of affected residents), regardless of symptoms (based on availability).

Based on record review and interview, the facility failed to perform staff testing for COVID-19 in accordance with CMS guidelines, when the facility failed to test staff at the recommended frequency of twice weekly, as required for the county COVID-19 positivity rate of 12.2%. Findings include: - On 11/4/20 at 9:25am, the Admissions Coordinator indicated that the facility began testing staff and residents for COVID-19 once weekly in September. The Admissions Coordinator indicated that the facility continued to test staff once weekly, on Mondays. On 11/4/20 at 10:09am, Nurse Aide (NA1) indicated that the facility tested all staff each Monday, with a rapid-result test. On 11/4/20 at 1:06pm, Licensed Practical Nurse (LPN1) indicated that the facility tested all staff each Monday. On 11/4/20 at 3:50pm, the Administrator indicated that the facility tested all staff every Monday. The Administrator indicated that because the facility currently was in an active outbreak, the facility completed testing once weekly, because they were informed that testing should be done every three to seven days. The Administrator indicated that once the outbreak was over, they would start testing staff twice weekly. Review of CMS guidance, dated 8/26/20, located in QSO memo 20-38-NH, documented: Routine testing should be based on the extent of [MEDICAL CONDITION] in the community, therefore facilities should use their county positivity rate in the prior week as the trigger for staff testing frequency. The guidance contained a data table which documented that counties with a medium rate of community transmission of 5%-10% should test staff once weekly. If a county had a rate of community transmission greater than 10%, the facility must test staff twice weekly. Review of county positivity rates, located at https://data.cms.gov/download/hsg2-yqzz/application%2Fzip, documented that the current positivity rate for(NAME)County, Missouri, was 12.1%. The archived positivity rates for(NAME)County, Missouri, documented that the county had been above the 10% threshold since 9/10/20. Review of the facility's policy, undated, titled COVID-19 Employee Testing Requirements, documented that if the county positivity rate was above 10%, employees would be tested twice weekly.

Based on observation, record review, and interview, the facility staff failed to use appropriate infection control/hand hygiene practices when a medication technician failed to wash/sanitize hands at appropriate intervals, during medication pass for three residents (Residents #1, #2 and #3) and when facility staff failed to wash/sanitize hands between glove changes during meal pass for two unidentified residents. The facility failed to fully implement Centers for Medicare and Medicaid Services (CMS) and Centers for Disease Control (CDC) recommended infection control practices, following the outbreak of a coronavirus disease 2019 (COVID-19, an infectious disease caused by severe acute respiratory syndrome coronavirus 2 ([DIAGNOSES REDACTED]-CoV-2)) pandemic, in order to control and/or prevent the potential spread of the disease among residents and facility staff failed to wear face coverings properly. The facility census was 82 residents. Record review of the facility's policy titled Infection Prevention and Control Program, dated August 2016, showed, in part, the following: -Staff should follow established general and disease- specific guidelines such as those of the Centers for Disease Control (CDC). 1. Record review of CDC.gov showed the following: -CDC recommends using alcohol based hand rub with greater than 60% [MEDICATION NAME] or 70% [MEDICATION NAME] in healthcare settings. Unless hands are visibly soiled, an alcohol based hand rub is preferred over soap and water in most clinical situations due to evidence of better compliance compared to soap and water. Hand rubs are generally less irritating to hands and are effective in the absence of a sink; -Hands should be washed with soap and water for at least 20 seconds when visibly soiled, before eating, and after using the restroom. 2. Record review of Resident #1's face sheet showed: -admitted to the facility on [DATE]; -[DIAGNOSES REDACTED]. Record review of Resident #1's May 2020 physician order [REDACTED]. -[MEDICATION NAME] (a water pill) 20 milligrams, one tablet by mouth daily; -[MEDICATION NAME] (an oral steroid) 15 mg, by mouth daily; -Raloxifene (a medication for bone health) 60 mg, one tablet by mouth daily; -[MEDICATION NAME] nasal spray (a nasal spray for allergies [REDACTED]. 3. Record review of Resident #2's face sheet showed: -admitted to the facility on [DATE]; -[DIAGNOSES REDACTED]. Record review of Resident #2's May 2020 physician order [REDACTED]. -[MEDICATION NAME] (an oral medication for diabetes) 50 mg, one tablet by mouth daily; -Sotolol (a blood pressure medication) 80 mg, one tablet by mouth twice -Cilostozol (a medication to increase blood flow) 50 mg, one tablet by mouth twice daily; -Repaglinide (an oral medication for diabetes) 2 mg, two tablets by mouth twice daily; -[MEDICATION NAME] (a medication for anxiety and depression), 10 mg one tablet by mouth daily; -[MEDICATION NAME] (a medication for nerve pain) 100 mg, one by mouth three times daily. 4. Record review of Resident #3's face sheet showed: -admitted to the facility on [DATE]; -[DIAGNOSES REDACTED]. Record review of Resident #3's May 2020 physician order [REDACTED]. -[MEDICATION NAME] (a [MEDICAL CONDITION] hormone replacement) 50 mcg, one tablet daily; -[MEDICATION NAME] (a blood thinner) 75 mg, one by mouth daily; -Carvidilol (a medication for blood pressure and heart rate control) 12.5 mg, one by mouth twice daily. 