Every finding on record at Community Springs Healthcare Facility

Based on interview and record review, the facility failed to support each resident's right to self-determination related to care when staff failed to care plan and provide showers per residents' preference for three residents (Resident #3, #28, and #6). Review of the facility's policy titled, Personal Hygiene, revised 03/2023, showed the following: -Purpose to establish guidelines for ensuring the hygiene needs of residents are addressed and met; -Purpose to identify the roles of the nursing staff and the patients in maintaining the patients' and residents' personal hygiene; -Staff are to assist with personal hygiene tasks as patients need; -If a patient is unable to care for self, nursing staff will provide full assist with bathing, changing clothing, oral care and other needs; -Patients are expected to shower at two-day intervals or more frequently when requested or required, maintain dental hygiene, wear clean clothes, and take care of personal grooming. 1. Review of Resident #3's Patient Information, showed the following: -admitted [DATE]; -Diagnoses included of bipolar II disorder (a chronic mental health condition characterized by alternating episodes of hypomania (elevated mood) and major depression). Review of the resident's current Care Plan showed staff to encourage/remind resident to request assistance. (Staff did not care plant related to the resident's preferred bathing frequency preference.) Review of the resident's Minimum Data Set (MDS - a federally mandated assessment tool completed by facility staff), with an assessment reference date (ARD) of 10/22/24, showed the following: -Resident was cognitively intact; -Resident required use of a walker; -Resident required partial to moderate assistance with shower/bath. Review of the resident's shower sheets, dated October 2024 through January 2025, showed the resident did not receive scheduled showers on the following dates: -On 10/17/24; -On 10/25/24; -On 11/01/24; -On 11/04/24; -On 11/14/24; -On 12/02/24; -On 12/23/24. During an interview on 01/02/25, at 3:02 P.M., the resident said staff seemed to not be able to keep up with showers. Sometimes he/she would go a week or so and not get a shower because there was no one to assist with showers. Residents are supposed to get two showers a week. 2. Review of Resident #6's Patient Information showed the following: -admitted [DATE]; -Diagnoses included acute and chronic respiratory failure with hypoxia (a condition where there is an inadequate supply of oxygen to the body's tissues). Review of the resident's current Care Plan showed the following: -Resident required partial to substantial assistance with my activities of daily living (ADL) and transfers related to weakness; -Resident required substantial assistance with showers. Staff to encourage resident to actively participate. (Staff did not care plant related to the resident's preferred bathing frequency preference.) Review of the resident's quarterly MDS, with an ARD of 10/02/24, showed the following: -Resident was cognitively intact; -Resident required substantial/maximal assistance with showers. Review of the resident's shower sheets, dated October 2024 through December 2024, showed the resident did no received showers on the following scheduled days: -On 10/05/24; -On 11/16/24; -On 12/29/24. During an interview on 01/02/25, at 3:02 P.M., the resident said residents should not have to wait to get showers. Resident are supposed to get showers two times a week and they are not providing residents with the showers. 3. Review of Resident #28's Patient Information showed the following: -admitted [DATE]; -Diagnoses included urinary tract infection, morbid (severe) obesity, dementia, and anxiety. Review of the resident's current Care Plan showed the following: -Resident required partial assistance with showers; -Staff to encourage resident to shower self and encourage independence. (Staff did not care plant related to the resident's preferred bathing frequency preference.) Review of the resident's quarterly MDS, with an ARD of 11/21/24, showed the following: -The resident was cognitively intact; -The resident required substantial/maximal assistance for showers. Review of the resident's shower sheets, dated October 2024 to December 2024, showed the resident did not get scheduled showers on the following days: -On 10/01/24; -On 10/15/24; -On 11/26/24. During an Interview on 01/01/25, at 4:51 P.M., the resident said residents are scheduled to receive showers twice per week. However, these showers often do not occur due to insufficient staff available to provide assistance. The facility attempts to schedule additional staff specifically for shower days, but this fails as well. The resident felt showers were needed more than twice weekly. 4. During an interview on 01/02/25, at 4:39 P.M., CNA 9 said there were different people designated as shower aides that handle nothing but showers. CNA 9 has helped with resident showers when the shower aide called off. Sometimes residents do not get shower like they are supposed to. 5. During an interview on 01/03/25, at 1:06 P.M., CNA 8 said there were issues with residents getting showers. Sometimes the shower aides have to be pulled off showers to help on the floor. They have make-up days where extra staff are called in the help with showers. 6. During an interview on 01/02/25, at 5:53 P.M., with the Director of Nursing (DON) and Staff Development Coordinator (SDC), the SDC said the facility had shower aides, but if a CNA calls off they will have to pull the shower aide to assist on the floor. Management is aware of the issue of residents not getting showers. Staff try to accommodate the resident as much as possible with getting their showers. The DON said staff always try to accommodate residents with showers, by providing them in the evening or the next day.

Based on record review and interview, the facility failed to ensure each resident's care plan was updated and review for accuracy timely when the care plans of five residents (Resident #37, #31, #33, #10, and #26) were not updated to reflect the residents' current conditions. Review of a facility's policy titled, Assessments in Long Term Care. dated 12/2024, showed the following: -The nursing care plan will be initiated according to identified needs from the admission assessment by a licensed nurse; -Licensed nursing personnel will update care plans as needs are assessed; -The dietitian, social worker, and rehabilitation personnel can assess patients, within the scope of their service and will integrate information into the medical record and assist in identifying and assigning priorities for the resident care needs via the care plan and progress notes. 1. Review of Resident 37's Patient Information showed the following: -admitted [DATE]; -Diagnoses included dementia. Review of the resident's Minimum Data Set (MDS - a federally mandated assessment completed by facility staff), with an Assessment Reference Date (ARD) of 08/15/24, showed the following: -Staff could not determine a cognitive assessment score for the resident; -The resident had both physical and verbal behaviors directed to self and to others. Review of the resident's Behavior Monitoring, dated 08/20/24, showed the resident grabbed the breast of a certified nurse aide (CNA). Review of the resident's Nurse Note, dated 08/21/24, showed the resident told a CNA that he/she had nice tits and attempted to grab his/her buttocks. Review of the resident's Nurse Note, dated 08/23/24, showed the nurse documented the resident made sexual advances to the nursing staff. Review of the resident's Behavior Monitoring, dated 09/14/24, showed while being changed by a CNA, the resident pulled the CNA's smock down and looked down his/her shirt. Review of the resident's Social Service Note, dated 11/07/24, showed the Director of Social Services (DSS) noted the resident would yell at the staff. Review of the resident's Nurse Note, dated 11/25/24, showed the resident had his/her hands around the throat of a staff member (trainee) and refused to receive care by a CNA. Review of the resident's current Care Plan showed staff failed to care plan the resident's verbal, physical, and sexual behaviors towards staff. During an interview on 01/01/25, at 5:03 P.M., the Director of Social Work (DSW) said there was no care plan in place that addressed the resident's sexual behaviors. During an interview on 01/01/25, at 6:21 P.M., the Director of Nursing (DON) confirmed there were no care plans in place for the resident that addressed his/her sexual behavior towards the staff. 2. Review of Resident #31's Patient Information, showed the following: -admitted [DATE]; -Diagnoses included dementia. Review of a the resident's MDS, with an ARD of 11/11/24, showed the following: -The resident had moderate cognitive impairment; -The resident had no physical or verbal behaviors directed to others. Review of the resident's Behavior Monitoring, dated 11/17/24, showed the resident admitted to a CNA that he/she was looking down in his/her shirt and then said his/her wallet did not contain condoms. Review of the resident's Behavior Monitoring, dated 11/30/24, showed the resident touched the cheek of a CNA and told the CNA he/she loved him/her and then asked that the CNA lay with him/her. Review of the resident's Behavior Monitoring, dated 12/01/24. showed the resident attempted to grab a CNA and made sexual comments to the CNA while the CNA provided the resident with a shower. Review of a the resident's current Care Plan, showed staff did not are plan related to the resident's sexual behaviors towards staff. During an interview on 01/01/25, at 5:03 P.M., the DSW said there was no care plan in place that addressed the resident's sexual behaviors. During an interview on 01/01/25, at 6:21 P.M., the DON confirmed there were no care plans in place for the resident that addressed his/her sexual behavior towards the staff. 3. Review Resident #33's Patient Information, showed the following: -admitted [DATE]; -Diagnoses included of post-traumatic stress disorder (PTSD - a mental health condition that's caused by an extremely stressful or terrifying event). Review of the resident's admission MDS, with an ARD of 08/19/24, showed the resident was cognitively intact. During an interview on 12/31/24, at 10:29 A.M., the resident confirmed his/her diagnosis of PTSD and said he/she had triggers from former abuse and the triggers included yelling, slamming doors, and the tone of a person's voice. Review the resident's current Care Plan showed staff did not care plan regarding the resident's PTSD diagnosis or associated triggers. During an interview on 01/03/25, at 9:41 A.M., the DON said she was not aware the resident's PTSD triggers were not incorporated into her care plan. She would have expected staff to place this information in the resident's care plan to make it individualized. 4. Review of Resident #10's Admission Record showed the following: -An admitted [DATE]; -Diagnoses included acute and chronic respiratory failure and secondary malignant neoplasm (cancer) of left lung. Review of the resident's Physician Order, dated 12/04/24, showed an order for oxygen at 5 liters (L). Staff may titrate up to 10 L via nasal cannula continuous and may switch over to mask, if needed. Review of the resident's Care Plan, dated 12/15/24, showed the resident was at risk for ineffective breathing pattern. Staff did not care plan the resident's oxygen usage. 5. Review of Resident #26's Admission Record showed the following: -admitted [DATE]; -Diagnoses included heart failure and cerebral vascular accident (stroke). Review of the resident's Physician Order, dated 05/19/20, showed an order for oxygen at 2 L via nasal cannula intermittent. Staff may titrate to keep blood oxygen levels greater than 90%. Review of the resident's Care Plan, dated 10/25/24, showed a history of congestive heart failure and shortness of air. Staff did not care plan the resident's oxygen usage. During an Interview on 01/01/25, at 4:09 P.M., the MDS Coordinator (MDSC) said the resident's oxygen usage was not care planned. 39857

Based on record review and interviews, the facility failed to ensure services were provided per standards of practice for all residents when staff failed to document timely follow-up regarding a possible bruise and failed document regarding resident's wishes to have an area removed for one resident (Resident #5). 1. Review of Resident #5's Patient Information, showed the following: -admitted [DATE]; -Diagnoses included urinary tract infection. Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment completed by facility staff), with an assessment reference date (ARD) of 11/20/24, showed the following: -The resident had cognitively impairment; -The resident required moderate assistance with dressing and toileting and setup with eating and oral hygiene; -The resident had no other skin problems present and did have a pressure reducing device for his/her bed. Review of the resident's Nurse Note, dated 11/22/24, showed upon resident return to facility from outing the family reported several concerns. The resident had a bruise on the back of his/her head that looked fresh with no yellow or green colors to it. This was noticed by hairdresser at hair appointment. Review of the resident's Nurse Note, dated 01/02/25, showed the resident had a soft knot on top of the posterior head of his/her head that was not discolored and non-tender. The resident said he/she had it forever and was asking to have it removed. Review of resident's current Care Plan showed staff did not document relating to the resident's soft knot on the resident's head. During an interview on 01/01/25, at 4:48 P.M., the MDS Coordinator (MDSC) said she reviewed all nurse notes prior to the daily stand-up meeting. She remembered seeing the note and mentioning it during their morning stand-up meeting. She said the resident's skin should have been checked after this was discussed in the meeting. During on interview on 01/02/24, at 8:32 A.M., the Infection Preventionist 1 (IP1) said the note written on 11/22/24 was incorrect. It was not a bruise, but a raised soft area. He/She assessed it the day after the note was written, but he/she did not document his/her assessment. He/she said when he/she assessed it the resident told him/her he/she had it a long time and wanted it removed. During an interview on 01/03/25, at 8: 37 A.M., the Director of Social Services (DSS) said it was discussed in their daily stand-up meeting. The next day she remembered IP 1 saying he/she would assess the resident's head. During an interview 01/03/25, at 8:55 A.M., Certified Nurse Aide (CNA) 7 said she would report a bruise to the charge nurse if she saw one. During an interview 01/03/25, at 11:35 A.M., IP 2 said normally he/she would be notified by the CNA if they saw a bruise and he/she would assess it, inform the Director of Nursing (DON) and notify the resident's physician.

Based on record review and interview, the facility failed to ensure the accuracy of all Minimum Data Sets (MDS - a federally mandated assessment completed by facility staff) when staff failed to accurately complete one resident's (Resident #56) MDS. Review of the RAI Manual, dated October 2023 showed the following: -Code residents identified as being in a hospice program for terminally ill persons where an array of services is provided for the palliation and management of terminal illness and related conditions; -The hospice must be licensed by the state as a hospice provider and/or certified under the Medicare program as a hospice provider. 1. Review of Resident #56's Patient Information, showed the following: -An admitted [DATE]; -Diagnoses included Alzheimer's disease. Review of the resident's quarterly MDS, with an assessment reference date (ARD) of 12/12/24, showed the following; -The resident had cognitive impairment; -The resident independent with all activities of daily living (ADL); -The resident received hospice care. Review of the resident's medical record showed staff did not document recommendations for hospice care. During an interview on 01/02/25, at 7:52 A.M., with the MDS Coordinator (MDSC) and the Director of Nursing (DON), the MDSC said the resident's MDS indicated that the resident received hospice services, which was the same as palliative care. She said since hospice and palliative care are similar and Section O of the MDS should be selected. The MDSC staid the MDS should be accurate. The DON said the MDS should be accurate. During an interview on 01/02/25, at 8:13 A.M., the Clinical Services Nursing Administration (CSNA) said Section O in the MDS should not be triggered under hospice care if the resident is receiving palliative care only.

Based on observation, interview, and record review, the facility failed to develop a person-centered comprehensive plan of care with measurable goals and plans for one resident (Resident #57) related to the resident taking antidepressant and an anti-anxiety medication. Review of the Minimum Data Set (MDS - a federally mandated assessment completed by facility staff) 3.0 Resident Assessment Instrument (RAI) Manual, dated 10/2024, showed the following: -The RAI process, which includes the federally mandated MDS, is the basis for an accurate assessment of nursing home residents; -The MDS information and the CAA (Care Area Assessment) process provide the foundation upon which the care plan is formulated; -There are 20 problem-oriented CAAs, each of which includes MDS-based trigger conditions that signal the need for additional assessment and review of the triggered care area; -Detailed information regarding each care area and the CAA process, including definitions and triggers; -After completing the MDS and CAA portions of the comprehensive assessment, the next step is to evaluate the information gained through both assessment processes in order to identify problems, causes, contributing factors, and risk factors related to the problems; -Subsequently, the IDT (Interdisciplinary Team) must evaluate the information gained to develop a care plan that addresses those findings in the context of the resident's goals, preferences, strengths, problems, and needs. 1. Review of Resident #57's Patient Information showed the following: -admitted [DATE]; -Diagnoses included dementia. Review of the resident's annual MDS, with an Assessment Reference Date (ARD) of 09/02/24, showed the following: -The resident had severe cognitive impairment; -The resident had no behavior directed to self or to others; -The resident had depression and anxiety; -The assessment indicated the resident received an antidepressant and an anti-anxiety; -Under the CAA, the resident triggered for the use of psychotropic medications and directed the staff to develop a care plan. Review of a the resident's current Care Plan showed staff did not care plan the resident's use of antidepressant and anti-anxiety medications. During an interview on 01/03/25, at 8:39 A.M., the MDS Coordinator (MDSC) confirmed she did not develop a care plan for the resident and the use of antidepressant and anti-anxiety medications. The MDSC confirmed the resident received medications for depression and anxiety during the assessment period.

Based on record review and interview, the facility failed to ensure all allegations possible abuse had documented complete investigations when staff failed to document a full investigation of an allegation of possible abuse by one resident (Resident #37). Review of a facility policy titled Patient Abuse/Neglect, Elder Abuse, and Persons with Disability Abuse, dated 08/2024, showed the following: -Personnel will complete an electronic Incident Report for further investigation by the designee(s), nursing administration, the Administrator, and/or other disciplines within the facility or outside to ensure resident safety and quality of care. 1. Review of Resident #37's Patient Information showed the following: -An admitted [DATE]; -Diagnoses included dementia and agitation. Review of a the resident's Behavior Monitoring, dated 12/28/24, showed the resident asked another resident to expose his/her breasts. Review of Department of Health and Senior Services (DHSS) records showed a written investigation regarding the allegation of possible abuse was not received. During an interview on 01/01/25, at 6:04 P.M., Registered Medication Technician (RMT) confirmed he/she observed the statement from Resident #37. He/she was not asked to provide a written statement by the abuse coordinator. During an interview on 01/01/25, at 6:21 P.M., the Director of Nursing (DON) said during a potential abuse investigation, witness statements should be gathered.

