Every finding on record at Cox Medical Centers Meyer Orthopedic and Surgical

Based on interview and record review, the facility failed to develop and update the comprehensive facility assessment annually, in accordance with all applicable Federal requirements. Failure to develop and update the comprehensive facility assessment annually could delay the services needed to care for the residents in day-to-day operations and in emergencies. This failure could affect all facility occupants. The facility census was 7. Review showed the facility did not provide a policy regarding the facility assessment. 1. Review showed the facility did not provide a facility assessment document. During an interview on 04/22/26, at 4:36 P.M., the Administrator said she thought the facility assessment was completed in May 2025 prior to her taking over as administrator. The assessment has not been located. The assessment should be completed annually. The Manager, Assistant Manager, and she were responsible for compliance.During an interview on 04/22/26 at 4:34 P.M., the manager said she was not familiar with the facility assessment and was not part of working on that. During an interview on 04/23/26, at 9:00 A.M., regulatory affairs staff said staff were working on the facility assessment now. She did not have a facility assessment and did not find one. She did not have a policy for the facility assessment. During an interview on 04/23/26. at 9:00 A.M., the Administrator said she did not have a facility assessment.

Based on observation, interview and record review, the facility failed to assess risks of entrapment from bed rails prior to installation, failed to ensure that the beds dimensions were appropriate for each resident's size and weight, and failed to develop and implement interventions for the use of side rails on the residents' care plans for three residents (Resident #2, Resident #10, and Resident #11). The facility's census was 7.Review showed the facility did not provide a policy regarding the use of side rails. 1. Review of Resident #2's face sheet (admission data) showed the resident admitted to the facility on [DATE]. Review of the resident's consent to use half side rails showed the following:-The resident's responsible party gave verbal consent for the resident's use of the side rails;-Staff signed the document (after verbal consent) on 01/15/26. Review of the resident's admission Minimum Data Set (MDS-a federally mandated comprehensive assessment instrument completed by facility staff), dated 01/18/26, showed the following:-Moderately impaired cognition;-Independent with rolling left and right;-Required substantial/maximal assistance to transfer to and from a bed to a chair (or wheelchair). Review of the resident's care plan, dated 03/04/26, showed a problem of musculoskeletal with intervention to return the resident's mobility to the safest level of function. Review of the resident's medical record showed staff did not complete or document a side rails assessment or gap measurements for use of the resident's side rails. An observation on 04/21/26, at 10:20 A.M., showed the resident lay in bed with bilateral upper side rails raised and the left lower side rail raised. During an interview on 04/21/26, at 10:20 A.M., Registered Nurse (RN) B said the resident could turn himself/herself side to side independently. Observations on 04/21/26, at 12:52 P.M. and 5:05 P.M., showed the resident lay in bed with bilateral upper side rails raised and the left lower side rail raised. An observation on 04/22/26, at 8:40 A.M., showed the resident lay in bed with bilateral upper side rails raised and the left lower side rail raised. Observation and interview on 04/23/26, at 9:38 A.M, Resident #2 said the following:-His/her upper side rails stay in an upright position;-He/She did not know how to lower the side rails;-He/She used the upper side rails to reposition himself/herself for comfort;-He/She had not noticed gaps in the side rails;-He/She did not know if staff checked the side rails for gaps;-The resident lay in bed with bilateral upper and lower side rails raised. During an interview on 04/22/26, at 1:50 P.M., Assistant Registered Nurse (RN) Director/MDS Care Plan Coordinator said the following:-The resident was unable to get out of bed on his/her own;-The resident's care plan did not include side rails. 2. Review of Resident #10's face sheet showed an admission date of 12/12/25. Review of the resident's consent to use half side rails showed staff contacted the resident's responsible party on 12/25/25 at 2:01 P.M. Review of the resident's care plan, dated 03/01/26, showed staff did not address the use of side rails. Observations on 04/22/26, at 6:56 A.M., showed the resident in bed with both side rails up on both sides of his/her bed. Review showed the facility did not provide or document a side rails assessment or gap measurements for use of the resident's side rails. During an interview on 04/22/26, at 1:50 P.M., the Assistant Manager/MDS Care Plan Coordinator said the resident cannot get up out of bed on his/her own and the side rails are not on the care plan. 3. Review of Resident #11's face sheet showed an admission date of 4/13/26. Review of the resident's consent to use half side rails showed the following:-The resident signed on 04/13/26, at 1:00 P.M.;-Staff signed on 04/13/26 at 1:00 P.M. Review of the resident's care plan last, revised 04/14/26, showed staff did not address the use of side rails. Observations and interview on 04/22/26, at 7:41 A.M., showed the resident in his/her bed with both side rails up at head of his/her bed. The resident said he/she used the side rails for mobility. Review showed the facility did not provide or document a side rails assessment or gap measurements for use of the resident's side rails. During an interview on 04/22/26, at 1:50 P.M., the Assistant Manager/MDS Care Plan Coordinator said the resident's care plan did not have side rails listed. During an interview on 04/22/26, at 1:36 P.M., Licensed Practical Nurse (LPN) A said staff did not direct him/her to complete side rail assessments or gap measurements. 4. During an interview on 04/22/26, at 1:43 P.M., Registered Nurse (RN) B said the following:-Staff review consent upon admission with a resident or responsible party to have side rails;-Staff can place three side rails up, but not four side rails which were considered restricted or a restraint;-He/she did not remember completing a side rail assessment or seeing them on care plans. During an interview on 04/23/26, at approximately 9:00 A.M., RN D said the following:-Staff completed an assessment for residents' cognitive abilities, but they did not complete a specific side rail assessment;-In the previous medical record program, staff had a specific assessment for side rails;-When residents admitted to the unit, they signed a consent for siderails that included the risks of using siderails. During an interview on 04/22/26, at 2:14 P.M., the Physical Therapist said the following:-Therapy staff assess a resident for bed mobility and for both side rails to be placed in the up position;-If a resident did not have safe bed mobility, staff did not raise two side rails up but would lower the rails.-Staff did not put all four side rails up if a resident was confused. During interviews on 04/22/26, at 11:40 A.M. and 1:50 P.M., the Assistant RN Director/MDS Care Plan Coordinator said the following:-Staff raised bilateral upper siderails on all residents' beds admitted to the unit unless they determined the siderails were contraindicated such as with confused residents who could climb over the siderails when getting out of bed;-All residents had a choice to use the siderails and signed consent for the siderails;-Staff should review side rail consent and permission to use or decline upon admission with a resident or responsible party;-She did not enter side rails on the care plans or document side rails as part of the care plan;-The side rails on the beds did not remove but staff could leave the rails down;-Other than the side rail consent form, staff did not complete a specific assessment related to side rails;-Staff assess residents upon admission on their bed mobility. During an interview on 04/22/26, at 4:34 P.M., the Manager said the following:-She was not aware of any assessment completed on side rails;-Staff should look at whether the residents use side rails for mobility to help turn in bed and become more mobile on their own;-Staff should look for gaps in the side rails to ensure the residents did not get any body part caught for safety issue. During interviews on 04/23/26, at 1:52 P.M. and 4:42 P.M., the Administrator said the following:-She expected staff to look for gaps with the side rails on the bed;-Staff could not remove the side rails but can put them down;-Staff should assess a resident's cognitive status and if there are side rail safety issues, place the side rails down;-She did not have a side rail policy and did not have gap measurements and/or bed monitoring documentation.