5. Observation on 5/27/2020, starting at approximately 11:10 A.M., showed Certified Medication Technician (CMT) A went into Resident #1 and Resident #2's room (shared room) and gave medication to one of the residents. The CMT then came out without performing hand hygiene and administered medications to Resident #3 in an adjoining room. 6. Observations on 5/27//2020, beginning at 11:30 A.M., showed CMT A gave an unidentified resident yogurt and water, touching his/her work station, his/her computer, and administering medications, touching his/her mask, opening drawers on the medication cart, and administering more medications without performing hand hygiene. 7. Observations on 5/27/2020, beginning at 11:35 A.M., showed a staff members did not wash or sanitize his/her hands after removing his/her gloves and touching a glass, a napkin, and touching the drinking end of a straw for a resident. 8. During an interview on 5/27/2020, at 12:00 P.M., Licensed Practical Nurse (LPN) B, said staff had skills checks on hand washing. Hand hygiene should be performed any time resident care was performed, or before handling resident meal plates. 9. During an interview on 5/27/2020, at 12:40 P.M., LPN C, said staff should perform hand hygiene before and after giving medications and performing resident care. 10. During an interview on 5/27/2020, at 2:00 P.M., the Assistant Director of Nursing said staff should sanitize or wash hands between residents 11. During an interview on 5/27/2020, at 2:20 P.M., the Director of Nursing and Administrator said staff had been given competency checks on hand washing and they expect staff to wash or sanitize their hands before and after resident care, and between glove changes. Hands should be washed or sanitized between residents during medication administration and meal pass. 12. Record review of CDC.gov showed the following: -Face coverings should cover the nose and mouth and fit under the chin. The covering should fit snugly under on the sides of the face. Observations on 5/27/2020, beginning at 11:58 A.M., showed one staff member with his/her mask under his/her nose. Observations on 5/27/2020, beginning at 12:35 P.M., showed one staff member with his/her mask missing a top strap and ill fitting. During an interview on 5/27/2020, at 2:20 P.M., the Director of Nursing and Administrator said masks should be worn where they cover the nose and mouth.

Based on record review and interview, facility staff failed to complete a quarterly Minimum Data Set (MDS, a federally mandated comprehensive assessment instrument, completed by facility staff) assessment for four residents (Resident #2, #3, #9, and #24) out of 19 sampled residents, within 14 days from the assessment reference date (ARD). The facility had a census of 91. Record review of the Centers for Medicare and Medicaid Services (CMS) Resident Assessment Instrument (RAI) Version 3.0 Manual, Chapter 2, Assessments for the RAI, showed the following information: -The quarterly assessment is an Omnibus Budget Reconciliation Act of 1987 (OBRA) non-comprehensive assessment for a resident that must be completed at least every 92 days following the previous OBRA assessment of any type; -The quarterly assessment is used to track a resident's status between comprehensive assessments to ensure critical indicators of gradual change in a resident's status are monitored; and -The ARD must be not more than 92 days after the ARD of the most recent OBRA assessment of any type. 1. Record review of Resident #2's MDS submitted reports showed the following information: -admitted to the facility 9/12/16; -Annual assessment; ARD 5/24/19; -Quarterly assessment; ARD 8/13/19; -Staff did not complete or submit a subsequent Quarterly assessment, due within 92 days. 2. Record review of Resident #3's MDS submitted reports showed the following information: -admitted to the facility 12/3/18; -Quarterly assessment, ARD 3/8/19; -Quarterly assessment ARD 6/2/19; -Staff did not complete or submit a subsequent Quarterly assessment, due within 92 days. 3. Record review of Resident #9's MDS submitted reports showed the following information: -admitted to the facility 9/3/19; -OBRA Admission; ARD 9/10/19; -Admission Assessment (14-day); ARD 9/16/19; -Staff did not complete or submit a Quarterly assessment, due within 92 days. 4. Record review of Resident #24's MDS submitted reports showed the following information: -admitted to the facility 9/26/18; -Quarterly Assessment, ARD 11/9/18; -Quarterly Assessment, ARD 2/5/9; -Quarterly Assessment, ARD 5/4/19; -Quarterly Assessment, ARD 8/17/19; -Staff did not complete or submit a subsequent Quarterly assessment, due within 92 days. 5. During an interview on 1/24/2020, at 11:22 [NAME]M., MDS Coordinator C said the following: -He/she was the only MDS Coordinator from (MONTH) to (MONTH) 2019, and he/she got behind in completing and submitting MDS assessments; -He/she knew some MDS assessments were late (not completed within 14 days of the ARD) and the administrator and corporate staff knew they were still behind; -Corporate staff did come to the facility to assist with MDS completion and transmissions, but they were still not caught up. Some assessments had not been completed. 6. During an interview on 1/24/2020 at 4:02 P.M., the facility administrator said he/she knew the MDS submissions were behind. The corporate MDS representative and staff from a sister facility had been onsite to assist with catching up.