Based on interview and record review, the facility failed to ensure all allegations of possible abuse were reported to the State Survey Agency (SSA - Department of Health and Senior Services (DHSS)) within two hours when staff failed to report an allegation of possible sexual abuse by one resident (Resident #37). Review of the facility policy titled, Patient Abuse/Neglect, Elder Abuse, and Persons with Disability Abuse, dated 08/2024, showed the following: -Purpose to guide staff, employees, physicians, and any mandated reporter in identifying victims of abuse and provide a reporting mechanism in accordance with all local, state and federal laws; -Purpose to provide safe and efficient care for the patients/residents; -Purpose to keep patients/residents free from abuse, mistreatment, and neglect. 1. Review of Resident #37's Patient Information showed the following: -An admitted [DATE]; -Diagnoses included dementia and agitation. Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment completed by facility staff), with an Assessment Reference Date (ARD) of 11/07/24, showed the following: -The resident had severe cognitive impairment; -The resident had verbal behaviors directed to others which occurred one to three times during the assessment period. Review of a the resident's Behavior Monitoring, dated 12/28/24, showed the resident asked another resident to expose his/her breasts. Review of DHSS records showed the facility did not report the allegation of possible resident to resident abuse. During an interview on 01/01/25, at 6:04 P.M., Registered Medication Technician (RMT) 1 confirmed she saw the resident make the comment to another resident to expose his/her breasts. He/she immediately reported the incident to Registered Nurse (RN) 1. All potential allegations of abuse were to be reported immediately. During an interview on 01/01/25, at 6:38 P.M., RN 1 confirmed he/she did not inform the facility's abuse coordinator of the potential sexual abuse from between the residents. During an interview on 01/01/25, at 4:28 P.M., the Minimum Data Set Coordinator (MDSC) said the resident asked another resident to expose his/her breasts on 12/28/24. During an interview on 01/01/25, at 5:03 P.M., Director of Social Work (DSW) confirmed she was the facility's abuse coordinator. She learned of the allegation of potential sexual abuse from Resident #37 towards another resident during the facility's morning meeting on 12/30/24. She did not report the allegation to the SSA. During an interview on 01/02/25, at 7:46 A.M., the Director of Nursing (DON) said all allegations of abuse were to be reported immediately to the abuse coordinator.

Based on observation, record review, and interview, the facility failed to establish procedures to estimate the water needed and ensure that water was available to essential areas if there was a loss of normal water supply, such as in an emergency. The facility has a capacity of 120 and had a census of 60 at the time of survey. Review of a Centers for Disease Control and Prevention (CDC) document named Emergency Water Supply Planning Guide for Hospitals and Healthcare Facilities, dated 2019, showed that water needs can vary greatly from facility to facility, but general guidelines show a need of one to three gallons of water needed per person, per day for consumption and sanitary needs. 1. Review of the facility's Emergency Operation Plan (EOP) showed the EOP hazard assessment stated the risk of loss of water supply as moderate. The EOP did not show any calculation of water needed per person, in case of emergency. The EOP did not show a facility-specific manner on how to obtain sufficient water for residents and staff in case of emergency. Review of a letter to the facility from food service provider, and dated 09/30/19, showed the provider should be able to deliver water within a 12 to 24 hour time frame. The provider allocated one gallon of water per resident and one gallon per employee per day ongoing throughout the emergency. Observation on 06/28/23, at 10:45 A.M., of a storage rack in the kitchen showed a 24-pack, plus a partial 24-pack, of 1/2-liter (16 ounces, approximately) plastic drinking water bottles. The total water stored in this area equaled approximately 642 ounces, or 5 gallons. During an interview on 06/28/23, at 10:52 A.M., the Dietary Manager said the facility tries to keep some water bottles on hand in case of need or emergency. The water is ordered with the other food order, about once per week. The facility tries to keep available about three 24-packs of 1/2 liter bottles (26 liters total, or 9 1/2 gallons). During an interview on 06/28/23, at 3:27 P.M., the Maintenance Director said, in case of emergency, the facility should be able to get water from a sister facility and integrated healthcare system (about about 45 miles away from the facility), or from the food provider (about 75 miles away from the facility). The facility expected to be able to get water from the two sources within the same day. In addition, the facility attempts to keep 48 or so (1/2 liter) water bottles (about 6 gallons) on-site, and stored in the kitchen. During an interview on 06/28/23, at 3:40 P.M., the Administrator said he was directed to keep an emergency water supply on site was not really necessary due to the agreements and the assumption of being able to have water available within a few hours.

Based on observation, interview, and record review, the facility failed to ensure food was protected from contamination at all times when staff touched resident food with bare hands and failed to complete hand hygiene after touching soiled surfaces during meal service. The facility census was 60. Review of the Food and Drug Administration (FDA) 2013 Food Code showed foods that are ready to eat should not be touched by staff's bare hands. Review of the facility Competencies for Food and Nutrition Services Employees checklist, undated, showed the following: -Practice appropriate hand hygiene and glove use when necessary during food preparation activities, such as between handling raw meat and other foods, to prevent cross-contamination; -Properly wash hands before serving food to resident after collecting soiled plates and food waste; -Prevent eating surfaces of dishware from coming into contact with staff clothing; -Handle cups/glasses on the outside of the container and knives, forks, and spoons by handles; -Practice hand hygiene after direct contact with resident's skin or secretions. 1. Observations of meal services on 06/27/23 showed the following: -At 11:30 A.M., Dietary Aide (DA) C dropped a spoon on the floor, picked the spoon up, and put the spoon onto the dirty tray of the cart. The DA then resumed passing [NAME] to residents. The DA did not completing hand hygiene after touching soiled surfaces; -At 11:55 A.M., DA C picked up a resident's hamburger and bun with hi/her bare hands. The DA took the top bun into one hand with the remaining bun and meat in the other hand, and rubbed the top bun across the burger to spread the mustard around. The DA then put the hamburger and bun back on the resident's plate and moved on to the next resident. The DA did not complete hand hygiene; -At 12:05 P.M., DA D picked up a menu from the floor and put it back on a resident table. The DA then continued serving resident plates. The DA did not perform hand hygiene after touching soiled surfaces; -At 12:06 P.M., DA C opened a resident's soda can and poured into a cup with ice, opened a straw wrapper, and put the straw in the cup by touching the top of the straw with his/her bare hands. The DA then moved to next resident opened and poured soda in to a cup, opened a straw touching the top of the straw with bare hands. The DA did not complete hand hygiene between residents. During an interview on 06/30/23, at 10:15 A.M., Registered Medication Technician (RMT) E said that staff should complete hand hygiene before and after all resident contact. Staff should complete hand hygiene between each meal tray during meal pass. If anything drops on the floor it should be picked up and disposed of and staff should their wash hands. During an interview on 06/30/23, at 10:25 A.M. Licensed Practical Nurse (LPN) A said that staff should complete hand hygiene between every meal tray at meal pass and before and after opening food items. Staff should not touch resident food with bare hands. Staff should hand sanitizer after picking anything up from the floor. During an interview on 06/30/23, at 11:05 A.M., DA D said that the Dietary manager and dietician provide various in-services about once per month and the facility holds all-staff updates. He/she had received hand hygiene in-services and said that hands should be cleaned with hand sanitizer after tray pass on the way back into the kitchen. Hands should be sanitized after any resident contact. Staff should not touch resident food with bare hands. During an interview on 06/30/23, at 11:20 A.M., the Dietary Manager said that dietary staff receive in-services from him/her and the registered dietician. He said that he/she expects staff to use hand sanitizer after touching a resident. Staff should wash hands and use gloves before touching food. Staff should use hand sanitizer before opening a condiment for residents and after helping the resident. Staff should request the resident open the bun for them if possible, otherwise staff should use utensils to put condiments on resident foods. The staff should not touch food with their bare hands. Staff should complete hand hygiene after picking anything up from the floor before continuing to pass meals. During an interview on 06/30/23, at 12:40 P.M., with the Administrator and Director of Nursing (DON), the DON said that staff should complete hand hygiene before, after, and between each resident contact. In the dining room staff should use hand sanitizer between each resident when assisting, and when passing plates, as well as between each hall tray. Staff should either wear gloves or use utensils to put condiments on the resident's food. The staff should not touch any food with their bare hands. The staff should be cleaning their hands after touching any contaminated items, such as dropped item on the floor, before continuing to pass drinks or meal plates.

Based on observation, interview, and record review, the facility failed to complete a documented side rail assessment including risks versus benefits, obtain written consent, obtain a physician order, and complete gap assessments prior to installing side rails for two residents (Residents #53 and #45) in a sample of eight residents with bed rails in use. The facility census was 60. Review of the facility policy entitled Bed Rails and Support Device in Long Term Care, revised 02/2023, showed the following: -Side rails/support devices are utilized if an assessed need is identified by the interdisciplinary team (IDT); -The IDT should complete and document assessment of side rail need; -Staff may utilize the LTC Device Decision Guide to assist with determining whether or not the device is considered a support device or restraint; -Bed rails and support devices require a physician order; -Family or guardian will be notified and consent obtained for use of side rails; -Use of side rails should be added to the resident care plan; -Need for side rails will be initially assessed, reassessed, documented, and care planned quarterly and as needed; -Physicians order will be reviewed quarterly and continued if appropriate; -Site facility maintenance/work order will be placed for maintenance to place on bed as well as quarterly checks, with the approval of the Administrator/Director of Nursing (DON)/Designee; -Gap analysis will be done by maintenance when side rail is placed on the bed and quarterly; -Bed rail consent should be obtained and scanned into the electronic medical record (EMR) and informational guide on bed safety be given to resident/guardian. See Guide to Bed Safety and Bed Rails and Support Device Consent attached to this policy. Review of a facility document entitled Guide to Bed Safety showed information including: -Statistics regarding bed rail entrapment; -The risks and benefits of bed rails; -Meeting patients' needs for safety. Review of a facility document entitled Bed Rail Consent Form showed information regarding safety and bed rails and benefits and risks of bed rails. 1. Review of Resident #53's face sheet (gives basic profile information) showed the following: -admitted [DATE]; -Diagnoses included stroke, vascular dementia with anxiety, Alzheimer's disease, insomnia, repeated falls, and weakness. Review of the resident's significant change Minimum Data Set (MDS - a federally mandated comprehensive assessment tool completed by facility staff), dated 05/23/23, showed the following: -Moderately impaired cognition; -Required extensive assistance of one person for bed mobility, transfers, locomotion by wheelchair, dressing, toileting, personal hygiene, and bathing; -Balance unsteady during seated to standing or surface to surface transfer; required human assistance to stabilize. Observation on 06/28/23, at 1:31 P.M., showed the resident rested in bed. Vertically shaped grab bars were attached on both sides of the resident's bed. Review of the resident's electronic medical record (EMR) showed no scanned documentation pertaining to the side rail pre-use assessment, informed consent, or gap assessment of installed side rails. Review of the resident's care plan, last updated 06/13/23, showed staff did not document information pertaining to the use of side rails. During an interview on 06/29/23, at 1:00 P.M., the Maintenance Supervisor said he/she had not received an order to install or remove side rails for the resident. The resident had changed beds during a COVID outbreak the month before, but staff did not tell maintenance that the new bed had side rails attached. Observation on 06/29/23, at 3:02 P.M., showed the resident rested in bed. Vertically shaped grab bars were attached on both sides of the resident's bed. During an interview on 06/30/23, at 9:52 A.M., the MDS Coordinator said the resident had changed beds at some time. He/she said there was no pre-use assessment or orders for the rails already on the bed. 41787 2. Review of Resident #45's face sheet showed the following information: -admitted [DATE]; -Diagnoses included dementia (the loss of cognitive functioning, thinking, remembering, and reasoning, to such an extent that it interferes with a person's daily life and activities), rheumatoid arthritis (chronic inflammatory disorder affecting many joints, including those in the hands and feet), repeated falls, weakness, pain in bilateral (both sides) shoulders, and pain in bilateral knees. Review of the resident's quarterly MDS, dated [DATE], showed the following information: -Moderate cognitive impairment; -Required limited assistance of one staff for bed mobility; -Required extensive assistance of one staff for transfers; -Required extensive assistance of one staff for toilet use and personal hygiene; -Used a wheelchair for locomotion. Observation and interview showed the following: -On 06/27/23, at 9:27 A.M., a side rail was in the upright position and the resident rested in bed with his/her eyes closed; -On 06/27/23, at 12:45 P.M., a side rail was in the upright position. The resident was sitting up in the bed eating lunch; -On 06/29/23, at 9:00 A.M., a side rail was in the upright position. The resident was resting with his/her eyes closed; -On 06/30/23, at 10:00 A.M., a side rail was in the upright position. The resident read a newspaper in bed. The resident said that he/she utilized the side rail to assist with positioning and transfers. He/she said that staff had him/her sign some paperwork just yesterday about the side rail. Review of the resident's care plan, dated 05/24/23, showed staff did not care plan the use of side rails. On 06/29/23, at 9:10 A.M., review of the resident's EMR showed the following: -Side rail admission assessment completed by staff on 01/20/23; -Care plan did not include any information related to use of side rails; -Physician's order sheet did not include an order for side rails; -No informed consent or risk and benefit education located in the chart. During an interview on 06/29/23, at 10:00 A.M., the Maintenance Director said that he did not locate measurements for resident bed. 3. During an interview on 06/30/23, at 9:50 A.M., the MDS Coordinator said that bed rail assessments are completed on admission and quarterly. Staff does not put on or take off side rails without the therapy department's involvement. If a resident changes beds or rooms, he/she tries to stay on top of ensuring they have the changes. Resident #45 admitted on a weekend, and staff failed to get all the bed rail process in place. When bed rails are utilized a doctor's order should be in place and the information should be in the resident's care plan. 4. During an interview on 06/30/23, at 10:25 A.M., Licensed Practical Nurse (LPN) A said that side rail assessments are completed on resident admission and there is also a 90-day re-assessment. Staff send a notice to therapy after admission for side rail assessment. 5. During an interview on 06/30/23, at 10:50 A.M., Physical Therapist B said that therapy completes side rail assessments on resident admission and on staff request when according to resident needs. 6. During an interview on 06/30/23, at 12:40 P.M., with the Administrator and the Director of Nursing (DON), the DON said that if a side rail is needed, staff should notify therapy for resident evaluation. When therapy states that the resident is okay for side rail use, then an order should be sent to maintenance to install the side rail. The information should then added to the physician's order, the care plan, and consent forms are completed. Resident side rail assessments should be completed at admission and on a quarterly basis. She was unsure why the residents' had not been completed.

Based on observation, interview, and record review, the facility failed to ensure all residents were cared for in manner that provided dignity and respect when staff failed to ensure catheter (tubing to drain the bladder) collection bags were placed inside a dignity bag (bag which prevents urine from being seen) for one resident (Resident #42). A sample of three residents with indwelling catheters was reviewed. The facility census was 60. Review of a facility policy entitled Urinary Catheterization, revised 08/2022, showed the policy did not include information pertaining to the use of a privacy bag for dignity. 1. Review of Resident #42's face sheet (a form that provides basic profile information) showed the following: -admitted [DATE]; -Diagnoses included urinary tract infection (UTI), prostate cancer, obstructive and reflux uropathy (prevents normal emptying of the bladder), and bladder infection. Review of the resident's significant change Minimum Data Set (MDS - a federally mandated assessment tool completed by facility staff), dated 06/13/23, showed the following: -Severely impaired cognition; -Required extensive assistance for bed mobililty; -Dependent on staff assistance for transfers, dressing, personal hygiene, and bathing. Review of the resident's care plan, last updated 06/13/23, showed the following: -admitted to the facility with Foley (type of catheter) in place for diagnosis of urinary retention. Catheter inserted on 05/14/21 while at hospital; -Trialed removal of catheter and within 12 hours had experienced pressure/lower quadrant. Staff reinserted the Foley. Observation on 06/27/23, at 9:44 A.M., showed the resident sat in a wheelchair in his/her room. A catheter collection bag hung under the resident's wheelchair without a dignity cover. Yellow urine was visible to the roommate and from the hallway. Observation on 06/27/23, at 1:29 P.M., showed a therapist pushed the resident's wheelchair down the hall away from the resident's room. A catheter collection bag hung under the wheelchair without a dignity cover. Yellow urine was visible to anyone facing the resident. Observation on 06/27/23, at 2:00 P.M., showed a therapist pushed the resident's wheelchair down the hall toward the resident's room. A catheter collection bag hung under the wheelchair without a dignity cover. Yellow urine was visible to anyone facing the resident. Observation on 06/30/23, at 9:00 A.M., showed the resident sat at a dining room table with two other residents. A catheter collection bag hung under the resident's wheelchair without a dignity cover. Yellow urine was visible to anyone who was more than a few feet away from the table and facing either side or the front of the resident. Observation on 06/30/23, at 9:30 A.M., showed a certified nurse aide (CNA) pushed the resident's wheelchair from the dining room toward the resident's room. A catheter collection bag hung under the resident's wheelchair without a dignity cover. Yellow urine was visible to anyone facing the resident or positioned to his/her side. During an interview on 06/30/23, at 10:41 A.M., CNA E said the catheter collection bag should be covered with the attached flap for dignity. During an interview on 06/30/23, at 10:46 A.M., CNA G said the catheter bag should be covered for dignity, with either the attached flap or by putting it in a pillowcase or something for privacy. During an interview on 06/30/23, at 10:48 A.M., Licensed Practical Nurse (LPN) A said staff should use the attached flap to ensure privacy. If a resident comes in with a non-covered bag, staff should tell the nurse so they can switch out the bag. The facility did not have separate dignity covers to use. LPN A was unaware that the resident's catheter bag was not covered. During an interview on 06/30/23, at 12:40 P.M., the Administrator and the Director of Nursing (DON) said catheter bags should be covered for dignity. The bags they use in the facility have an attached flap cover. If a resident comes in with a catheter without the attached dignity cover, the nurse should change out the catheter collection bag.

Based on interview and record review, the facility failed to consistently monitor pressure ulcers and failed to document routine thorough wound assessments two residents (Resident #1 and #2). The facility census was 58. Record review of the U.S. Department of Health and Human Services Clinical Practice Guidelines, Number 15, treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] -Assess the pressure ulcer initially for location, stage, size, tracts, exudate (any fluid that has been forced out of the tissues or its capillaries because of inflammation or injury), necrotic tissue (death of tissue in response to disease or injury), and presence or absence of granulation tissue (formation of new tissue, usually pink to red in color) and epithelialization (healing by the growth of epithelium over a denuded surface); -To monitor progress or deterioration, the examiner must accurately measure the length, width, and depth of the ulcer; -Reassess pressure ulcers at least weekly; -Indicators of a deteriorating pressure ulcer include increases in exudate and wound [CONDITION(S)] (swelling or puffiness from fluid), loss of granulation tissue, and a purulent (containing pus) discharge; -A clean pressure ulcer should show evidence of some healing within two to four weeks. If no progress can be demonstrated, reevaluate the adequacy of the overall treatment plan as well as adherence to this plan, making modifications as necessary. Record review of the facility's policy, revised 8/2021, Pressure Ulcer/Wound, Assessment and Treatment, showed the following information: -The skin assessment procedure in long term care includes the skin risk assessment score will be documented by nursing on the admission assessment; -Basic skin assessment is completed on residents weekly; -For pressure ulcer staging, stage according to pressure ulcer/wound stage description, measure size of pressure ulcer/wound in centimeters to include length x width x depth, and document this in the electronic medical record; -Document the assessment of wounds that require treatment in the Wound Assessment Intervention once per shift and as needed; -Document the actual treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . 1. Record review of Resident #1's medical record showed the following information: -An admitted [DATE]; -A discharge date of [DATE]; -diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the resident's nursing admission note, dated 5/5/22, showed the following: -The resident arrived to the facility at approximately 9:15 P.M.; -The resident had a small red area to left buttocks that measured 0.5 centimeters (cm) X 0.5 cm; -An order was placed for calazinc (a protectant that helps to prevent skin irritation). Record review of the resident's physician orders, dated 5/5/22, showed the following: -An order to clean red area to left buttocks, pat dry, apply [MEDICATION(S)] (a cream that protects skin from wetness, urine, or stools) every shift and as needed until resolved. Record review of the resident's care plan, start date 5/6/22, showed the following information: -admitted to facility with [CONDITION(S)]; -Monitor for signs and symptoms of infection and notify physician if no noted improvement. (The resident's care plan did not mention impaired skin integrity.) Record review of the resident's comprehensive admission Minimum Data Set (MDS - a federally required assessment tool completed by facility staff), dated 5/11/22, showed the following information: -The resident was severely cognitively impaired; -The resident was at risk for developing pressure ulcers; -The resident had no pressure ulcers upon admission or during the assessment period; -The resident had moisture associated skin damage upon admission or during the assessment period; -The resident required extensive assistance of two staff for bed mobility. Record review of the resident's History and Physical, dated 5/11/22, showed the following: -The resident was hospitalized and found to have [CONDITION(S)] (irregular heartbeat) and [CONDITION(S)], and treated with oral [MEDICATION(S)] (antiinfective medication); -The resident's skin assessment showed scattered resolving bruising on bilateral (both sides) upper extremities from IV (access to vein) sticks, chronic discoloration of both lower extremities, scab on right posterior foot, and right wrist in splint and not removed. Record review of the resident's physician orders, dated 5/23/22, showed the following: -An order to clean wounds to left, medial, right buttocks every shift, pat dry, apply skin prep around wound, allow to air dry, apply [MEDICATION(S)] (a highly absorbent non-woven pad used to absorb wetness from wounds) to open areas only and cover with [MEDICATION(S)] (adhesive foam dressing). Staff to monitor dressing every shift. Record review of the resident's May 2022 Treatment Administration Record (TAR) showed the following: -The right buttocks wound was assessed with [MEDICAL RECORD OR PHYSICIAN ORDER] (Staff did not document a measurement or description of the wound.) Record review of the resident's medical record showed no other wound assessments or measurements by staff documented between 5/5/22 and 5/24/22. Record review of the resident's wound assessment, dated 5/24/22, showed the resident had a stage 2 pressure ulcer (an open wound characterized by partial thickness skin loss into but no deeper than the dermis, the layer of skin between the epidermis and subcutaneous tissues) to the right buttocks. (Staff did not document measurements or detailed description of the wound.) Record review of the resident's medical record showed staff did not document any additional wound assessments between 5/24/22 and 5/29/22 (discharge date ). Record review of the resident's nurses' notes showed staff did not document any changes or measurements of the resident's right buttock wound after the 5/5/22 initial nursing assessment note. During an interview on 6/1/22, 3:00 P.M., the Director of Nursing (DON), said the following: -The DON was not aware that the resident had gangrene of his wound. That diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] -The resident was admitted with a wound on his/her buttocks. -Licensed Practical Nurse (LPN) B had been doing the resident's dressing changes; -There had been no weekly wound assessments with measurements documented for the resident's buttock wound. During an interview on 6/1/22, at 1:59 P.M., the MDS Coordinator said the following: -The resident came to the nursing home facility positive for [CONDITION(S)]; -The MDS Coordinator said he/she did not lay eyes on the resident's buttock wound on admission; -The resident's buttocks wound may have just been reddened like the nurses' notes showed. During an interview on 6/1/22, at 3:24 P.M., Registered Nurse (RN) A said the following: -The resident's wound order was for [MEDICATION(S)] cream, but that on 5/23/22 RN A changed the treatment order to something more appropriate. At that time the resident's buttock wound was an open wound; -RN A notified the doctor and DON when he/she changed the treatment order. RN A said it was a standing treatment order. During an interview on 6/1/22, at 4:42 P.M., Certified Nurse Aide (CNA) C said the following: -The resident had a change in condition about a week ago when CNA C was caring for the resident on the floor.; -CNA C noticed a change in the resident's skin. The resident's buttock wound appeared bigger and darker in color but not black; -CNA C reported the wound change to a night shift nurse. 2. Record review of Resident #2's medical record showed the following information: -admitted [DATE]; -diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the resident's Significant Change of Status Minimum Data Set (MDS- a federally required assessment of the resident), dated 4/13/22, showed the following information: -Cognitively intact; -At risk for developing pressure ulcers; -Stage 4 pressure ulcer; -Dependent on two staff members for bed mobility. Record review of the resident's care plan, last reviewed 4/14/22, showed the following information: -The resident had a stroke in 2012 that left him/her with left-sided weakness; -The resident has a stage 4 pressure ulcer to his/her intergluteal cleft (the groove between the buttocks that runs from just below the sacrum to the perineum). Record review of the resident's TAR, dated 4/19/22, showed the following: -Staff documented the wound was getting bigger and deeper. (Staff did not document any other details, measurements, or other assessments.) Record review of the resident's wound assessment, dated 4/28/22, showed the following information: -Acquired Stage 4 intergluteal cleft pressure ulcer; -The resident has presence of pain to the pressure ulcer; -Wound appearance is reddened, slough; -Wound surrounding tissue appearance is blanched (tissue becomes white with pressure)/dull, tunneling (a wound that develops into passageways beneath the skin); -Moderate wound drainage that is yellow. (Staff did not document measurements of the wound.) Record review of the resident's medical record showed staff did not document a detailed wound assessments with measurements between 4/1/22 and 4/28/22. Record review of the resident's TAR, dated 05/08/22, showed the following: -Staff documented the wound looked deeper. (Staff did not document any other details, measurements, or other assessments.) Record review of the resident's wound assessment, dated 5/12/22, showed the following information: -Acquired Stage 4 intergluteal cleft pressure ulcer; -The resident has presence of pain to the pressure ulcer; -Wound appearance is reddened, slough; -Wound surrounding tissue appearance is blanchable/dull, tunneling; -Moderate wound drainage that is yellowish/bloody. (Staff did not document measurements of the wound.) Record review of the resident's medical record showed no detailed wound assessments with measurements were done between 4/28/22 and 5/12/22. Record review of the resident's wound assessment, dated 6/3/22, showed the following information: -Stage 3 (full-thickness loss of skin, in which subcutaneous fat may be visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present.) intergluteal cleft pressure ulcer that measures 6 cm x 4 cm x 3 cm; -The resident has presence of pain to the pressure ulcer; -Wound appearance is bleeding. Record review of the resident's medical record showed no detailed wound assessments with measurements were done between 5/12/22 and 6/3/22. 3. During an interview on 6/1/22, at 3:24 P.M., RN A said the following: -With a change in condition of a wound, the nurse assesses the resident, applies a new wound dressing, and notifies the DON, doctor, and family; -The nursing staff monitor residents for change of condition of wounds. 4. During interviews on 6/1/22, at 3:00 P.M., and on 6/22/22, at 10:01 A.M., the DON said the following: -The wound nurse quit several months ago; -The MDS Coordinator had done some wound assessments with measurements documented since the wound nurse left; -LPN B was doing the skin assessments, but LPN B had just now started doing them this week; -The facility had a lot of agency nurses that typically did not document well. 5. During an interview on 6/7/22, at 1:22 P.M., the Administrator, DON, MDS Coordinator, and Facility Nurse Practitioner said the following: -The charge nurse should do an assessment of the skin/wound with approximate measurements with a ruler, contact the doctor for orders, and change the treatment order per the doctor; -The facility was currently training LPN B in the wound nurse position; -The facility had not had any one person doing weekly wound assessments, wound monitoring, or wound measurements; -The MDS Coordinator said he/she had done some wound measurements here and there; -The MDS Coordinator said he/she had never done weekly wound assessments, monitoring, or measurements on any residents. MO 894

Based on interview and record review, the facility staff failed to notify one resident's (Resident #1) family of a change of condition of a wound. The facility census was 58. Record review of a facility's policy titled, Changes in Resident Condition, Notification Guidelines, revised August 2020, showed the following information: -Physicians, residents, hospice when applicable, and families will be notified in a timely manner of changes in clinical conditions and environmental changes affecting the resident; -When resident changes are noted facility staff will notify the following: resident's physician, resident, legal representative (if resident is incompetent) and/or interested family member; -Notification will occur as soon as possible when there is: an accident or injuring involving the resident, a significant change in the resident's physical, mental, or psychosocial status, deterioration in health, mental, and/or psychosocial status in either life-threatening conditions or clinical complications (conditions or clinical complications may include but are not limited to development of a stage two pressure sore, onset or recurring periods of [CONDITION(S)], recurrent urinary tract infection or onset of symptoms of depression), the need to alter treatment significantly including but not limited to a need to discontinue an existing form of treatment due to adverse consequence or to commence a new form of treatment. 1. Record review of Resident #1's medical record showed the following information: -An admitted [DATE]; -A discharge date of [DATE]; -diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the resident's nursing admission note, dated 5/5/22, showed the resident arrived to the facility at approximately 9:15 P.M. The resident had a small red area to left buttocks that measured 0.5 centimeter (cm) X 0.5 cm. An order was placed for calazinc (a protectant that helps prevent skin irritation) Record review of the resident's physician order, dated 5/5/22, showed the following: -An order to clean red area to left buttocks, pat dry, apply [MEDICATION(S)] (a cream that protects skin from wetness, urine, or stools) every shift and as needed until resolved. Record review of the resident's care plan, start date 5/6/22, showed the following information: -admitted to facility with [CONDITION(S)]; -Monitor for signs and symptoms of infection, and notify physician if no noted improvement. Record review of the resident's comprehensive admission Minimum Data Set (MDS - a federally required assessment tool completed by facility staff), dated 5/11/22, showed the following information: -The resident was severely cognitively impaired; -The resident was at risk for developing pressure ulcers; -The resident had no pressure ulcers upon admission or during the assessment period; -The resident had moisture associated skin damage upon admission or during the assessment period; -The resident required extensive assistance of two staff for bed mobility. Record review of the resident's physician order, dated 5/23/22, showed the following: -An order to clean wounds to left, medial, right buttocks every shift, pat dry, apply skin prep around wound, allow to air dry, apply [MEDICATION(S)] (a highly absorbent non-woven pad used to absorb wetness from wounds) to open areas only and cover with [MEDICATION(S)]. Monitor dressing every shift. Record review of the resident's wound assessment, dated 5/24/22, showed the resident had a stage 2 pressure ulcer (an open wound characterized by partial thickness skin loss into but no deeper than the dermis, the layer of skin between the epidermis and subcutaneous tissues) to the right buttocks. Record review of the resident's nurses' notes showed staff did not document notifying the resident's family regarding the change of the right buttock wound or the change in treatment. During an interview on 6/1/22, at 3:00 P.M., the Director of Nursing (DON) said he/she was unsure if Registered Nurse (RN) A notified family when the resident's right buttock treatment changed on 5/23/22. During an interview on 6/1/22, 3:24 P.M., RN A said the following: -With change of condition of a wound the nurse should assess the resident, do a new wound dressing, and notify the DON, doctor, and family of the change. -He/she did not remember calling the resident's family about the new wound order; During an interview on 6/1/22, at 3:53 P.M., Licensed Practical Nurse (LPN) B said the following: -Family are notified of a resident's change in condition once orders are received from the doctor; -LPN B was unsure if the resident's family was notified of his change of condition of the his wound/wound treatment. During an interview on 6/7/22, at 11:09 A.M., the Social Service Director (SSD) said the following: -Nurses are supposed to notify family of change in condition, including wound appearance changes and wound treatment changes; -The SSD did not recall anything about the resident's wounds or any change of condition in them; -The SSD did not know if the resident's wound change of condition was reported to the family. During an interview on 6/7/22, at 1:22 P.M., the Administrator, DON, MDS Coordinator, and Facility Nurse Practitioner, said the following: -The charge nurse should do an assessment of the skin/wound and get approximate measurements, contact the doctor for orders, change the treatment order per the doctor, then notify the family of the change of condition and new treatment order; -The DON said the resident's buttock wound appeared to have changed from admission to discharge; -Family notification should always be documented; -The DON said he/she expects family/responsible party to be notified with any wound treatment changes, including the wound treatment change for the resident on 5/23/22. MO 894

Based on interview and record review, the facility failed to ensure their policies and procedures included all required parts when the facility policy did not include a process to ensure the implementation of additional precautions, intended to mitigate the transmission and spread of COVID-19 (a highly contagious virus that causes serious illness or death), for staff not fully vaccinated for COVID-19. The facility census was 58. 1. Record review of the facility's matrix showed the following: -Thirty-seven vaccinated staff; -Thirty-four staff with religious or medical exemptions. During an interview on 4/6/22, at 9:30 A.M., the Administrator said there had been no positive COVID cases in the prior four weeks. Record review of the facility's COVID-19 policies showed the policies did not address what additional precautions were in place to mitigate the spread of COVID-19 for staff there were not fully vaccinated for COVID-19. During an interview on 4/6/22, at 11:20 A.M., the Business Office Manager (BOM) said there is no policy for non-vaccinated staff to do any additional precautions. During an interview on 4/6/22, at 4:08 P.M., Certified Nurse Assistant, (CNA) A said the following: -If a staff member is not vaccinated or have their boosters, staff have to wear goggles and N-95 mask, they think; -This just started today and doesn't know if this is policy. During an interview on 4/6/22, at 4:25 P.M., Licensed Practical Nurse (LPN) B said the following: -If a staff member has not been vaccinated or is vaccinated without a booster, staff gets tested on e time a week and wear a surgical mask unless the county rate goes higher. During an interview on 4/6/22, at 4:39 P.M., Registered Nurse (RN) C said the following: -There is nothing additional unvaccinated staff are doing that is different from vaccinated staff. During an interview on 4/6/22, at 4:53 P.M., CNA D said the following: -Unvaccinated staff are wearing goggles and N-95 mask and this started today; -Before today, all staff was wearing a surgical mask if they wanted and not wearing goggles. During an interview on 4/6/22, at 5:02 P.M., the Administrator said the following: -There is no policy that says unvaccinated staff have to do any additional precautions compared to vaccinated or staff that has their boosters; -The facility's policies are written by their home office.