Based on record review and interview, the facility failed to transmit a Death in Facility Minimum Data Set (MDS, a federally mandated assessment instrument, required to be completed by facility staff for care planning) record within 14 days of a death in the facility for one resident (Resident #6). The facility had a census of 91. Record review of the Centers for Medicare and Medicaid Services (CMS) Resident Assessment Instrument (RAI) Version 3.0 Manual, Chapter 2, Assessments for the RAI, showed the following information: -The Death in Facility Tracking Record consists of demographic and administrative items; it must be completed when the resident dies in the facility or when on leave of absence (LOA); -The record must be completed within seven days after the resident's death, and within 14 days after the resident's death, staff should electronically transmit encoded, accurate, and complete MDS data to the CMS System. 1. Record review of Resident #6's medical record showed the following information: -admitted to the facility on [DATE] from another skilled nursing facility; -Expired in the facility on [DATE]. Record review of the resident's MDS submitted reports showed the following: -Entry Tracking [DATE]; -Admission assessment [DATE]; -Staff did not transmit a report following the resident's death in the facility. 2. During an interview on [DATE], at 11:22 [NAME]M., MDS Coordinator C said the following: -He/she was the only MDS Coordinator from (MONTH) to (MONTH) 2019, and he/she got behind in completing and submitting MDS assessments; -He/she knew some MDS assessments were late (not completed within 14 days of the ARD) and the administrator and corporate staff knew they were still behind; -Corporate staff did come to the facility to assist with MDS completion and transmissions, but they were still not caught up. Some assessments had not been completed. 3. During an interview on [DATE], at 4:02 P.M., the facility administrator said he/she knew the MDS submissions were behind. The corporate MDS representative and staff from a sister facility had been onsite to assist with catching up.

Based on observation, record review, and interview, the facility failed to complete a side rail assessment to include a risk/benefit review and alternatives attempted prior to use, and failed to obtain informed consent for the use of side rails for four residents (Resident #29, #67, #95 and #101). The facility failed to complete bed rail measurements for one resident (Resident #95). A sample of 19 were reviewed. The facility census was 91. Record review of a facility policy entitled, Bed Safety (Revised (MONTH) 2007), showed the following information: -Facility shall strive to provide a safe sleeping environment for the resident; -Resident's sleeping environment shall be assessed by the interdisciplinary team, considering the resident's safety, medical conditions, comfort, and freedom of movement, as well as input from the resident and family regarding previous sleeping habits and bed environment; -To try to prevent deaths/injuries from the beds and related equipment (including the frame, mattress, side rails, headboard, footboard, and bed accessories), the facility shall promote the following approaches: -Inspection by maintenance staff of all beds and related equipment as part of our regular bed safety program to identify risks and problems including potential entrapment risks; -Review that gaps within the bed system are within the dimensions established by the Food and Drug Administration (FDA). The review shall consider situations that could be caused by the resident's weight, movement or bed position; -Ensure that bed side rails are properly installed using the manufacturer's instructions and other pertinent safety guidance to ensure proper fit; -If side rails are used, there shall be an interdisciplinary assessment of the resident, consultation with the attending physician, and input from the resident and/or legal representative; -The staff shall obtain consent for the use of side rails from the resident or the resident's legal representative prior to their use; -Side rails may be used at the resident's request to increase a sense of security, to help manage a medical symptom or condition, or to help the resident reposition or move in bed and transfer, and no other reasonable alternatives can be identified; -Before using side rails for any reason, the staff shall inform the resident and family about the benefits and potential hazards associated with side rails. 1. Record review of Resident #29's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument, completed by facility staff, dated 1/8/2020, showed the following information: -admitted to the facility 7/7/17; -[DIAGNOSES REDACTED]. -Required extensive assistance from two staff for bed mobility and transfers; -Moderate cognitive impairment. Record review of the resident's care plan, last updated 1/8/2020, showed the following information: -Required extensive staff assistance for transfers; used a Hoyer lift (machine used to lift the resident's entire body); -Ensure resident's bed in lowest position when left unattended; -Staff did not document information pertaining to bed rails. Observation on 1/20/2020, at 3:23 P.M., showed the resident's bed with half side rails in place on each side of the bed. Record review of the resident's physician order [REDACTED]. -Transfers per Hoyer (mechanical) lift; -Staff did not document any order pertaining to bed rails. Record review of the resident's electronic medical record (EMR) and paper medical record did not show staff completed any evaluation, risk assessment, or documentation of informed consent to use the bed side rails. 2. Record review of Resident #67's care plan showed the following information: -On 11/6/19: Required assistance to complete daily activities of care safely, related to limited weight bearing and weakness. -Required assistance of four to six staff for transfers, activities of daily living (ADLs) and bed mobility; -Transfers using a Hoyer (mechanical lift). -Observe for additional assistive devices/positioning devices as needed; -On 12/9/19: Ensure bed in lowest position; -Staff did not document regarding the use of side rails. Record review of Resident #67's 5-day admission MDS, dated [DATE], showed the following information: -admitted to the facility 11/6/19; -[DIAGNOSES REDACTED]. -Required extensive assistance from two staff for bed mobility and transfers; -Moderate cognitive impairment. Observation and interview on 1/21/2020, at 12:22 P.M., showed the resident's bed with half side rails in place on each side of the bed. The resident said he/she used the side rails for mobility assistance. Record review of the resident's physician order [REDACTED]. Record review of the resident's EMR and paper medical record did not show staff completed any evaluation, risk assessment, or documentation of informed consent to use the bed side rails. 