Based on interview and record review, the facility failed to protect residents from misappropriation of property when staff discovered missing doses of controlled medications which were replaced with another medication while in the possession of the facility for seven residents (Resident #1, #2 #3, #4, #5, #6, and #7). The facility census was 58. The administrator and Director of Nursing (DON) were notified on 06/11/21, of the Past Non-Compliance which was discovered on 6/11/21. Facility staff notified the Department of Health and Senior Services (DHSS) of the noncompliance, started an investigation, and began in-servicing licensed staff who were involved in medication pass and medication storage. In-services were finished on 06/15/21. The noncompliance was corrected 6/15/21. Record review of the facility's policy titled, Controlled Substances - Ordering and Distribution, last revised 10/2019, showed the following: -Purpose to provide for proper storage, ordering, delivery and administration of controlled substance throughout the organization; -Purpose to maintain optimal quality control over high-risk substances and to prevent diversion; -Any controlled substances not stored in the automated dispensing cabinet will be counted at the change of shift by both the licensed nurse leaving the shift and the nurse coming on duty. Both nurses must sign the narcotic inventory sheet thereby verifying that the count is correct; -Whenever staff discover an irregularity, example tampering with the controlled substances, they are responsible for immediately notifying the supervisor and/or the director of pharmacy; -The medications involved will be segregated pending further investigation. An event report shall be generated to document investigation findings; -A significant loss of drugs or theft will be reported by the director of pharmacy to the chief executive officer and the nearest drug enforcement administration office. Record review showed the facility did not provide a copy of the facility's policy regarding misappropriation. 1. During a phone interview on 8/12/21, at 3:32 P.M., Registered Nurse (RN) D said the following: -On 6/11/21, between 2:00 A.M. and 5:00 A.M., he/she went to administer a scheduled [MEDICATION(S)] (a narcotic pain medication used to treat moderate to severe pain) for Resident #5 and noticed the medication was a smaller size and different from the other [MEDICATION(S)] in that particular card; -He/she showed Registered Medication Technician (RMT) B Resident #5's narcotic card and they both noticed the card was taken apart around the bottom edge of the card; -He/she and RMT B started a count of narcotics and noticed Resident #6's [MEDICATION(S)] was smaller and different and notified the DON . During interviews on 8/12/21, at 11:12 A.M., and 8/13/21, at 10:19 A.M., RMT B said the following: -On 6/11/21, at 5:00 A.M., he/she came into the facility for his/her shift. RN D noticed a [MEDICATION(S)] pill was small and the card had been pulled apart at the bottom and up the right side of the card. The pill had been taken out and replaced with a blood pressure pill; -He/she noticed Resident #6's [MEDICATION(S)] card had been tampered with along the bottom and up the right side. The [MEDICATION(S)] had been replaced with a blood pressure medication; -RN D notified the Director of Nursing (DON) and administrator. The DON and administrator arrived to the facility within two hours to investigate the tampered medications; -The DON and administrator took the narcotic cards out of both medication carts and to the board room; -The Nurse Practitioner, DON, and administrator looked at each card to compare medications. During an interview on 8/13/21, at 12:39 P.M., the DON said on 6/11/21, at 5:00 A.M., Resident #5 requested a pain pill and RN D noticed the pill looked different. Record review of the facility's investigation for narcotic discrepancy, dated 6/11/21, completed by the facility DON and received in the Department of Health and Senior Services (DHSS) office on 6/15/21, at 2:28 P.M., showed the following: -The DON interviewed residents and nurses if they ever witnessed a staff member doing anything that would harm a resident or suspected a nurse or medication technician of stealing medications; -The DON, pharmacist, and nurse practitioner reviewed the records of all residents with missing narcotics and compared the narcotic count sheets to the medication bubble pack; -The facility staff informed the resident, responsible parties, and physicians of the missing narcotics. 2. Record review of Resident #1's face sheet (admission data) showed the resident admitted to the facility on [DATE]. Record review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff), dated 6/8/21, showed the following information: -Cognitively intact; -diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] -He/she received scheduled and as needed pain medications; -He/she had pain frequently; -Pain limited his/her day to day activities. Record review of the resident's physician order, dated 3/9/21, showed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the resident's June 2021 medication administration records (MAR) showed an order, dated for 3/9/21, for [MEDICATION(S)] 5 mg by mouth, one tablet every six hours as needed for pain. Record review of the resident's two narcotic count sheets, dated 6/7/21, showed the following: -A page for the resident's [MEDICATION(S)] 5-325 mg with directions to administer one tablet by mouth every six hours for pain. Staff signed tabs 60 through 44 administered; -The final entry on the narcotic count sheet showed on 6/11/21, at 4:50 A.M., a nurse signed administration of the medication. Record review, interview, and observation with the DON on 8/13/21, at 12:41 P.M., of the resident's two narcotic bubble pack cards, dated 6/7/21, showed the following: -[MEDICATION(S)] 5/325 with directions to administer one tablet by mouth every six hours for pain showed the [MEDICATION(S)] to be replaced with four Tylenol pills; -[MEDICATION(S)] 5/325 with directions to administer one tablet by mouth every six hours for pain showed the [MEDICATION(S)] to be replaced with 26 Tylenol pills; -On 6/11/21, while reviewing this resident's narcotic count sheets and searching for the medication, the facility staff discovered the resident's 4 tablets on one card and 26 tablets on another card of [MEDICATION(S)] were replaced with Tylenol. During a phone interview on 8/13/21, at 12:01 P.M., the pharmacist said the following: -On 6/11/21, while reviewing this resident's narcotic count sheets and searching for the medication, the facility staff discovered the resident's 4 tablets on one card and 26 tablets on another card of [MEDICATION(S)] were replaced with Tylenol. 3. Record review of Resident #2's face sheet showed the resident was admitted on [DATE]. Record review of the resident's quarterly MDS, dated [DATE]. showed the following: -Severe cognitive impairment; -diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] -He/she received scheduled and as needed pain medications; -He/she had pain almost constantly; -Pain limited his/her day to day activities. Record review of the resident's physician order, dated 3/18/21, showed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the resident's June 2021 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the resident's narcotic count sheet, dated 6/8/21, showed: -A page for the resident's [MEDICATION(S)] 5-325 mg with directions to administer one tablet by mouth every four hours for pain; -The final entry on the narcotic count sheet showed on 6/11/21, at 1:45 A.M., a nurse signed administration of the medication. Record review, interview, and observation with the DON on 8/13/21, at 12:41 P.M., of the resident's narcotic bubble pack card, dated 6/7/21, showed the following: -[MEDICATION(S)] 5/325 with directions to administer one tablet by mouth every six hours PRN for pain (direction to refer to MAR for change to every four hours) showed the [MEDICATION(S)] to be replaced with 22 Tylenol; -On 6/11/21, while reviewing this resident's narcotic count sheets and searching for the medication, the facility staff discovered the resident's 22 tablets on the card to be Tylenol instead of the ordered [MEDICATION(S)]. During a phone interview on 8/13/21, at 12:01 P M., the pharmacist said the following: -On 6/11/21, while reviewing this resident's narcotic count sheets and searching for the medication, the facility staff discovered the resident's 22 tablets on the card to be Tylenol instead of the ordered [MEDICATION(S)]. 4. Record review of Resident #3's face sheet showed the resident admitted to the facility on [DATE]. Record review of the resident's physician order, dated 5/20/21, showed the following: -an order for [MEDICAL RECORD OR PHYSICIAN ORDER] -an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the resident's quarterly MDS, dated [DATE], showed the following: -Severe impaired cognition; -diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] -He/she received scheduled pain medication; -He/she showed no pain presence. Record review of the resident's June 2021 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] -An order, dated 5/20/21, for [MEDICATION(S)] 5/325 mg one tablet every six hours PRN; -An order, dated 5/20/21, for [MEDICATION(S)] 5/325 mg one tablet two times per day. Record review of the resident's narcotic count sheet, dated 5/21/21, showed the following: -A page for the resident's [MEDICATION(S)] 5-325 mg with directions to administer one tablet by mouth two times daily and one tablet every six hours as needed; -The final entry on the narcotic count sheet showed on 6/10/21, at 6:18 P.M., a RMT signed administration of the medication. Record review, interview, and observation with the DON on 8/13/21, at 12:41 P.M., of the resident's narcotic bubble pack card, dated 5/21/21, showed the following: -[MEDICATION(S)] 5/325 with directions to administer one tablet by mouth BID and one tablet every six hours PRN. [MEDICATION(S)] showed to be replaced with two potassium pills; -On 6/11/21, while reviewing this resident's narcotic count sheets and searching for the medication, the facility staff discovered the resident's two tablets on the card to be potassium instead of the ordered [MEDICATION(S)]. During a phone interview on 8/13/21, at 12:01 P.M., the pharmacist said the following: -On 6/11/21, while reviewing this resident's narcotic count sheets and searching for the medication, the facility staff discovered the resident's two tablets on the card to be potassium instead of the ordered [MEDICATION(S)]. 5. Record review of Resident #4's face sheet showed the resident admitted to the facility on [DATE]. Record review of the resident's annual MDS assessment, dated 7/27/21, showed the following: -Cognitively intact; -diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] -He/she received scheduled pain medications; -He/she showed no pain presence. Record review of the resident's physician order, dated 8/12/20, showed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the resident's June 2021 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the resident's narcotic count sheet, dated 8/12/20, showed the following: -A page for the resident's [MEDICATION(S)] 5-325 mg with directions to administer one tablet by mouth every six hours as needed for moderate to severe pain; -The final entry on the narcotic count sheet showed on 6/4/21, at 1:26 P.M., a RMT signed administration of the medication. Record review, interview, and observation with the DON on 8/13/21, at 12:41 P.M., of the resident's narcotic bubble pack card, dated 8/12/20, showed the following: -[MEDICATION(S)] 5/325 with directions to administer one tablet by mouth every six hours PRN for moderate to severe pain. [MEDICATION(S)] showed to be replaced with three potassium pills; -On 6/11/21, while reviewing this resident's narcotic count sheets and searching for the medication, the facility staff discovered the resident's three tablets on the card to be potassium instead of the ordered [MEDICATION(S)]. During a phone interview on 8/13/21, at 12:01 P.M., the pharmacist said the following: -On 6/11/21, while reviewing this resident's narcotic count sheets and searching for the medication, the facility staff discovered the resident's three tablets on the card to be potassium instead of the ordered [MEDICATION(S)]. 6. Record review of Resident #5's face sheet showed the resident admitted to the facility on [DATE]. Record review of the resident's quarterly MDS, dated [DATE], showed the following: -Cognitively intact; -diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] -He/she received scheduled pain medications; -He/she had pain occasionally. Record review of the resident's physician order, dated 6/15/20, showed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the resident's June 2021 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the resident's narcotic count sheet, dated 5/21/21, showed the following: -A page for the resident's [MEDICATION(S)] 10-325 mg with directions to administer one tablet by mouth every six hours as needed for pain; -The final entry on the narcotic count sheet showed on 6/11/21, at 1:55 A.M., a nurse signed administration of the medication. Observation and interview with the resident on 8/12/21, at 2:59 P.M., showed the following:-He/she received scheduled pain medications which help with pain; -In June 2021, he/she could tell a difference that his/her pain level increased; -His/her pain level is better now. Record review, interview, and observation with the DON on 8/13/21, at 12:41 P.M., of the resident's narcotic bubble pack card, dated 5/21/21, showed the following: -[MEDICATION(S)] 10/325 with directions to administer one tablet by mouth every six hours PRN for pain. [MEDICATION(S)] showed to be replaced with ten pills of Hyzarr (medication to treat high blood pressure); -On 6/11/21, while reviewing this resident's narcotic count sheets and searching for the medication, the facility staff discovered the resident's ten tablets on the card to be Hyzarr instead of the ordered [MEDICATION(S)]. During a phone interview on 8/13/21, at 12:01 P.M., the pharmacist said the following: -On 6/11/21, while reviewing this resident's narcotic count sheets and searching for the medication, the facility staff discovered the resident's ten tablets on the card to be Hyzarr instead of the ordered [MEDICATION(S)]. 7. Record review of Resident #6's face sheet showed the resident admitted to the facility on [DATE]. Record review of the resident's quarterly MDS, dated [DATE], showed the following: -Cognitively intact; -diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] -He/she received scheduled and as needed pain medications; -He/she had pain frequently. Record review of the resident's physician order, dated 11/13/20, showed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the resident's June 2021 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the resident's narcotic count sheet, dated 3/15/21, showed the following: -A page for the resident's [MEDICATION(S)] 10-325 mg with directions to administer one tablet by mouth every six hours as needed for kidney cancer pain; -The final entry on the narcotic count sheet showed on 6/10/21, at 7:35 P.M., a RMT signed administration of the medication. Record review, interview, and observation with the DON on 8/13/21, at 12:41 P.M., of the resident's narcotic bubble pack card, dated 3/15/21, showed the following: - [MEDICATION(S)] 10/325 with directions to administer one tablet by mouth every six hours PRN for kidney cancer pain. [MEDICATION(S)] showed to be replaced with 10 pills of Hyzarr; -On 6/11/21, while reviewing this resident's narcotic count sheets and searching for the medication, the facility staff discovered the resident's ten tablets on the card to be Hyzarr instead of the ordered [MEDICATION(S)]. During a phone interview on 8/13/21, at 12:01 P.M., the pharmacist said the following: -On 6/11/21, while reviewing this resident's narcotic count sheets and searching for the medication, the facility staff discovered the resident's ten tablets on the card to be Hyzarr instead of the ordered [MEDICATION(S)]. During an interview on 8/12/21, at 11:54 A.M., the resident said the following:-He/she asked RMT F a few months ago on two or three occasions of the difference in how the pain pill looked. RMT F said the pain pill was made different. The pain medication did not help with his/her pain on those occasions; -RMT F gave him/her round pills, but the medication he/she took should had been oval and white. 8. During interviews on 8/12/21, at 10:35 A.M., and 8/13/21, at 10:17 A.M., RMT A said the following: -Narcotic counts are counted before and after shift; -Staff should report to their supervisor if a narcotic count is not correct or a card is tampered with; -He/she would consider tampering and replacing medications in a narcotic card misappropriation. 9. During interviews on 8/12/21, at 11:12 A.M., and 8/13/21, at 10:19 A.M., RMT B said the following:-Staff are to count the narcotic cards each shift change; -He/she had never seen medications tampered with until on 6/11/21; -This is a misappropriation of property; -Staff should never open a narcotic card and replace the medication with another medication; -Staff should report immediately to the charge nurse of a tampered card or different pill in the card. 10. During an interview on 8/12/21, at 1:01 P.M., the DON said the following:-On 6/11/21, the pharmacist audited the narcotic cards and nurses' locked box; -Staff reviewed each individual card and performed a reference check and determined the incorrect pills for the seven residents named; -Staff audited and found the medications were replaced with a similar color and shape but the markings and size were different. 11. During an interview on 8/12/21, at 3:16 P.M., Licensed Practical Nurse (LPN) C said the following: -Nursing staff are to count the medication carts each shift change; -He/she has never seen a narcotic count off; -He/she has never seen tampered narcotic cards. 12. During an interview on 8/13/21, at 10:36 A.M., LPN E said the following:-Staff should count and check to make sure no pills are missing or tampered at each shift change; -If there is a tampered card, the DON is notified; -He/she would consider this misappropriation if a card is tampered with or pills are replaced. 13. During a phone interview on 8/13/21, at 12:01 P.M., the pharmacist said the following: -Nursing staff should do narcotic counts before and after each shift; -Staff should sign out a medication whenever they dispense a controlled drug; -He/she inspects the narcotics every month at the facility; -This incident happened between one of his/her inspections; -On 6/11/21, he/she came to the facility and did an audit on the narcotic cards; -On 6/11/21, he/she looked at each of the seven residents' cards and determined the pills were not what they were suppose to be; -It looked like the bottom of the card was tampered; -He/she determined the incorrect pills for the residents named with a pharmacy resource he/she utilized. 14. During an interview on 8/13/21, at 12:39 P.M., the DON said the following: -If the count is off, he/she is to be notified; -If the card is tampered with, he/she is to be notified; -Medication technicians should notify the charge nurse if a narcotic count or card is tampered with. 15. During an interview on 8/13/21, at 1:34 P.M., the administrator said the missing narcotics were never found. MO 924, MO 563, and MO 151

Based on observation, interview, and record review, the facility failed to adhere to professional standards when staff failed to properly disinfect glucometers (small hand-held devices that check blood glucose (sugar) levels for residents) while collecting blood glucose samples on residents with a [DIAGNOSES REDACTED]. This practice affected six residents (Resident #7, #10, #12, #19, #23, and #35) out of a sample of 16. The facility census was 61. Record review of the Centers for Disease Control and Prevention (CDC) website showed the following information: -Blood glucometers approved for use for more than one person must be cleaned and disinfected. The CDC investigated multiple outbreaks of [MEDICAL CONDITIONS] (disease affecting the liver) among residents in long-term care (LTC) communities that were attributed to shared devices and other breaks in infection-control practices related to blood glucose monitoring devices. When blood glucose monitoring devices are shared between individuals, there is a risk of transmitting [MEDICAL CONDITIONS] other blood borne pathogens. Record review of the facility's blood glucose monitoring policy, dated (MONTH) 2019, showed the following information: -Meter disinfection procedure: -Remove visible soiled and organic material prior to disinfecting. Meter is to be disinfected after each resident use; -Use a fresh bleach wipe to disinfect by gently wiping the outside of the meter display area three times horizontally and three times vertically and carefully wipe around the test port area, making sure no liquid enters the test strip port; -Ensure the surface of the meter remains damp for one minute; -Dry the meter thoroughly with a dry cloth. Visually verify that no solution is seen on the meter. Record review of the package label of orange-top Sani-Cloth Bleach Wipes (name brand of wipes) found on the medication carts showed the following: -For cleaning and decontaminating against HIV-1 (Aids virus - human immunodeficiency virus transmitted through direct contact [MEDICAL CONDITION]- infected body fluids), [MEDICAL CONDITION] virus (HBV - [MEDICAL CONDITION] that can cause [MEDICAL CONDITION] (a serious liver infection) and spread through bodily fluids), and [MEDICAL CONDITION] virus (HCV - causes [MEDICAL CONDITION] (a [MEDICAL CONDITION] infection that causes liver inflammation) and spread through contaminated blood), all blood and other body fluids must be thoroughly cleaned from surfaces and objects before disinfection by the germicidal wipe. Open, unfold, and use first germicidal wipe to remove heavy soil. Use second germicidal wipe to thoroughly wet surface. Allow to remain wet one minute, let air dry; -Use second germicidal wipe to thoroughly wet surface. Allow to remain wet one minute, let air dry; -Although efficacy at one minute contact time has been shown to be adequate against HIV-1, HBV, and HCV, this time is not sufficient for all organisms listed on this label. Therefore a four minute wet contact time must be used for TB ([MEDICAL CONDITION] - potentially serious infectious disease that mainly affects your lungs) and pathogenic fungi. 1. Record review of Resident #23's face sheet (general resident information) showed the following information: -admission date of [DATE]: -[DIAGNOSES REDACTED]. Record review of the resident's (MONTH) 2020 physician's orders [REDACTED]. 2. Record review of Resident #19's face sheet showed the following information: -admission date of [DATE]; -[DIAGNOSES REDACTED]. Record review of the resident's (MONTH) 2020 physician's orders [REDACTED]. 3. Record review of Resident #7's face sheet showed the following information: -admission date of [DATE]; -[DIAGNOSES REDACTED]. Record review of the resident's (MONTH) 2020 physician's orders [REDACTED]. 4. Observation on 1/9/2020, at 11:03 [NAME]M., showed Registered Nurse (RN) A performed a blood glucose test with the glucometer on Resident #10. RN A left the resident's room and placed the glucometer directly on top of the medication cart. RN A wiped the glucometer off on all sides with the disinfecting wipe for 20 seconds. The RN A did not wrap the glucometer with the wipe and let it remain wet. (The glucometer was not wet the required one minute.) Observation on 1/9/2020, at 11:20 [NAME]M., showed RN A performed a blood glucose test on Resident #23 with the same glucometer used on Resident #10. RN A wiped off all surfaces of the glucometer with the disinfecting wipe for 20 seconds and placed the glucometer directly on the medication cart. RN A did not wrap the glucometer with a wipe and let it remain wet. (The glucometer was not wet the required one minute.) During an observation on 1/9/2020, at 11:27 [NAME]M., RN A performed a blood glucose test on Resident # 19 with the glucometer that had been used on Resident #23. RN A sat the used glucometer directly on top of a box of gloves. RN A wiped off the glucometer for 15 seconds with the disinfecting wipe. RN A sat the glucometer back on top of a box of gloves. (The glucometer was not wet the required one minute.) Observation on 1/9/2020, at 11:29 [NAME]M., showed RN A performed a blood glucose test on Resident #7 with the glucometer used on Resident #19. RN A wiped the glucometer off on all sides with the disinfecting wipe for 25 seconds and placed the glucometer directly on the medication cart. RN A did not wrap the glucometer with a wipe and let it remain wet. (The glucometer was not wet the required one minute.) During an interview on 1/9/2020, at 4:36 P.M., RN A said the following: -For glucometer cleaning, nurses are to wipe the glucometer off after each use with a bleach wipe; -Afterwards, nurses usually wipe the front of it with an alcohol wipe in order to see the screen better; -Nurses then let the glucometer air dry, and that doesn't take long; -Staff get an in-service annually on the glucometers, which includes the cleaning process. 5. Record review of Resident #35's face sheet showed the following information: -admission date of [DATE]; -[DIAGNOSES REDACTED]. Record review of the resident's (MONTH) 2020 physician's orders [REDACTED]. 6. Observation on 1/9/2020, at 3:59 P.M., showed Licensed Practical Nurse (LPN) B performed a blood glucose test on Resident #12. LPN B wiped the glucometer off on all sides for five seconds with the disinfecting wipe. LPN B sat the glucometer directly on top of the medication cart. (The glucometer was not wet the required one minute.) During an observation and interview on 1/9/2020, at 4:30 P.M., LPN B performed a blood glucose test on Resident #35 using the same glucometer used on Resident #12. LPN B wiped the glucometer off for less than five seconds on the front and back portion of the glucometer. LPN B said the policy for glucometer cleaning was to use the Sani-Cloth Bleach wipes in between each resident. Nurses have to do three swipes on each side of the glucometer. The glucometer air dries in between times for about two minutes. If a glucometer is not cleaned properly, infection control is impaired. Staff receive training at the competency fair in July. The facility makes sure staff know how to use the glucometers. (The glucometer was not wet the required one minute.) 7. During an interview on 1/10/2020, at 1:38 P.M., the Director of Nursing (DON) said the following: -Facility policy is for staff to wipe the glucometer off with the bleach wipes in between uses; -Staff should wait one full minute before using the glucometer on another resident; -Staff should wipe off the front, back, and both sides as well; -The glucometer should remain wet for one minute. The bleach wipes are in an orange-top container; -Some nurses cover the glucometer for one minute with a wipe; -Staff education is provided on cleaning glucometers upon hire and are annually checked again; -RN C, present during the interview, said he/she agreed with what the DON had just said as far as glucometer cleaning was concerned.

Based on interview and record review, the facility failed to keep one resident (Resident #1) free from abuse when Certified Nurse Aide (A) touched the resident inappropriately and exposed his/her genitalia to the resident. The resident admitted to being scared and experiencing significant anxiety symptoms and feeling isolated after the incident. The CNA was charged with sexual misconduct. The facility census was 70. The Director of Nursing was notified on 3/1/19, at approximately 5:00 P.M., of the Immediate Jeopardy (IJ) Past Non-Compliance which occurred on 2/2/19. On 2/2/19, the administrator became aware of the violation of the facility's abuse/neglect policy. The staff member was suspended pending investigation and later terminated. The facility inserviced the staff on the abuse/neglect policy and procedures. The IJ was removed and corrected on 2/11/19. Record review of the facility's Patient Abuse/Neglect, Elder Abuse, and Persons with Disability, Abuse policy, last revised (MONTH) 2019, showed the purpose of the policy was the following: -To guide staff and any mandated reporter in identifying victims of abuse and provide a reporting mechanism in accordance with all local, state, and federal laws; -To provide safe and efficient care for the patients/residents; -To keep patients/residents free from abuse, mistreatment, and neglect. Record review of the appendices of the facility's Abuse/Neglect policy showed the following: -Sexual abuse is the misuse of a child/elder/disabled adult for sexual pleasure or gratification; -Examples of sexual abuse include, but are not limited to: fondling of genitals; oral, anal, or vaginal sex with a child or unwilling elder or disabled individual; child/elder prostitution; fording or persuading a child/elder to perform sexual acts; and sexual harassment, sexual coercion, or sexual assault. 1. Record review of Resident #1's face sheet (general resident information) showed the following: -admission date of [DATE]; -[DIAGNOSES REDACTED]. Record review of the resident's quarterly Minimum Data Set (MDS - a federally mandated resident assessment tool completed by facility staff), dated 12/26/18, showed the following: -Resident cognitively intact; -Resident frequently incontinent of urine; -Resident required limited assistance of one staff for transfers, walking, toileting, and personal hygiene; -Resident had no behaviors. Record review of the resident's nursing progress note dated 2/2/19, at 4:04 A.M., showed the following: -The resident called Licensed Practical Nurse (LPN) B into room. The resident asked if Certified Nurse Aide (CNA) A could hear him/her. The LPN said the CNA A was in the dirty utility room. The resident said he/she had a complaint. The resident said that CNA A had come into the resident's room and molested him/her. This nurse asked how and the resident stated CNA A put his/her mouth on his/her private parts, and attempted to expose his/her genitalia. Social Service Director (SSD) C called and asked to speak to the resident. A portable phone was taken to the resident. SSD C spoke to this nurse after speaking to the resident and gave this nurse instructions to call the police and have a rape kit done. The police department was notified at 3:00 A.M. The officer arrived 3:10 A.M. The officer gave this nurse instructions to have the resident sent to the hospital to have the rape kit done, and that officer would be taking bed sheets and other items off the bed for the investigation. The officer also asked for a copy of all video from the cameras. The ambulance was notified at 3:15 A.M. Record review of the resident's hospital physician note, signed on 2/2/19 at 6:16 A.M., showed the following: -The resident reports he/she was assaulted at the nursing home by a provider. The resident states the staff member penetrated his/her genitalia with his/her fingers, and had his/her mouth around his/her genitalia. The resident denies the staff member penetrated him/her with his/her genitalia. The resident is cooperative and anxious. The resident is tearful at times when describing his/her assault. Sexual assault kit was collected and provided to law enforcement. Record review of a police report dated 2/2/19, at 6:57 A.M., showed on 2/2/19, at approximately 2:58 A.M., an officer responded to the facility regarding a report of attempted rape of a resident by an employee. The nurse informed the officer the resident was aware of his/her surroundings. The officer met with the victim. The victim identified the CNA by his/her first name. The resident said he/she needed to go to the bathroom and he/she wasn't going to make it. The resident said CNA A came to help. The resident said CNA A put his/her fingers inside and mouth inside him/her. The CNA then pulled down his/her pants and showed the resident his/her genitalia. The resident said CNA A didn't stick or touch him/her with his/her genitalia, so he/she did not know if it was rape or not. Record review of the facility's incident investigation summary report showed on 2/2/19 an interview with Resident #3 showed the resident said CNA A has never done anything to him/her, but he/she is a little weirded out by the CNA, just a little uneasy. The resident thinks it is because it is at night, and there have been a few times where I have roused up, and CNA A would be standing there. Record review of a the facility's incident investigation summary showed an addendum dated 2/4/19 at 8:27 A.M.,that showed the following interview with Resident #1: -The resident said his/her call light was on. CNA A came in and answered the call light. The resident told CNA A that he/she had to go to the bathroom and he/she tried to help the resident up. CNA A had the resident grab his/her shoulders to help the resident up and CNA A put his/her hands around the resident and his/her hands kept moving down and they just kept roaming. The resident told CNA A that he/she couldn't get up. He/she told CNA A that he/she hurt and it was too late. The resident laid there and after about 15 minutes the CNA A stood him/her up, pulled down his/her incontinence brief, and that is when he/she started his/her routine. The resident thought that CNA A was just trying to check him/her from where he/she fell the other day, and the next thing the resident knew CNA A had his/her hands all over him/her and his/her mouth was on the resident's genitalia and was licking the resident. CNA A was pulling his/her pants down to show the resident his/her you know what. The resident told CNA A to stop because he/she hurt, because he/she had his/her weight on his/her right leg because his/her left leg hurt. The resident told CNA A to get out of the room and he/she pulled his/her pants up and left. After about five minutes, the resident turned the call light on again in hopes to get the nurse. The resident was scared that CNA A would come back. The CNA had rubbed the resident in the front and back before, but the resident thought the CNA was checking him/her to make sure the resident was okay and dry before. Record review of the CNA A's written statement, dated 2/5/19 and untimed, that was part of the facility's incident investigation summary report, showed the following: -At 3:00 A.M. Saturday (no date specified) morning, CNA A checked on the resident, as he/she had been incontinent. CNA A had found his/her bed wet and needing to be changed. CNA A woke the resident up to let him/her know CNA A needed to change his/her bed and clothing, during which CNA A said he/she showed him/herself to the resident inappropriately; -The statement was signed by CNA A on 2/5/19. Record review of an addendum to the facility's incident investigation summary report, entered by the administrator on 2/5/19 at 10:41 A.M., showed the following: -The Chief of Police came to the facility this afternoon to further question the resident. He stated his/her statement was still consistent, and he/she gave him more details, and he/she does wish to prosecute. Record review of an addendum to the facility's incident investigation summary report, entered by the administrator on 2/5/19 at 11:27 A.M., showed the following: -CNA A came in at 10:38 A.M. and spoke with SSD C and and the administrator. The administrator explained to CNA A that Resident # 1 had made an allegation of sexual abuse towards him/her which CNA A replied that it was true- .Just like he/she said. Without telling him/her what Resident # 1's allegation was, the administrator asked CNA A to document what had occurred. CNA A admitted to exposing himself/herself to Resident # 1. Record review of a police report, dated 2/5/19, showed an interview with the resident, dated 2/5/19 at 1:54 P.M. The resident was asked to explain what happened that night. The resident said the incident did not occur at night, and had occurred in the morning at 3:00 A.M. The resident explained he/she triggered the call light to ask for help and what CNA A had done to him/her had really upset him/her. The resident had to use the restroom and he/she was unable to get up because of a past physical injury. The resident said CNA A had placed his/her arms around his/her neck to help the resident get up. When he/she stood up, he/she knew CNA A's hands were on his/her butt. The resident said CNA A's hands then went around to his/her front and into his/her genitalia. The resident continued to explain CNA A laid him/her down in a diagonal direction on the bed and placed his/her mouth on his/her genitalia. The resident said he/she felt sick when the CNA did this. The resident said it just felt like it was not right. The resident said this happened out of the blue. The resident said that went on for no more than two minutes. The resident said he/she knew what CNA A was doing and it scared him/her. The resident said he/she had to tell CNA A to stop, and the CNA did not stop immediately. The resident said he/she had to tell CNA A to stop twice. The resident said the CNA had been on his/her knees and had to get up. The resident said CNA A's genitalia was not erected, but was getting there. The resident said he/she was unhappy about all of this. The resident said he/she wished to prosecute CNA A. A criminal history of the suspect showed him/her to be a tri-state offender, Kansas, Arkansas, and Missouri, with an extensive history, but no sexual crime-related arrest or conviction. Record review of the resident's Mental Health Intake form, signed by a Licensed Clinical Social Worker (LCSW), on 2/5/19, at 5:58 P.M., showed the following: -Received a consult request from SSD C at the facility. The resident would like an opportunity to see a counselor to deal with some difficulty he/she is having. The resident identifies he/she is struggling with the loss of his/her spouse and trauma/recent sexual assault. The resident is a victim of his/her recent sexual assault by a caregiver. The resident is also experiencing significant anxiety symptoms, including feeling nervous, anxious, on edge, worry, difficulty relaxing, feeling restless, feeling down, depressed, hopeless, grief, and feeling isolated. The resident will return to individual counseling with this LCSW weekly for a 50 minute session for Cognitive Behavioral Therapy (CBT), (a short-term, goal oriented psychotherapy treatment) to improve mental health and behaviors. Record review of the facility's incident investigation summary report showed the following: -On 2/6/19, at 9:52 A.M., SSD C documented he/she spoke to the resident by phone at approximately 2:45 A.M. on 2/2/19. The resident stated a staff member was cleaning him/her up from an incontinent episode, then put his/her mouth on his/her genitalia, after which CNA A pulled his/her genitalia out of his/her pants. The resident also stated he/she told CNA A to get out of his/her room. When the nurse went by the resident's room, he/she yelled for LPN B to come in, and the resident explained the situation. The resident does not have a history of confusion and is generally lucid. Arrangements were made to see a counselor. The counselor had a session with the resident on 2/5/19. The resident will continue to see the counselor on a weekly basis. Resident is also seeking spiritual support at this time. On 2/5/19, the administrator and SSD met with CNA A. CNA A was asked to recount the events of the night in question and stated I am admitting my guilt. When asked what he/she was admitting, he/she stated All of it; whatever Resident #1 said he/she had done. CNA A was asked to write a statement of the account, and he/she had done so. CNA A wanted to know what the resident had said and CNA A was told staff could not tell him/her that part, as it is part of the investigation. Record review of the resident's physician's progress note dated 2/6/19, at 10:05 A.M., showed the following: -This resident suffered an incident over the weekend where he/she was sexually assaulted by one of the aides, and the investigation is ongoing both on the police side as well as on the facility side. The resident's only concern is that the CNA is gone and no longer will be around him/her. Record review of an addendum to the facility's investigation summary report, dated 2/6/19 at 11:34 A.M., showed the following: -The Catholic Priest came to visit the resident at 11:15 A.M. today at the resident's request and left at 11:35 A.M. Record review of a police report, dated 2/7/19, showed an interview of CNA A completed on 2/7/19, at approximately 2:11 P.M. CNA A said the resident had wet himself/herself, and he/she placed the resident in the chair while he/she obtained new sheets and clothing for the resident. The CNA said he/she pulled the straps of each side of the diaper and removed it. CNA A said he/she followed the standard of care by spreading the resident's genitalia apart and wiping each area in a downward motion. CNA A said he/she laid the resident on his/her back on the bed, then showed the resident his/her genitalia. The CNA said his/her genitalia was partially erected. CNA A explained he/she got excited when he/she was cleaning the resident's genitalia. CNA A said after he/she was done, he/she showed the resident his/her genitalia. CNA A said the resident asked him/her what he/she was doing. CNA A said he/she pulled his/her pants up and left the room. The CNA denied performing oral sex. The police issued CNA A a citation for sexual misconduct in the first degree. Record review of the resident's care plan, dated 2/8/19, showed the following: -Updated 2/8/19 for resident has been recently been sexually assaulted by a staff member. Resident is seeing a therapist to help the resident cope. During an interview on 2/19/19, at 12:17 P.M., SSD C said the following: -He/she had spoken to the resident on the phone after the facility notified her of the incident. The resident sounded very upset. The resident told her she had been molested by CNA A, and that he/she had touched him/her inappropriately. The SSD informed the nurse to remove CNA A and call the police department. He/she asked the nurse to send the resident to the emergency room to have a rape kit done, since the resident said CNA A had put his/her mouth on her genitalia. The resident was alert and oriented, and aware of his/her surroundings, and what was going on. SSD believed the resident and that oral contact was made. SSD C would consider this sexual abuse even if CNA A had just exposed himself/herself to the resident, because it was unwanted and inappropriate. On 2/5/19, the SSD was with the administrator when CNA A entered the administrator's office and said I am admitting my guilt. The administrator explained the situation to CNA A. CNA A asked what Resident #1 had said. CNA A said, Whatever Resident #1 said I did, I did. The administrator told CNA A he couldn't tell him/her what the resident had said, and asked CNA A to write a statement, so he/she did that. CNA A never said he/she exposed himself/herself, but he/she wrote it down. CNA A never spoke as to what he/she had done. CNA [NAME] had picked the resident up Saturday morning on 2/2/19 after the rape kit had been done. CNA [NAME] said the resident had mentioned the incident to him/her. SSD C had heard from other staff members that Resident #1 had mentioned the incident to several residents in the dining room the next day, but wasn't aware of anyone in particular. Staff got counseling for the resident and a priest to see him/her. During a phone interview on 2/19/19, at 1:03 P.M., the Director of Nursing (DON) said the following: -She interviewed the resident on 2/2/19. She felt it was sexual abuse that the resident described. She reassured the resident that he/she was safe. The resident thought CNA A was getting away with it and was upset. During a phone interview on 2/19/19, at 2:41 P.M., LPN B said he/she was on duty when the incident occurred between the resident and CNA A, and agreed with his/her written statement. LPN B believed the resident, who was alert and oriented. The resident seemed believable. The resident seemed upset, scared, and worried. The resident seemed like he/she was afraid of getting into trouble. The resident never changed his/her story with the LPN. LPN B would consider what the resident described as sexual abuse. During a phone interview on 2/19/19, at 3:27 P.M., CNA A said the following: -CNA A agreed to his/her written statement signed and submitted to the facility. CNA A said he/she did not make physical contact with the resident, and did not make oral contact with the resident's genitalia. CNA A said he/she did not know why the resident would say that. CNA A said the resident asked him/her what he/she was doing, and he/she apologized. CNA A apologized because he/she woke the resident up, and the resident had been in and out of sleep. CNA A said he/she adjusted himself/herself and was being inappropriate. CNA A felt he/she was being inappropriate because he/she should not have done that there and then. CNA A did not think that incident was sexual abuse. CNA A stuck his/her hands in his/her pants. When asked if his/her genitalia was ever exposed, CNA A said they needed to go somewhere. CNA A thought he/she needed to adjust themselves, and it was a bad thing. CNA A would define sexual abuse as an event that was pushed and progressed into something that made it happen, but nothing happened. During an interview on 2/19/19, at 3:46 P.M., Resident # 4 said the following: -Resident # 1 had told him/her that someone had molested him/her. Resident #1 seemed very distressed over the incident, and Resident #4 felt sorry for Resident #1. During an interview on 2/19/19, at 4:07 P.M., the administrator said the following: -The DON got the call around 3:00 A.M. on 2/2/19. The resident told the charge nurse what had happened. The charge nurse called the police and sent CNA A to the break room. The police arrived and questioned CNA A and the resident. The facility sent CNA A home and the resident to the hospital. The DON interviewed other residents which was inconclusive on the subject. The facility got CNA A to come in and told CNA A the facility had an allegation against him/her. The CNA A asked what the resident had said, but staff would not tell the CNA. CNA A said whatever the resident said is what he/she had done. The facility had no previous concerns about CNA A. The DON had disciplined CNA A once verbally, and not in writing, concerning utilizing his/her time better when he/she was a Nurse's Aide (NA) before getting his/her CNA license here. All staff are trained on abuse including sexual abuse such as inappropriate touching all the way to rape. This instance falls somewhere in between. CNA A 's story was that he/she did not make physical contact, and the resident's story was that CNA A did make physical contact. If the incident happened the way the resident said it did or the way CNA A said it did, he would consider that sexual abuse. The police said if what the resident said happened had occurred, it would be a felony ( a crime, typically involving violence, regarded as more serious than a misdemeanor, and usually punishable by imprisonment for more than one year or by death). If what CNA A said happened had occurred, it would be a misdemeanor (minor wrongdoing and not indictable-liable to be charged with a crime). During an interview on 2/19/19, at 4:27 P.M., CNA D said the following: -He/she had given report to CNA A the evening of 2/1/19 reporting bumps on the resident genitalia, and to keep an eye on those bumps. During a phone interview on 2/20/19, at 1:50 P.M., CNA [NAME] said the following: -CNA [NAME] had brought Resident #1 back from the hospital in a wheelchair. CNA [NAME] had went to the emergency room to pick up the resident, and asked him/her how he/she was doing, and the resident said not good. The CNA had no idea of the accusation that had been made. The resident said he /she tried to rape me. The CNA apologized. The resident didn't say anymore about that to the CNA. The resident thanked the CNA for saying he/she was sorry that had happened to him/her. The CNA took the resident to the dining room and he/she started telling everyone in there. Complaint MO 428