3. Record review of Resident #95's quarterly MDS, dated [DATE], showed the following information: -admitted to the facility 6/19/19; -[DIAGNOSES REDACTED]. -Required extensive assistance from two staff for bed mobility and transfers; -Mild cognitive impairment. Record review of the resident's care plan, last updated 12/27/19, showed the following information: -Required limited assistance with transfers; -Had turn bar to the right side of bed to enable independent positioning. Record review of the resident's physician order [REDACTED]. -TLSO (thoracolumbosacral (thorax and the lumbar and sacral regions of the back) orthosis, a corset-style brace, designed to restrict the movement of the torso) brace to be worn while sitting, standing, and walking. -Brace did not need to be worn while laying down; -Mobility by wheelchair; -Staff did not document any order pertaining to bed rails. Record review of the maintenance log for bed rail measurements, dated 1/13/2020, showed no documentation for side rails on the resident's bed. Observation on 1/21/2020, at 1:06 P.M., showed the resident's bed with half side rails in place on each side of the bed. Record review of the resident's electronic medical record (EMR) and paper medical record showed staff did not complete any evaluation, risk assessment, or documentation of informed consent to use the bed side rails. 4. Record review of Resident #101's care plan, last updated 8/1/19, showed the following information: -Required extensive staff assistance for transfers; -Staff did not document information pertaining to bed rails. Record review of the resident's quarterly MDS, dated [DATE], showed the following information: -admitted to the facility 11/22/17; -[DIAGNOSES REDACTED]. -Required extensive assistance from one staff for bed mobility and transfers; -Mobility with walker or wheelchair; -Cognitively intact. Record review of the resident's physician's orders [REDACTED]. Observation on 1/20/2020, at 2:06 P.M., showed the resident's bed with half side rails in place on each side of the bed. Record review of the resident's electronic medical record (EMR) and paper medical record showed staff did not complete any evaluation, risk assessment, or documentation of informed consent to use the bed side rails. 5. During an interview on 1/23/2020, at 1:20 P.M., the Director of Therapy Services said the following: -The physical therapist or occupational therapist evaluates a resident for bed rail needs; -The therapist sends a copy of the bed rail order to the maintenance department, including the type of rail or enabler needed. Maintenance should then install the rails and complete the safety checks and measurements; -A full listing of all bed rails in use is generated at month-end and quarterly. The list is given to maintenance to conduct routine safety checks and measurements; -Therapy notifies the nursing department, who is to complete the resident assessment and all required paperwork and computer entries. Nursing should ensure the new information is included on the MDS and care plan. 6. During an interview on 1/24/2020, at 4:06 P.M., with the administrator and the Director of Nursing (DON), the DON said therapy evaluates a resident for bed rails, then a request is placed in Mediprocity (electronic messaging system) to the DON and maintenance. Staff should fill out the enabler device form and notify the resident representative. A user defined assessment should be completed, and maintenance will measure and put rails on the resident's bed.

Based on observation, interview, and record review, the facility failed to ensure staff cleaned and maintained a continuous positive airway pressure machine ([MEDICAL CONDITION] - treatment for [REDACTED]. [REDACTED].#310); and failed to ensure staff changed oxygen equipment per professional standards, and failed to address in the care plan the use of oxygen for one resident (Resident #95), out of a sample of 19 residents. The facility had a census of 91. Record review of the facility's policy titled, [MEDICAL CONDITION] Support, dated (MONTH) (YEAR), showed the following information: -Used to improve arterial oxygenation in residents with respiratory insufficiency, obstructive sleep apnea, or [MEDICAL CONDITION]; -Review the resident's medical record to determine his/her baseline oxygen saturation, respiratory, circulatory, and gastrointestinal status; -Review the physician's orders [REDACTED]. -Review and follow manufacturer's instructions for [MEDICAL CONDITION] machine set up and delivery; -Obtain equipment and supplies; -Wash hands; -Connect filter to air flow outlet; -Connect one end of the large-bore tubing to the outlet port of the humidifier and the other to the [MEDICAL CONDITION] circuit tubing; -Position the exhalation port of the mask away from the resident's face and free from obstruction; -Set [MEDICAL CONDITION] settings on the machine, as prescribed; -Holding the mask to the resident's face, turn on the machine and allow him/her to become acclimated to the pressure; -Once the resident is acclimated, secure the mask on his/her face; -General guidelines for cleaning, specific cleaning instructions are obtained from the manufacturer/supplier of the [MEDICAL CONDITION] device; -Wipe machine with warm, soapy water and rinse at least once a week and as needed; -Use clean, distilled water only in the humidifier chamber; -Clean humidifier weekly and air dry; -To disinfect, place a vinegar and water solution (1 to 3 ratio) in the clean humidifier. Soak for 30 minutes and rinse thoroughly; -Rinse washable filter under running water once a week to remove dust and debris. Replace this filter at least once a year; -Clean masks, nasal pillows, and tubing daily by placing in warm, soapy water and soaking/agitating for 5 minutes. Rinse with warm water and allow to air dry between uses; -Wash headgear (strap) with warm water and mild detergent as needed. Allow to air dry; -Document the general assessment, including the vital signs, in the resident's medical record; -Document the time [MEDICAL CONDITION] was started and duration of the therapy; -Document how the resident tolerated the procedure. Record review of the facility's policy titled Respiratory Therapy, dated (MONTH) 2011, showed the following information: -Review the resident's care plan to assess for any special circumstances or precautions related to the resident; -Assemble the equipment and supplies needed; -Distilled water used in respiratory therapy must be dated and initialed when opened, and discarded after 24 hours; -Check water levels of refillable humidifier units daily; -Check water levels of any pre-filled reservoir every 48 hours; -Change the oxygen cannula and tubing every seven days, or as needed; -Keep the oxygen cannula and tubing used as needed (PRN) in a plastic bag when not in use; -Wash filters from oxygen concentrators every seven days with soap and water. Rinse and squeeze dry; -Wash hands after procedure. 