Based on observation, interview, and record review, the facility failed ensure a resident was free from accidents hazards when staff failed to transfer one resident (Resident #53), with a history of a fall from a transfer sling, according to the sling's manufacturer guidelines. A sample of 18 residents were selected for review in a facility with a census of 69. Record review of the facility's policy and procedure titled Patient/Resident Handling, with an approval date of (MONTH) (YEAR), showed, the following: -Because the resident handling activities have been identified as a significant risk of injury to employees and others in the delivery and receipt of health care services within our organization, establishing and maintaining safe procedures for providing resident care is a high priority; -Purpose: To provide the safest possible work environment for our employees who are responsible for resident handling activities; -Employees assigned patient handling activities receive orientation and continuing education in risk identification, assessment, and injury prevention; -To minimize the risk of injury to both the employee and the resident. The corporation has adopted a limited-lift policy eliminating manual lifting activities whenever possible. The Mobility and Transfer Decision Flow Chart, is used when selecting the appropriate assistive device during assessment of resident capabilities for care planning and prior to resident handling activities. Where indicated on the patient care plan, the required assistive devices may be varied according to the decision flow chart. Otherwise, staff will follow standard care planning procedures and/ or specific physician orders [REDACTED]. -Varied equipment provided to minimize the risks in lifting and transferring patients/residents and should be utilized following the specific instructions or procedures and manufacturer's recommendations for use. Record review of the (undated) Lumex manufacturer sling guide for toileting slings, provided by the facility, showed: -Toileting slings (a horseshoe shaped sling with four connection straps used for transferring residents on and off a toilet) are designed to facilitate the toileting procedures by allowing the lowering of clothing. The sling is well padded under the arms and in the lumbar area for maximum comfort. A hook and loop belt and separate buckle strap hold the sling securely in place; -Toileting slings must only be used when transferring a resident from a seated position. They can be used for transfers from sitting on a bed to a chair, wheelchair, or toilet, or chair to chair. 1. Record review of Resident #53's fall risk assessment, dated 11/08/18, showed the resident's score indicated the resident was a moderate fall risk. Record review of the resident's quarterly Minimum Data Set (MDS - a comprehensive assessment tool completed by facility staff), dated 11/13/18, showed: -Severely impaired cognitive skills for daily decision making; -[DIAGNOSES REDACTED].>-Always incontinent of bladder and always continent of bowel; -Totally dependent on two or more staff for transfers and toileting assistance; -Totally dependent on one staff for bed mobility and dressing; -Used wheelchair for mobility; -Functional range of motion impaired to one upper extremity and both lower extremities; -Balance not steady during transfers (transitions between bed and chair or wheelchair), resident only able to stabilize with human assistance. Record review of the resident's post fall communication fall note, dated 11/26/18 at 10:47 P.M., showed: -A nursing assistant (NA) asked for the nurse's assistance; -Upon entering the room, the nurse observed the resident lying on the floor with his/her head lying on the metal base of the transfer lift; -The resident was crying out; -The aides reported while transferring the resident from the chair to the bed, they heard the resident scream and observed the resident falling through the opening in the toileting sling; -The resident fell to the floor; -The nurse helped staff to place the resident onto the bed and the nurse applied pressure to a laceration on the resident's head until bleeding was controlled; -Emergency medical technicians (EMTs) arrived and noted a small wound on the top portion of the occipital region (back of head); -The facility sent the resident to the hospital for evaluation. Record review of the resident's current plan of care, last reviewed 11/26/18, showed the following: -At risk for falls related to immobility and confusion; -Did not ambulate and was wheelchair bound; -Required total assistance with bed mobility as the resident cannot do it by him/herself; -Required total assistance with dressing and undressing: -Resident's main locomotion was a geri-chair (a high back cushioned wheel chair that reclines) propelled by staff/family; -Incontinent of bladder and wore incontinent briefs; -Required a transfer lift for all transfers with two staff assistance; -Facility staff to implement appropriate fall precautions, call light in reach, keep care areas well lighted, keep floors dry, use assistive equipment as ordered, and encourage use of non-skid footwear; -Educate resident/family on call light (resident does not use); -Recent falls: 11/26/18, subdural hematoma fall out of transfer lift sling, two staff for all transfers. Record review of the resident's nurse note, dated 11/27/18 at 4:10 P.M., showed: -Resident arrived from the hospital by ambulance; -[DIAGNOSES REDACTED]. -Laceration to the back of the resident's head had three staples and area covered with a bandage. Record review of the resident's physical therapy screening, dated 11/29/18, showed: -Screening performed due to the resident's recent fall; -Nursing requested screening to see if the hygiene sling for the total lift is still appropriate for the resident; -On 11/28/18, therapy observed certified nursing assistants (CNAs) transferring the resident with the hygiene sling and transfer lift. The resident appeared relaxed, non-combative, accepting, and tolerated the lift. Resident did not attempt to move arms out of the sling. Resident did not demonstrate any sliding out of the sling. Therapist and CNAs discussed the need for the resident's arms to remain out of the sling for safety. The hygiene sling continues to be appropriate choice for transferring the resident to toilet. Changes in function will merit further screening from therapy staff. -Therapy provided CNA education on hygiene sling and need for bilateral arms outside of sling for safety to significantly decrease risk for falling out of sling. Record review of the resident's fall team meeting notes, dated 11/29/18 at 11:37 PM., showed: -Fall team reviewed fall on 11/26/18; -Active interventions in place: Resident utilizes geri-chair and has total assistance with transfers; -New interventions: Therapy screened the resident for safety and filling of the transfer sling; -Additional training for nursing staff provided. During an interview on 12/12/18 at 4:00 P.M., Licensed Practical Nurse (LPN) E said the following: -Nursing Assistant (NA) F came to her on the evening of 11/26/18 and informed her the resident fell out of a toileting sling; -The nurses sent the resident to the hospital for evaluation; -The resident stayed in the hospital for several hours for observation and returned with a [DIAGNOSES REDACTED]. The resident received three staples to the back of his/her head; -At the time of the fall, two staff were present in the room. NA F and CNA/Certified Medication Technician (CMT) G, both reported they were attempting to transfer the resident from a geri-chair to the bed when the fall occurred; -The aides were using a toileting lift sling that was too big for the size of the resident's body; -The aides reported the resident initially held onto the lift bar above his/her head, but the resident's hands slipped off mid transfer. The resident fell thru the toileting hole in the sling pad; -The toileting hole was larger than the resident's body; -The transfer lift was in the high position at the time of the fall; -The sling remained attached to the lift when the nurse entered the room; -LPN E said he/she was unsure if staff used the sling for toileting the resident, or if the resident was incontinent of bladder and bowel. During an interview on 12/12/18, at 5:15 P.M., NA F said on the evening of 11/26/18 the following occurred: -The NA and CNA/CMT G were assisting the resident in transferring from a geri-chair to the bed; -The NA reported the CNA/CMT G placed the resident on a toileting sling and connected the resident to the transfer lift; -The NA said CNA/CMT G failed to secure a safety belt around the resident's waist; -The resident's arms hung down to his/her sides during this time; -The NA secured the belt and the CNA/CMT proceeded to lift the resident up using the controls on the transfer lift; -The NA said he/she changed the resident's incontinent brief with the resident suspended in the air; -The NA said it is easier to change the resident while up in the lift, because otherwise the resident can be combative with staff; -In mid transfer, the NA said she turned away from the resident to prepare the resident's bed; -The NA said the resident screamed, the NA looked around to see the resident falling to the floor; -The NA said he/she was orienting the CNA/CMT G to work the floor that evening, and believed it was his/her second shift working in the facility. -The resident is not able to sit up without physical support. During an interview on 12/12/18, at 5:46 P.M., CNA/CMT G said the following: -On 11/26/18 during the evening shift, he/she orientated to the floor with NA F; -CNA/CMT G stood by and watched while NA F attached the resident's transfer sling to the lift and operated the transfer lift for the resident; -During the transfer, the resident fell head first out of the sling to the floor; -The resident hit his/her head on the base of the transfer lift. Observation and interviews on 12/13/18, at 10:15 A.M., showed the following: -CNA I and Shower Aide H entered the resident's room to assist the resident from the bed to the toilet; -CNA I placed the toileting transfer sling behind the residents lower back and down to the resident's lateral thighs and connected the upper and lower sling straps to the transfer lift; -CNA I did not crisscross the lower straps between the resident's inner thighs; -A picture diagram on the lift showed the straps crisscrossed between the legs; -The shower aide asked CNA I, Did you crisscross them (the straps)? and the CNA replied, No, on this one we don't. -Staff raised the resident from a lying position off the bed. The resident's buttocks and thighs came up off the bed, the resident's back arched and the resident's upper back, shoulders, and head remained on the bed; -The resident began to cry out; -Staff manually lifted the resident's back, shoulders and head off the bed and attempted to re-adjust the resident in the lift, so the resident did not lean back as far; -Staff moved the resident from the bed into the bathroom for toileting while suspended in the sling, during this time the resident continued to lean back in the sling and cry out; -Staff lowered the resident to the toilet and the resident quieted; -CNA I said when the resident leans back like this; he/she really needs to be in a full sling; -The shower aide said there had been a lot of talk about whether or not staff should crisscross the lower straps; -CNA I said on some of the other slings staff crisscross the straps, but on this one staff cannot; -CNA I said the resident is the only resident using a toileting sling. During an interview on 12/13/18, at 11:40 A.M., the Assistant Director of Nursing (ADON) said staff should crisscross the legs straps between the resident's thighs when using the toileting sling. During an interview on 12/13/18, at 2:42 A.M., the Rehab Coordinator/Physical Therapist (PT) J said the following: -He/she re-evaluated the resident in the toileting sling after his/her fall; -The resident tolerated the sling and his/her positioning in the sling was fine; -The staff do not crisscross the leg straps on the toileting sling, if they did the resident could not go to the bathroom and have clothes pulled up and down; -Staff can use the resident's toileting sling to bring the resident from a lying to a sitting position. During an interview on 12/13/18, at 3:24 P.M., the Director of Nursing (DON) said the following: -She expects staff to follow the manufacturer's recommendations and instructions for use of the toileting sling; -According to the sling guide, staff should not use the toileting sling to transfer a resident from lying on the bed to sitting; -She did not believe the resident was able to sit up on the side of the bed; -She was not able to find the specific manufacturer's instructions for use of the resident's toileting sling. During an interview on 12/13/18 at 3:27 P.M., the administrator said the facility staff should have specific manufacturer instructions for use of the resident's toileting sling.