1. Record review of Resident #310's face sheet (a document that gives a resident's information at a quick glance) showed the following information: -admission date of [DATE]; -[DIAGNOSES REDACTED]. Record review of the physician's orders [REDACTED]. Record review of the resident's 48 hour care plan, undated, showed staff did not document use of the [MEDICAL CONDITION] machine. Record review of the resident's admission inventory form, titled Inventory of Personal Effects, dated 1/7/2020, did not show any documentation of a [MEDICAL CONDITION] with the resident's belongings. Record review of the resident's nurse's note, dated 1/7/2020, at 4:18 P.M., showed staff documented the resident admitted to the facility and had sleep apnea with no [MEDICAL CONDITION]. Record review of the resident's care plan, dated 1/8/2020, showed staff did not document any information about the use of a [MEDICAL CONDITION]. Record review of the nurse's note, dated 1/9/2020, at 3:17 [NAME]M., showed staff documented the resident had a [MEDICAL CONDITION] in place and personal caregiver sleeping in the other bed in the room. Observation and interview on 1/20/2020, at 1:49 P.M., showed a [MEDICAL CONDITION] machine sat on the windowsill to the right side of the resident's bed, tubing and mask intact on top of the machine. The resident's personal caregiver said he/she puts the [MEDICAL CONDITION] mask on the resident at night, or during an extended nap, and turns on the machine. During an interview on 1/24/2020, at 1:57 P.M., Licensed Practical Nurse (LPN) B reviewed the resident's medical record and did not find any documentation of orders for the [MEDICAL CONDITION]. During an interview on 1/24/2020, at 3:02 P.M., the resident's family member said the [MEDICAL CONDITION] at the bedside is the resident's personal [MEDICAL CONDITION] from his/her home. The resident did not use oxygen but has used the [MEDICAL CONDITION] for many years. 2. Record review of Resident #95's face sheet showed the following information: -admission date of [DATE]; -[DIAGNOSES REDACTED]., [MEDICAL CONDITION] disorder, [MEDICAL CONDITION], and diabetes mellitus. Record review of the resident's admission Minimum Data Set (MDS), a federally mandated comprehensive assessment instrument, completed by facility staff, dated 6/26/19, showed the resident received oxygen while being a resident at the facility and before admission to the facility. Record review of the resident's care plan, last updated on 12/27/19, showed staff did not document any information about the use of oxygen. Record review of the physician's orders [REDACTED]. Record review of the resident's medication administration record (MAR) showed an order for [REDACTED]. Observation on 1/20/2020, at 11:35 [NAME]M., showed the resident rested in bed with oxygen on at 2L/NC, with the oxygen tubing dated 1/11. Observation on 1/21/2020, at 1:53 P.M., showed the resident in bed with oxygen on at 2L/NC, with the oxygen tubing dated 1/11. Observation on 1/24/2020, at 1:51 P.M., showed the resident's oxygen tubing, dated 1/11 (13 days since tubing changed). During an interview on 1/24/2020, at 1:54 P.M., LPN D said orders to change O2 tubing will be on the physician order [REDACTED]. The LPN reviewed the physician's orders [REDACTED]. 3. During an interview on 1/24/2020, at 4:06 P.M., with the administrator and the director of nursing (DON), the DON said staff should change oxygen tubing and clean filters every Friday on the day shift. He/she expects them to date the tubing and sign the MAR after completing these tasks. The oxygen humidifier tank should be dated when opened and changed when empty. The DON said the oxygen and [MEDICAL CONDITION] should have an order and [DIAGNOSES REDACTED].

Based on record review and interview, facility staff failed to complete an annual Minimum Data Set (MDS, a federally mandated comprehensive assessment instrument, completed by facility staff) assessment for three residents (Resident #3, #12 and #24) within the required 14 days from the assessment reference date (ARD). A sample of 19 residents was selected for review; the facility had a census of 91. Record review of the Centers for Medicare and Medicaid Services (CMS) Resident Assessment Instrument (RAI) Version 3.0 Manual, Chapter 2, Assessments for the RAI, showed the following information: -The Annual assessment is an OBRA (Omnibus Budget Reconciliation Act of 1987) comprehensive assessment for a resident that must be completed on an annual basis (at least every 366 days) unless an SCSA (Significant Change in Status Assessment) or an SCPA (Significant Correction to Previous Assessment) has been completed since staff completed the most recent comprehensive assessment; -The Annual assessment ARD is the ARD of previous OBRA comprehensive assessment plus 366 calendar days, and ARD of previous OBRA Quarterly assessment plus 92 days. 1. Record review of Resident #3's MDS submitted reports showed the following information: -admitted to the facility 12/3/18; -Quarterly assessment, ARD 3/8/19; -Quarterly assessment, ARD 6/2/19; -Staff did not complete or submit a subsequent Comprehensive or Annual Assessment within 366 days of admission. 2. Record review of Resident #12's MDS submitted reports showed the following information: -admitted to the facility 1/15/18; -Annual assessment, ARD 12/21/18; -Staff did not complete or submit an Annual assessment within 366 days. 3. Record review of Resident #24's MDS submitted reports showed the following information: -admitted to the facility 9/26/18; -Quarterly assessment, ARD 11/9/18; -Quarterly assessment, ARD 2/5/9; -Quarterly assessment, ARD 5/4/19; -Staff did not complete or submit an Annual assessment within 366 days of admission. 4. During an interview on 1/24/2020, at 11:22 [NAME]M., MDS Coordinator C said the following: -He/she was the only MDS Coordinator from (MONTH) to (MONTH) 2019, and he/she got behind in completing and submitting MDS assessments; -He/she knew that some MDS assessments were late (not completed within 14 days of the ARD) and the administrator and corporate staff knew they were still behind; -Corporate staff did come to the facility to assist with MDS completion and transmissions, but they were still not caught up. Some assessments had not been completed. 5. During an interview on 1/24/2020, at 4:02 P.M., the facility administrator said he/she knew the MDS submissions were behind. The corporate MDS representative and staff from a sister facility had been onsite to assist with catching up.