Based on observations, interview, and record review, the facility failed to schedule and post organized activities on the special care unit (SCU); failed to care plan the preferred activities and attendance of activities for two residents who resided in the SCU (Resident #44 and #54); and failed document attendance of activities, or invitation declined to activities for one resident (Resident #54) who resided on the SCU. The SCU census was 13 and the facility census was 69. Record review of the facility's policy titled Activity Program, dated 10/2018, showed the following information: -The purpose of the program is to encourage the resident toward increased involvement in daily leisure activities and to provide therapeutic activities that will stimulate resident's physical, mental, and emotional skills to rehabilitate the resident to their most optimal level of functioning. Special care is taken to respect the resident's rights regarding activities in order to assure the ongoing preservation of the rights of each resident in the provision of activities and to promote self-determination; -The staff will remind, invite, and assist residents to the activity, making adaptations that may be necessary to allow residents to participate more productively. (i.e., segment into simple steps, provide adaptive equipment, compensate for audio and visual handicaps, etc.). 1. Observations in the SCU between the dates of 12/10/18 to 12/13/18, showed the following: -On 12/10/18, there was a calendar of activities available to residents on the unit such as coloring pages, games, and a calendar of activities for the month of (MONTH) (YEAR) for the main facility. The calendar did not include scheduled activities on the SCU; -From 12/11/18 to 12/13/18, the activity list was not posted on the unit;. -The television showing the Hallmark Channel was on consistently during the observation period. 2. Record review of Resident #54's face sheet showed the following information: -admitted to the facility 12/9/16; -[DIAGNOSES REDACTED]. Record review of the resident's annual Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 11/13/18, showed the following information: -Moderately cognitively impaired; -Verbal behaviors directed at others; -Limited assistance with transfers, toileting, and bathing; -Ambulates and eats independently. Record review of the resident's daily activity assessment information, dated 8/1/18 to 12/1/18, showed the resident enjoyed games, music, television, relaxation, and crafts. Record review of the resident's care plan, last revised 12/4/18, showed staff did not care plan in the resident's participation in or interest in activities. Observation and interview on 12/11/18, at 1:30 P.M., showed the resident in the dining area of the SCU, standing by the refrigerator looking at the activity calendar for the main facility. The activity listed was bible study. The resident said I am going to bible study; they usually come get me. The resident said sometimes he/she gets bored. Observation on 12/11/18, at 1:40 P.M., showed residents in the dining room outside the activity office for bible study. No residents from the SCU were present. During an interview on 12/12/18, at 9:37 A.M., the resident said he/she loves all types of music and religious programs. He/she loves to be around children especially at the holidays. He/she used to read, but cannot see as well now. He/she will usually go to any activities in the main facility if asked. Record review of the resident's records showed staff did not document which activities the resident attended, or was invited to an declined. 3. Record review of Resident #44's face sheet showed the following information: -admitted [DATE]; -[DIAGNOSES REDACTED]. Record review of the resident's annual MDS, dated [DATE], showed the following information: -Severely cognitively impaired; -Behavior of wandering; -Limited assistance with dressing, bathing, hygiene, and toileting; -Independent with transfers, ambulation, and eating. Record review of the resident's daily activity assessment, dated from 9/3/18 to 11/30/18, showed the resident enjoyed church, bingo, games, television, and relaxation. Record review of the resident's care plan, last revised 12/1/18, showed staff did not care plan in the resident's participation in or interest in activities. 4. During an interview on 12/12/18, at 9:47 A.M., Registered Nurse (RN) A said there is one staff member on the SCU at all times, usually a certified nurse assistant (CNA). Sometimes there are two staff if the Certified Medication Technician (CMT) is on the unit passing medications or the nurse is called for an emergency, such as a fall. There is a telephone on the unit to call for assistance. The CNA on the unit is expected to answer call lights and check residents regularly for toileting, positioning, and needs such as hydration, hunger and/or the residents' whereabouts. The CNA has a list of activities and activity supplies to conduct individual and group activities on the SCU. Some residents attend some of the activities in the main dining room, and activities staff come to the unit to invite and take them. There are three or four residents that are able to attend activities outside the unit. 5. During an interview on 12/12/18, at 2:47 P.M., CNA B said he/she is the only staff on the unit this afternoon. He/she can accomplish some activities with the residents on the unit, but may have to stop the activity to answer a call light or help another resident. 6. During an interview on 12/13/18, at 9:02 A.M., CNA C said he/she does not work consistently on the unit. He/she is able to assist residents on the unit with activities of daily living (ADLs - dressing, grooming, bathing, eating, and toileting), but not much else. Residents on the unit usually sleep in their rooms, or sit in the television area. Three or four residents are able to go to activities in the main dining room. If there is time, some games are played on the unit such as ring toss or bowling. If another resident needs assistance during an activity, the aide will interrupt the activity, and come back to it if there is time. The residents on the unit do not have enough to do, and he/she feels they are isolated from the rest of the facility and outdoor activities when the weather is good. Three or four of the residents go to the main facility for activities if activity staff are able to come and get them. 7. During an interview on 12/13/18, at 9:50 A.M., the Director of Nurses (DON) said there is usually one staff on the unit at all times. Sometimes the CMT, or the nurse go back to the unit. The nurse also covers another hall outside the unit. He/she is aware it is difficult for one aide to cover the needs of the unit and conduct activities. An activity on the unit is interrupted, if another resident has a physical need. 8. During an interview on 12/13/18, at 9:19 A.M., Activity Assistant D said he/she is a part time employee. He/she assists with activities in the main facility, and gets residents from the unit for activities. There is usually three to four that will attend. Aides conduct most of the activities on the unit. 9. During an interview on 12/13/18, at 9:57 A.M., the Activity Director said activities on the unit are conducted two times per day and supplies are provided for the aides. He/she will also try to offer an activity on the unit one time per week such as a craft. He/she and his/her assistant also get three or four residents from the unit to attend some activities in the main dining room such as, exercise, games, bingo, or music. The television is usually on in the unit or music. Bible study is also conducted on the unit. He/she is unaware why residents were not included this week when the children came to sing, and why Resident #54 was not included in bible study in the main facility. 10. During an interview on 12/13/18, at 11:12 A.M., the administrator said he/she is aware two aides are needed on the unit in order to conduct activities. He/she is working on staffing for the unit.

Based on observation, interview, and record review, the facility failed to keep the area around the dumpsters reasonably free of debris, and failed to keep the dumpsters closed when not in use. This failure could potentially affect all residents. The facility census was 75. Observations made on 11/16/16, at 8:07 A.M., on the outside grounds of the facility showed that the two facility dumpsters both had their lids open. The dumpsters were not currently in use. There was an accumulation of trash around the dumpsters, including bags, cups, broken glass, plastic gloves, a pizza box, and bed pads (among other items and debris). During an interview on 11/18/16, at 1:15 P.M., the administrator and DON said they were unaware of the debris and trash around the dumpsters. They were unaware of the necessity to keep the lids closed to the dumpsters when not in use. Record review of a cleaning responsibility chart provided by the facility showed that the maintenance director was responsible for cleaning or maintaining the large area outside the facility building, including the area where the dumpsters were located.