Based on observation, interview, and record review, the facility failed to clarify [MEDICATION NAME] (blood thinning medication) orders and failed to monitor and obtain laboratory tests ordered by the resident's physician related to the International Normalization Ratio (INR - a blood test that measures how long it takes for blood to clot) levels for one resident (Resident #21) with an admitting [DIAGNOSES REDACTED]. The resident was admitted to the hospital with [REDACTED]. Four residents were sampled, in a facility with a census of 100. Record review of the facility's policy titled Anticoagulation-Clinical Protocol, revised April 2013, showed the following: -The nurse shall assess and document current anticoagulation therapy, including drug and current dosage; recent labs, including therapeutic dose monitoring; other current medications; and all active diagnosis; -The physician will identify potentially serious medication interactions with [MEDICATION NAME] (a medication that thins the blood to prevent blood clots). The physician should stop, taper, or change medications that interact with [MEDICATION NAME], and monitor the [MEDICATION NAME] time (PT)/INR (a coagulation (clotting) factor that is needed for the normal clotting of blood) very closely while the individual is receiving [MEDICATION NAME] to ensure the PT/INR stabilizes; -The physician will order appropriate lab testing to monitor anticoagulant therapy and potential complications, for example periodically checking hemoglobin/hematocrit (tests to measure the volume of the red blood cells), platelets (a test to measure the part of the blood that makes it clot), INR and stool for occult blood (blood in the feces). The staff should use a [MEDICATION NAME] flow sheet or comparable monitoring tool to follow trends in anticoagulant dosage and response. According to the National Library of Medicine, National Institutes of Health, antibiotic medications are associated with an increased risk of bleeding among patients receiving [MEDICATION NAME]. [MEDICATION NAME] has a narrow therapeutic range and requires frequent monitoring to avoid potentially life-threatening complications from both under-and over-coagulation. 1. Record review of Resident #21's Face Sheet (admission information) showed the following: -admitted to the facility on [DATE]; -Admitting [DIAGNOSES REDACTED]. Record review of the resident's admission Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff), dated 1/15/17, showed the following: -Moderate cognitive impairment; -[DIAGNOSES REDACTED]. Review of the resident's initial care plan (completed by facility at the time of admission), dated 1/9/17, showed the following: -Resident on anticoagulant therapy; -Staff to monitor for bruising and bleeding daily; -Staff to coordinate lab work as ordered. Record review of the resident's hospital discharge summary dated 1/9/17 at 12:56 P.M., showed the following: -The resident was being followed by urology (speciality that deals with the treatment of [REDACTED]. He/she has been on chronic [MEDICATION NAME] therapy for a number of years for a mechanical aortic valve replacement. His/her [MEDICATION NAME] was stopped on 12/29/16 secondary to gross hematuria. His/her hemoglobin was stable at 9.7 (normal range for men 13.5 to 17.5; normal range for women 12.0 to 15.5) which is unchanged from his/her hemoglobin that was drawn on 1/3/17 at the urology office; -an order for [REDACTED].>-An addendum to discharge summary dated 01/09/17 at 1:37 P.M., showed the hospital physician discussed anticoagulation with the resident's cardiologist. The cardiologist recommended starting resident back on half of his/her normal [MEDICATION NAME] dose at time of dismissal, since he/she has been off of all [MEDICATION NAME] since 12/29/16. Resident will be sent to a skilled nursing facility with a script for [MEDICATION NAME] 2.5 milligrams (mg) by mouth (PO) daily and INR completed two days following discharge. Record review of the resident's hospital discharge orders dated 1/9/17 at 12:54 P.M., showed the medication orders did not include [MEDICATION NAME]. Record review of two separate prescriptions, dated 1/9/17 and completed by the hospital physician, showed the following: -an order for [REDACTED].>-an order for [REDACTED]. Record review of the resident's January 2017 physician's orders [REDACTED]. -The primary care physician signed and dated orders on 1/13/17; -An order dated 1/9/17, for [MEDICATION NAME], 250 mg, every six hours to treat an urinary tract infection [MEDICAL CONDITION]; -Order for CBC (complete blood count - blood test used to evaluate overall health and detect a wide range of disorders) with differential and PT/INR to be done on 1/10/17; -Order for [MEDICATION NAME] 2.5 mg tablet, take one tablet PO daily for A-fib; -The POS did not contain orders for continued PT/INR testing. Record review of the resident's nurses' notes showed staff did not document contacting the resident's physician regarding the resident's [MEDICATION NAME] orders that were not included on the hospital discharge orders. Record review of the resident's laboratory results, dated 1/10/17, showed INR results of 1.5. The physician on 1/11/17 wrote no change to [MEDICATION NAME] due to bleeding and recheck on Monday (1/16/17). Record review of the resident's CBC, dated 1/10/17, showed the resident's hemoglobin (a protein red blood cells that carries oxygen throughout the body) was 8.9 L (normal range for men 13.5 to 17.5; normal range for women 12.0 to 15.5). On 01/11/17, the physician wrote to recheck lab on Monday (1/16/17). Record review of the resident's nurse's notes, dated 1/10/17, showed the resident with a small amount of blood noted to head of penis. Resident noted with moderate amount of hematuria. Resident states this has been a chronic problem and he is suppose to have a cystoscopy with physician in the next few weeks. Resident is scheduled for CBC and PT/INR this day (1/10/17). Record review of the resident's nursing home visit notes, dated 1/11/17, showed the following: -Initial nursing home visit completed by the primary care physician. -Resident has been admitted to