Based on record review and interview, the facility failed to assess, monitor and document on one resident (Resident #1) according to acceptable nursing practice when the resident had a change in condition. The resident exhibited elevated temperature, pulse, respirations, and changes in blood pressure for approximately 72 hours, along with episodes of labored breathing, facial grimacing, calling out and/or crying before staff notified the physician. The resident required transfer to the hospital for evaluation and treatment. Additionally, facility staff failed to assess, monitor, document, and notify the physician regarding one resident (Resident #13) who experienced signs and symptoms of a stroke and a significant decline in his/her functional abilities. As a result the resident was transferred to the hospital hours after onset, which delayed emergency medical treatment. The resident was diagnosed with [REDACTED]. The facility census was 61. 1. Record review of the facility's Documentation policy, revised 06/03/13, showed when a pertinent entry is missed or not written in a timely manner, a late entry should be used to record the information in the medical record. Record review of the facility's Changes in Resident Condition Notification Guidelines policy, revised 11/15/10, showed the following information: -Physicians and families will be notified in a timely manner of changes in clinical conditions; -When resident changes are noted, facility staff will notify the physician and legal representative; -Notification will occur as soon as possible when there is a significant change in the resident's physical status, deterioration in health or clinical complications. Life threatening conditions may include but are not limited to [MEDICAL CONDITION] or stroke; -When a resident condition changes and staff are unable to contact the physician, staff will follow the urgent and non-urgent notification flowcharts. Record review of the facility's Urgent Notification Flowchart, dated 06/11/12, showed the following information: -Urgent changes requiring immediate action include: new or uncontrollable pain, injury requiring transport, critical lab results, medication reactions, life threatening signs/symptoms, and uncontrollable aggressive behavior; -Initiate emergency action as needed; -Call the physician or back up; -If no answer or response within one hour, notify the registered nurse (RN) on call; -If no answer from the RN on call, call the Director of Nursing (DON); -If no answer from the DON, call the administrator; -If no answer from the administrator, call the facility medical advisor. 2. Record review of Resident #1's quarterly Minimum Data Set (MDS), a federally mandated assessment completed by facility staff, dated 11/23/13, showed staff assessed the following diagnoses/information: -[MEDICAL CONDITION] (the heart is unable to provide sufficient pump action to maintain blood flow to meet the needs of the body); -[MEDICAL CONDITIONS] (stroke); -[MEDICAL CONDITION] (weakness on one side of the body); -[MEDICAL CONDITION] disorder; -Required extensive assistance from staff for bed mobility, transfers, dressing, and personal hygiene; -Required total assistance from staff for toileting and bathing. Record review of the resident's care plan, dated 05/20/13, showed staff documented the resident had an ineffective breathing pattern with history of [MEDICAL CONDITION] and [MEDICAL CONDITION]. Review showed the plan directed staff to: -Assess level of consciousness; -Respiratory assessment; -Monitor for signs of respiratory fatigue including rapid, shallow ventilation, paradoxical abdominal wall motion, hypoxemia, confusion, poor coloring, oxygen saturation levels; -Monitor for elevated temperature and [MEDICAL CONDITION](rapid heart rate). Record review of the physician's orders [REDACTED]. -[MEDICATION NAME] (Tylenol) 650 mg (milligrams) by mouth two times daily; -[MEDICATION NAME] 650 mg every four hours as needed for pain or elevated temperature; -Vital sign parameters for physician notification included; temperature below 96.0 degrees or above 101.5 degrees, pulse below 60 beats per minute or above 120 beats per minute, and respirations below 12 per minute or above 20 per minute and blood pressure of below 90/60 or above 140/90. Record review of the nurse's notes, dated 12/24/13 at 10:20 A.M., showed day shift staff documented that the night shift nurse reported during shift change that the resident had a temperature of 101.9 degrees during the night. Staff documented the resident was medicated with PRN Tylenol earlier in the shift and fluids encouraged. Staff documented the resident's current temperature as 99.0 degrees. Review of the nurse's notes showed night shift facility staff failed to document any information to show the resident had a fever, or that staff administered PRN Tylenol to the resident. Additionally, night shift staff failed to document an assessment of the resident's condition at this time. Record review of the December 2013 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Review of the resident's record, showed facility staff failed to document any assessments of the resident's condition after the fever was identified. Record review of the facility's intake records for 12/24/13 showed the following information: -The resident ate 25% of his/her breakfast with 420 ml (milliliters) of fluid with the meal; -The resident ate only bites of his/her lunch with 120 ml of fluid with the meal; -The resident ate 10% of his/her supper with 220 ml of fluid with the meal; -The resident normally averaged 50%-100% of meal intake for the month of December; -The resident normally averaged 420 ml of fluid intake with meals for December. Record review of the resident's vital signs and MAR indicated [REDACTED] -At 1:07 A.M., temperature of 104.4 degrees, pulse rate of 146 beats per minute, respirations of 38 per minute, blood pressure of 141/59, oxygen saturation of 95% on room air (According to the Mayo clinic for an adult, fever usually isn't dangerous unless it reaches 103 degrees or higher); -At 1:12 A.M., the resident received a PRN (as needed) dose of Tylenol; -At 2:12 A.M., temperature of 103.2 degrees orally; -At 3:36 A.M., temperature of 102.2 degrees. Review of the resident's nurse's notes, dated 12/25/13 on the night shift, showed staff did not document any information to show they notified the resident's physician of the continued fever, increased pulse, increased respirations, and elevated blood pressure. Record review of the nurse's notes, dated 12/25/13 at 5:49 A.M., showed staff documented the resident was febrile (elevated temperature) most of the night. Staff documented the resident's temperature read 104.4 degrees earlier in the shift and staff administered Tylenol 650 mg by mouth, the resident's temperature came down to 102.2 degrees, and he/she rested quietly after that. Staff documented the resident's LCTA (lungs clear to auscultation), fluids encouraged, and the resident refused to allow facility staff to put a cool washcloth on him/her. The facility staff failed to notify the physician at this time of the resident's elevated temperature. Record review of the resident's vital signs and MAR, dated 12/25/13, showed the following information: -At 6:01 A.M., temperature of 100.4 degrees; -Staff did not administer any Tylenol when the resident was eligible to receive it at 5:12 A.M.; -At 9:08 A.M., the resident received a scheduled dose of Tylenol; -At 1:15 P.M., temperature of 98.5 degrees, pulse of 90 beats per minute, respirations of 22 per minute, BP of 112/70, oxygen saturation of 98% on room air; -At 3:01 P.M., the resident received a PRN dose of Tylenol. The facility staff failed to document the resident's temperature at the time of the PRN dose of Tylenol; -At 4:08 P.M., facility staff documented the resident showed occasional labored breathing; -At 7:43 P.M., temperature of 99.9 degrees; -Staff did not administer any Tylenol when the resident was eligible to receive it at 7:01 P.M.; -At 9:54 P.M., temperature of 102.7 degrees, pulse of 117 beats per minute, respirations of 44 per minute, BP of 111/47, oxygen saturation of 97% on room air; -At 11:01 P.M., the resident received a PRN dose of Tylenol. Staff documented the resident had occasional labored breathing, body language tense and distressed, and exhibited facial grimacing and calling out or crying. The facility staff failed to document the resident's temperature with the administration of the Tylenol; -At 11:21 P.M., temperature of 103.8 degrees, pulse of 67 beats per minute, respirations of 20 per minute, BP of 104/68; oxygen saturation of 91% on room air. Review of the resident's nurse's notes, dated 12/25/13 on the day, evening, and night shifts, showed staff did not document any information to show they notified the resident's physician of the resident's continued fever, increased pulse, and increased respirations. Record review of the facility's intake records, dated 12/25/13, showed the following information: -The resident ate none of his/her breakfast with 240 ml of fluids with the meal; -The resident ate none of his/her lunch with 120 ml of fluids with the meal; -The resident ate 100% of his/her supper with 1500 ml of fluids with the meal. Record review of the vital signs documented on 12/26/13 at 12:43 A.M., showed the resident had a temperature of 101.9 degrees. Record review of the resident's nurse's notes, dated 12/26/13 at 5:14 A.M., showed the resident again had been febrile during the night. His/her temperature was 103.8 degrees and staff administered Tylenol. His/her temperature decreased to 101.9 degrees. The resident refused to allow cool moist cloths to his/her forehead. Review showed facility staff failed to notify the resident's physician of the continued fever. Staff failed to document any further assessments of the resident's condition. Record review of the resident's Focus Note (a note that is electronically sent to the physician), on 12/26/13 at 5:17 A.M. showed staff documented the resident had an elevated temperature as high as 104.4 for the last three nights. Lungs were clear to auscultation with no cough noted. The facility staff requested an order for [REDACTED].M. with an order to transfer the resident to the emergency room for evaluation and treatment. Record review of the vital signs and MAR, dated 12/26/13, showed the following information: -At 6:12 A.M., temperature 98.4; -At 7:43 A.M., the resident received his/her scheduled dose of Tylenol; -At 8:07 A.M., temperature 101.7, pulse 146, respirations 36, BP 127/84. Staff did not document any oxygen saturation levels. Record review of the resident's nurse's notes, dated 12/26/13 at 8:19 A.M., showed the resident's temperature was 101.7 degrees, pulse was 144 beats per minute, respirations were 36 per minute, and BP of 127/84 with lung sounds basically clear yet extremely diminished to the bases. Facility staff documented they requested an ambulance transfer for the resident to the hospital and were waiting for the ambulance. Record review of the resident's nurse's notes, dated 12/26/13 at 8:29 A.M.,. showed the ambulance arrived to transport the resident to the hospital. Record review of the resident's Emergency Physician Record, dated 12/26/13, showed the following information: -Chief complaint of lethargy (a lack of energy and enthusiasm) and fever; -Sudden onset of high fever and [MEDICAL CONDITION](heart rate that exceeds normal range); -Onset of 24 hours; -General appearance described as lethargic and severe distress; -Coarse rhonchi lung sounds (a coarse rattling respiratory sound); -[DIAGNOSES REDACTED]. -[DIAGNOSES REDACTED]. Record review of the resident's hospital laboratory report, dated 12/26/13, showed the resident's blood culture was positive for E-coli (E. coli gets into the blood and causes poisoning, which is also known [MEDICAL CONDITION]. Some of the most common signs and symptoms [MEDICAL CONDITION] include elevated heart rate, very high body temperature, abnormally high respiratory rate, and abnormally high amount of white blood cells). Record review of the resident's hospital progress note, dated 12/26/13 at 10:00 A.M.,. showed the following information: -Resident presented to the hospital with three days of cough, high fevers, and diminished breath sounds at the bases of the lungs; -Presented with a temperature of 103.7 degrees, a right sided infiltrate (the appearance of any abnormal substance that has accumulated in the lungs); -admitted with a [DIAGNOSES REDACTED]. Record review of the hospital admission orders [REDACTED].M., showed the resident was admitted to the hospital. Record review of the hospital history and physical, dated 12/26/13, showed the following information: -The resident admitted to the hospital with [REDACTED]. He/she had been sick for several days running a temperature of 103-104 degrees in the nursing home and the facility finally sent him/her to the hospital for evaluation where he/she admitted with pneumonia; -Blood pressure reading of 133/101; -Lung sounds showed rhonchi and bibasilar (bases of both the left and right lungs) wheezes; -History of cardiovascular disease; -Impression included pneumonia, probable pneumosepsis (a potentially fatal pneumonia), urinary tract infection, low platelets (help the blood clot), low Hemoglobin (the molecule in red blood cells that carries oxygen), possible [MEDICAL CONDITION], and elevated troponins suggesting [MEDICAL CONDITION] damage. Record review of the laboratory final report, dated 12/29/13, showed a positive urine culture for E. Coli. During an interview on 01/09/14 at 1:00 P.M., Licensed Practical Nurse (LPN) F said he/she worked the day shift on 12/24/13. LPN F said report from the night shift included information regarding the resident having an elevated temperature. LPN F said when a resident has an elevated temperature, he/she would expect staff to monitor the resident's vital signs every two hours until the vital signs are stable. He/she would complete a full head to toe assessment of the resident and focus on the area of concern. During an interview on 01/09/14 at 1:12 P.M., LPN G said he/she worked on the evening shift on 12/24/13. LPN G said report from the day shift included information that the resident had a temperature during the prior night shift, but no fever during the day shift. LPN G said an assessment would only be completed if the issue continued. LPN G said since staff reported to him/her that the temperature had not been active during the day shift, he/she did not assess the resident during the shift. During an interview on 01/09/14 at 1:20 P.M., Registered Nurse (RN) B said he/she worked on the evening shift on 12/25/13. RN B said report from day shift included information that the resident had a temperature the night before. He/she said staff should monitor the resident's vital signs at least once every four hours to monitor the resident's condition when the resident has an elevated temperature, which included a complete head to toe assessment. RN B said if the assessment of the resident was normal, the information did not have to be documented. RN B said the resident had a slightly elevated heart rate during his/her shift and he/she then decided to monitor the resident. RN B said an elevated heart rate can occur when a resident is getting sick. During an interview on 01/09/14 at 10:45 P.M., RN A said he/she normally works on the opposite side of the building. RN A said he/she worked on the day shift on 12/25/13 and the previous shift reported the resident had an elevated temperature the night prior but not during day shift. RN A said staff should monitor the resident for continued symptoms or for new symptoms when an elevated temperature is reported. RN A said there is not a specific protocol for when to notify the physician about irregular vital signs. During an interview on 01/09/14 at 10:50 P.M., RN E said he/she worked the night shift on 12/23/13, 12/24/13, and 12/25/13. RN E said the certified nurse aides obtain residents' vital signs during the shift. RN E said the resident had a temperature of 101.9 on the night shift of 12/23/13 and he/she administered Tylenol. The resident responded to the Tylenol and his/her temperature returned to a normal level. He/she said on the third night of the resident spiking temperatures, he/she notified the physician of the resident's condition through a "focus note." RN E said when the resident had a temperature of 104.4 degrees with an elevated pulse of 146 beats per minute and respirations of 38 per minute, he/she would have contacted the physician if the resident had not responded to the Tylenol. RN E said staff notify the physician of a change in condition when three or more symptoms are present. RN E said because the resident only had an elevated temperature, it did not justify a phone call to the physician. RN E said the resident's elevated heart rate and respirations did not count as additional symptoms because they are part of the vital signs. During an interview on 01/10/14 at 1:31 P.M., Certified Nurse Aide (CNA) C said he/she could tell the resident was not feeling well during the time period of 12/24/13 through 12/26/13, as the resident was more tired than usual. CNA C notified more than one charge nurse of the resident's condition, and expected that licensed nurses would "handle" the situation. CNA C said part of his/her duties include checking residents' vital signs once per shift. CNA C said if the vital signs suggest that a resident is ill, the facility staff will continue to check the vital signs. During an interview on 01/10/14 at 1:35 P.M., the resident's physician said there are no set parameters for the facility staff to notify the physician regarding elevated temperatures. The facility staff normally notify him no later than the next day of any vital signs outside of normal ranges. The only time staff notified the physician regarding the resident's condition was on 12/26/13 when the physician gave the order to send the resident to the hospital for evaluation and treatment. When the resident's temperature reached 104.4 degrees with a pulse of 146 beats per minute, and respirations of 38 per minute, he would have expected the facility staff to notify a physician. He said the facility had an on-call physician that can be reached after hours or on holidays. He said the resident's vital signs were indicative of a possibly serious issue. During an interview on 01/10/14 at 1:43 P.M., CNA D said the resident had been spiking fevers over the last couple of days that the resident was in the facility. The nurse gave the resident medications and the temperatures would go up and down. The resident looked tired and sluggish. He/she reported the change in the resident's condition to the charge nurse. During an interview on 01/10/14 at 3:20 P.M., the DON said she first became aware of the resident's condition on the day the resident was sent to the hospital. The DON said staff should have notified the resident's physician of the resident's continued elevated temperature. Staff should have notified the resident's physician and assessed the resident when the resident's vital signs showed elevated respirations of 38 and 44 per minute, and when the resident's pulse was assessed at 146 beats per minute. The DON said staff should have assessed the resident in an attempt to determine the cause of the continued elevated temperatures. She said staff should have given the resident a fever-reducing medication in regular intervals if the resident's temperature continued to be 100.4 degrees or higher. During an interview on 01/10/14 at 3:11 P.M., the medical director said facility staff should contact the physician with elevated temperatures, elevated pulse rates, and elevated respirations. He said the combination of the resident's symptoms was a sign of a problem and the physician should have been called rather than faxed without delay due to the potentially serious problem. The medical director said if the primary care physician cannot be reached by telephone, he expected the facility to contact himself or the on-call physician. 3. Record review of Resident #13's quarterly Minimum Data Set (MDS), a federally mandated comprehensive assessment completed by facility staff, dated 11/30/13, showed the following information: -Brief Interview for Mental Status (BIMS) score of 15, which represents no cognitive deficits; -Required supervision for bed mobility; -Required supervision for transfers; -Required supervision with ambulation; -Required limited assistance with toileting and personal hygiene; -Continent of bowel and bladder; -Used an assistive walker to achieve ambulation; -No impaired range of motion; -History of a stroke; -[MEDICAL CONDITION] (a medical term for high blood cholesterol. High cholesterol can increase the chances of [MEDICAL CONDITION] and stroke); -Diabetes Mellitus (Serious long-term complications include cardiovascular disease); -Heart Block (a type of heart rhythm disturbance); -Hypertension (high blood pressure. Hypertension is also a major risk factor for stroke); -[MEDICAL CONDITION] disease (a group of [MEDICAL CONDITION] related to disease of the blood vessels supplying the brain. The results of [MEDICAL CONDITION] disease can include a stroke). Record review of the resident's care plan, dated 11/2/11, showed the following information: -Monitor for signs or symptoms of abnormal blood pressure; -Assess vital signs and report abnormal findings to the physician. Review of the resident's care plan, dated 11/2/11, showed staff failed to plan care for the resident's risk for stroke as a result of history of stroke, [MEDICAL CONDITION], diabetes mellitus, heart block, hypertension, and [MEDICAL CONDITION] disease as identified in the MDS. -The facility staff failed to identify the resident's risk for a stroke based on the facility's MDS assessment. Record review of the resident's care plan review, dated 11/26/13, showed the facility placed the resident on a restorative nursing plan that consisted of a walk-to-dine program to maintain his/her current level of functioning. Record review of the resident's Restorative Nursing Notes, dated 12/1/13-12/8/13, showed the resident participated in the walk-to-dine program. Record review of the resident's vital sign documentation, dated 12/9/13 at 7:13 A.M., showed staff documented the resident's blood pressure as 142/74. The facility's computerized charting flagged the blood pressure as high. Staff did not document additional blood pressure monitoring. Review of Brunner & Suddarth's Textbook of Medical Surgical Nursing, ninth edition, showed normal adult values range from 100/60 to 140/90. Record review of the restorative nursing notes, dated 12/9/13, at 10:14 A.M. and 7:54 P.M., showed the resident completed the session of the walk to dine program. Record review of the resident's nurse's notes, dated 12/10/13 at 1:48 A.M., showed the following information: -When assisting the resident to the bathroom, he/she required a wheelchair instead of his/her walker due to left arm and left hand unable to grasp the assistive walker device. The resident was unable to hold up his/her arm. The resident's left grip was much weaker and he/she had difficulty using his/her left leg; -Vital signs: temperature 97.2, pulse 55, respirations 19, an elevated blood pressure 150/78 which the facility's computerized charting flagged as high, and an oxygen saturation of 92%; -Staff documented the resident told staff that he/she noticed weakness when he/she got ready for bed the last evening; -Review showed staff faxed the nurse's note to the physician via the facility computer system. Record review of the resident's nurse's notes, dated 12/10/13, at 4:40 A.M., showed staff attempted to contact the resident's daughter and left a message. Staff did not document the reason for the attempt to contact the resident's daughter at this time. Staff documented the resident denied pain, had no difficulty talking, and did not exhibit facial drooping. Staff did not document an attempt to contact the physician by phone with the resident's change of condition identified earlier. Record review of the resident's nurse's note, dated 12/10/13 at 6:12 A.M., showed the resident continued with left sided weakness to the left upper extremity and the left lower extremity. Staff documented the resident reported he/she was scared. Staff documented they notified the resident's physician and received an order to transfer the resident to the hospital for a medical evaluation. Staff called emergency services. Record review of the resident's hospital Emergency Physician Record, dated 12/10/13 at 6:35 A.M., showed the following information: -Complaint of weakness and difficulty with standing or walking; -Onset of five hours; -The physician documented the resident woke up at 2:00 A.M., to use the restroom and could not use his/her left arm or leg. No attempt to go to the emergency room until the regular nurse arrived at 6:00 A.M. The facility staff told the emergency room physician the resident "didn't want to go"; -The physician assessed left sided weakness and [MEDICAL CONDITION] (weakness on one side of the body where the patient can move the impaired side of their body, but with reduced muscular strength); -Clinical impression of a stroke; -The physician admitted the resident to the hospital. Record review of the resident's hospital Discharge Summary, dated 12/13/13 at 10:50 A.M., showed the following information: -[DIAGNOSES REDACTED]. -Fairly dense stroke involving the left upper extremity and left lower extremity with a little more movement, slight movement with the left shoulder; -The resident discharged from acute care to a swing bed for accelerated physical therapy. During an interview on 1/14/14 at 9:18 A.M., Licensed Practical Nurse (LPN) J said he/she had worked the evening shift on 12/09/13, and noticed nothing out of the ordinary for the resident. LPN J said the resident ate well and voiced no complaints. He/she said the resident was able to ambulate to and from the bathroom independently on his/her scheduled shift. During an interview on 1/14/14 at 9:10 A.M., Nurse Aide (NA) I said the following: -The resident used his/her call light to use the restroom on the night shift on 12/9/13; -The resident said he/she felt weird on his/her left side; -NA I said he/she thought the resident experienced a stroke; -NA I assisted the resident to the bed and got the nurse; -The nurse assessed the resident and NA I obtained a set of vital signs at approximately 12:00 A.M. to 1:00 A.M.; -LPN H and NA I assisted the resident to get up and to use the restroom; -NA I said it was abnormal for the resident to require physical assistance to get up and use the restroom; -NA I said the resident requested assistance to the bathroom again (unknown time) and required NA I and LPN H to assist him/her to a wheelchair due to the resident was unable to grip the assistive walker; -NA I said the resident required assistance to the restroom a third time during the morning hours of the night shift and a mechanical lift had to be used to transfer the resident because the resident's condition declined and he/she was "extremely weak"; -NA I said the nurse did not have him/her monitor the resident's vital signs throughout the shift. During an interview on 1/14/14 at 10:12 A.M., LPN H said he/she worked on the night shift on 12/9/13 to the morning of 12/10/13. He/she said the resident was weak on the left side when he/she got up to use the restroom the first time. LPN H said he/she asked the resident if he/she wanted to go to the hospital and the resident declined. LPN H said he/she was unable to reach the resident's family (documentation showed an attempt at 4:40 A.M.). LPN H said the resident's condition declined during the night shift from using a walker to requiring a mechanical lift to transfer. LPN H said he/she was not sure why he/she did not call the physician to notify him/her of the resident's change in condition. LPN H said he/she was going to call the physician once it was closer to daylight. LPN H said when the day nurse reported for duty, the day nurse assessed the resident and immediately sent the resident to the hospital for an emergency evaluation. During an interview on 1/14/14 at 9:08 A.M., LPN K said he/she arrived to work the day shift at 6:00 A.M. on 12/10/13. LPN K said LPN H reported that the resident complained of left sided weakness at 3:00 A.M., and LPN H was unable to contact the resident's family. LPN K said he/she went to the resident's room upon LPN H's report at the change of shift of the resident's change in condition. LPN K assessed the resident, contacted the family, contacted the physician, and sent the resident to the hospital for an emergency evaluation. During an interview on 1/14/14 at 10:20 A.M., the DON said there are multiple things considered a change of condition including increased temperature, out of range blood pressure, or anything that would change from the resident's "normal". The DON said that staff should perform a head to toe assessment and document findings in the resident's chart when a resident presents with signs or symptoms of a stroke. She said she expected staff to notify the physician when the resident required more assistance with transfers due to the resident's weakened grip. The DON said she expected the staff to monitor blood pressure when a resident has signs or symptoms of a stroke, while waiting for emergency transport. During an interview on 1/14/14 at 9:01 A.M., the physician said if the nursing staff were concerned the resident experienced a stroke, the staff should have called him and not faxed a report. He said stroke symptoms require a phone call and an emergency evaluation. He said "time is of the essence with stroke care and management." NOTE: At the time of the 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 onsite visit, the nursing staff assessed all residents for signs and symptoms of infection or other changes in condition, disciplined the involved staff, re-educated the nursing staff on the policy and procedures for changes in condition, completion of nursing assessments, vital signs parameters, and documentation. The facility also developed additional quarterly and on-going competencies for the nursing department on reporting changes in conditions, and developed measures for ongoing monitoring of staff performance of the above tasks. A final revisit will be conducted to determine if the facility is in substantial compliance with participation requirements. At the time of exit, the severity of the deficiency was lowered to the "G" 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). MO 783