facility for rehabilitation due to weakness following hospital admission for GI bleed. -Resident went to the hospital for the evaluation of one large dark tarry stool and gross hematuria. -Resident has been on chronic [MEDICATION NAME] therapy for a number of years for a mechanical aortic valve replacement. -Resident's [MEDICATION NAME] was stopped on 12/29/16 secondary to gross hematuria. -Resident's hemoglobin is stable and no recurrence of hematochezia (a passage of fresh blood usually in or with stools) . -[MEDICATION NAME] 2.5 mg daily for A-fib. Record review of the resident's nurses' notes showed the following: -On 1/13/17 at 9:52 A.M., resident with blood noted in urine; -On 1/13/17 at 4:37 P.M., resident with 450 milliliters (ml) of red tinged urine. Staff notified physician in the facility. Record review of the resident's medical record showed no documentation of the INR testing or CBC lab ordered for 1/16/17. Record review of the resident's nurse's note dated 1/17/17, at 10:09 A.M., showed staff contacted the resident's urologist regarding a stop date for the [MEDICATION NAME]. The urologist stated to continue the [MEDICATION NAME] until the resident's next appointment. Record review of the resident's POS, dated 1/16/17 through 2/8/17, showed no order for INR testing. Record review of the resident's Physician order [REDACTED]. Record review of the resident's January 2017 Medication Administration Record [REDACTED] -Staff administered [MEDICATION NAME], 2.5 mg daily, to the resident from 01/09/17 through 01/31/17; -Staff administered [MEDICATION NAME], 250 mg, every six hours to the resident from 01/10/17 through 01/12/17, and 01/13/17 at 6:00 P.M., through 01/25/17; -Staff administered [MEDICATION NAME], 100 mg, twice daily to the resident from 01/26/17 through 01/31/17. Record review of the resident's February 2017 POS showed an order for [REDACTED].) Record review of the resident's POS, dated 2/8/17, showed the physician wrote on the POS an order to restart [MEDICATION NAME] 2.5 mg daily and PT/INR in one week and then weekly. Record review of the resident's nurses' note, dated 2/8/17, showed new orders for medication changes received from the physician. Staff did not document regarding the restart of [MEDICATION NAME] order. Record review of the resident's medical record showed no documentation of nursing staff clarifying the physician order [REDACTED].>Record review of the resident's February 2017 MAR indicated [REDACTED] -Staff administered [MEDICATION NAME], 2.5 mg, daily to the resident from 2/1/17 through 2/11/17 and on 2/13/17; -Staff administered [MEDICATION NAME], 100 mg, twice daily from 2/1/17 through 2/4/17. Record review of the resident's note dated 2/14/17 at 11:34 A.M., showed staff indicated it was a late entry for 2/13/17 at 5:00 P.M., related to possible hospice services. On 02/15/17, at 10:30 A.M., staff added an addendum to the note. The addendum stated the resident's sitter reported to the nurse that the resident had a nose bleed during the night and he/she had blown his/her nose and a large clot came out. The nurse checked on the resident and noted the resident had old dried blood to his/her nares. The nurse cleaned the resident's nares with no fresh bleeding noted. Record review of the resident's nurse's note dated 2/14/17 at 6:31 A.M., showed the resident noted with small amount of blood in stool. The resident is on [MEDICATION NAME] for A-fib and has a history of GI bleed. The staff received an order for [REDACTED]. Observations on 2/14/17 at 11:10 A.M., showed the resident sitting in his/her room in his/her wheelchair and making valentines with the facility staff. During an interview, the resident shook his/her head and stated I'm no good and have no energy. During the interview, the resident's speech became garbled and unable to be understood. Record review of the resident's nurse's note dated 2/14/17 at 1:31 P.M., showed the resident with dark red rectal bleeding and a nose bleed. Resident is on [MEDICATION NAME] and PT/INR was drawn that morning. Staff are currently awaiting results. The resident's family had been discussing possible hospice. This nurse called resident's spouse to ask how he/she would like for facility to proceed with this. This nurse explained that facility was still awaiting lab results and the resident's current blood pressure was 100/49 mm/Hg (measured in millimeters of mercury; normal blood pressure would be recorded as under 120/80 mm/Hg). The resident's spouse stated he/she would call his/her child and talk to him/her and then would report back to the facility. During an interview on 2/14/17 at 1:38 P.M., Licensed Practical Nurse (LPN) A said he/she was unable to locate the INR test results for 1/16/17. He/she acknowledged the physician had ordered an INR to be rechecked on 1/16/17. He/she verified an INR was drawn on 2/14/17 related to the resident having rectal bleeding and nose bleed. Record review of the resident's nurse's note dated 2/14/17 at 9:04 P.M., showed the lab called the facility at 2:50 P.M. regarding PT/INR results. The resident's INR was 24.9. The facility contacted the physician and received an order to give 10 mg vitamin K immediately. The facility did not have the vitamin K in the building. Staff contacted the physician who gave an order to send the resident to the emergency room to receive vitamin K intravenously and evaluate for bleeding. Record review of the resident's laboratory results, dated 2/14/17, showed the resident's INR at a critical level of 24.49. Record review of the resident's hospital history and physical, dated 2/14/17, showed the resident was brought in due to bleeding problems and has had a a nosebleed for four days. His/her INR was obtained and was noted to be significantly elevated. The resident also had some emesis that was bloody and had blood from his/her rectum today. Record review of the resident's hospital intake and output results sheet, dated 2/15/17, showed the resident received 891 cubic centimeters (cc) of blood product. During interviews on 2/14/17 at 2:50 P.M., and 5:15 P.M., Licensed Practical Nurse (LPN) B said the following: -After the physician orders [REDACTED]. Staff should write the order on the facility calendar at the nurses' desk; -Staff should write the lab due on the calendar and place a checkmark when the lab is drawn. Staff should notify the physician of results and highlight on the calendar once the physician has addressed; -He/she said if the physician writes the order for lab on the lab result sheet, staff should enter it into the computer; -He/she said if the order is to check the lab in one week, staff should enter it into the computer. If PT is to be drawn on the tenth of every month, staff should enter this order into the computer; -He/she said PT/INR orders depend on the resident and he/she is unaware of the INR policy. He/she said there is no way of knowing how to track INR labs, if the order is not entered into the computer. He/she said if the resident has been off the medicine, INR should be checked weekly and when stable checked monthly; -He/she said if INR results are done and not in the medical record, staff should go into the computer and enter the resident's name to view the recent lab. If staff discover a lab is not completed, the physician is notified; -A resident who is admitted from the hospital should come with the hospital discharge medication list; -He/she said all medications should be indicated on the discharge medication list. If a hard prescription is sent and the medication is not listed on the discharge medication list, staff should call the physician to clarify orders and document in nurses' notes. During an interview on 2/14/17 at 3:12 P.M., the Director of Nursing (DON) said the following: -The physician orders [REDACTED]. Staff should write the order on the lab calendar located at the nurses' desk; -Staff should place a check mark on the calendar when the lab is drawn. When the physician has addressed the order, staff should highlight the order on the calendar to indicate it has been completed; -Staff should enter PT/INR orders into the lab book, write on the calendar at the nurses' desk, and place the order underneath the correct date due; -When the DON was asked how the facility monitors if a lab is missed, she said she reads the nurses' notes daily and will look at the lab calendar and if the lab is not there, staff should put lab draw on it. -She said she expected staff to have the resident's lab drawn on 1/16/17 and entered into the computer. She is unaware if the lab order was entered into the computer or who noted it; -Regarding new admission process from the hospital, if a prescription comes with the med list, staff will enter the orders into the computer. She said the physician may add orders that are not on the discharge med list; -She said a discharge summary comes with the resident from the hospital. She said the admitting nurse will input the information and on the following business day, the DON, medical record personnel, and ADON will perform a clinical review by going through the hospital records and information entered into the facility system. Staff cross reference this information and will double check orders; -She said she did not feel there was a discrepancy with the [MEDICATION NAME] orders since the prescriptions were signed and the primary physician later signed the POS; -She said she was unaware of the reason the physician documented restart on the [MEDICATION NAME] order dated 2/8/17 due to the medication was the same dose as given since 1/9/17. During interviews on 2/14/17 at 4:55 P.M., and on 2/15/17 at 11:25 A.M., the physician/medical director said the following: -If a resident is admitted to the facility on [MEDICATION NAME], staff usually monitor for bleeding and follow up with PT/INR; -If a resident has a [DIAGNOSES REDACTED]. If a resident is off [MEDICATION NAME] awhile, they should start back slowly. INRs should continue weekly until two weeks of stable results are obtained and then monitor monthly; -He was unaware the resident was receiving [MEDICATION NAME] and thought it was discontinued until the order was written on 2/8/17 to restart. It was his understanding that the resident was not on the [MEDICATION NAME] this whole time; -He said he was unaware of the prescription for the [MEDICATION NAME] from the hospital physician; -He was unaware the INR testing was not completed on 1/16/17 as ordered. During an interview on 2/14/17 at 5:35 P.M., the MDS/care plan coordinator said she does not include the PT/INR monitoring on the care plan due to this being physician driven. During an interview on 2/14/17 at 5:50 P.M., Certified Nurse Aide (CNA) C said he/she had worked the last five days, except for 2/13/17. He/she said the resident has lately been a little bit off, agitated, and upset. During an interview on 2/14/17 at 5:50 P.M., CNA D said in the last few days the resident has had no pep and always seems exhausted. He/she said the resident's family has said the resident has had issues with bleeding in the past. During an interview on 2/15/17 at 11:19 A.M., LPN H said staff monitor residents on [MEDICATION NAME] by drawing PT/INR labs which depends on the physician orders. PT/INR tracking is done by staff obtaining order from the physician with frequency. This lab order is placed in the lab book and on the lab calendar. Staff receive lab results and depending if it is critical staff should contact the physician. #MO 686 Note: At the time of the abbreviated survey, the violation was determined to be at the immediate and serious jeopardy level J. Based on observation, interview, and record review completed during the onsite visit, it was determined the facility had implemented corrective action to address and lower the violation at the time. During the on-site visit, the facility developed a plan of correction which included immediate inservicing of staff on the facility's chart review to include review of new orders, labs, physician progress notes [REDACTED]. A final revisit will be conducted to determine if the facility is in substantial compliance with participation requirements. On 02/16/17, the severity of the deficiency was lowered to the D 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 Class I violation(s).