Based on observation, interview, and record review, the facility failed to ensure resident environment remained as free from accident hazards as possible when the facility had water temperatures in excess of 120 degrees Fahrenheit ( F) in multiple resident rooms. The facility had a census of 7.Review of the United States Consumer Product Safety Commission (CPSC) document Avoiding Tap Water Scalds, dated 03/2012, showed the following:-Most injuries involving tap water scalds are to the elderly and children under the age of five;-The CPSC urges all users to lower their water heaters to 120 degrees F;-Most adults will suffer third-degree burns if exposed to 150 degrees F water for two seconds;-Burns will also occur with a six-second exposure to 140 degrees F water or with a thirty second exposure to 130 degrees F water;-If the temperature is 120 degrees F, a five-minute exposure could result in third-degree burns Review of the facility water management plan, reviewed [DATE], showed the following:-The Central Domestic Hot Water System identified two gas fired water heaters with 140 degrees F water;-The water distributed to a mixing valve (combines cold and hot water to lower water temperature in transit to final area of use) down to 125 degrees F for building distribution;-The plan also identified three steam powered instant hot water heaters with no mixing valve providing 125 degrees F water to the building. 1. Review showed an outside vendor calibrated the facility multimeter (a device used to measure various electrical currents with some manufactured with ability to measure temperature) on [DATE]. The calibration expired on [DATE]. Observation on [DATE] showed the following resident room hot water temperatures:-At 1:08 P.M., room [ROOM NUMBER] (unoccupied) had a sink water temperature of 133 degrees F. The Engineering Supervisor tested the water temperature with a multimeter. The temperature was 131 degrees F;-At 1:09 P.M., room [ROOM NUMBER] (unoccupied) had a sink water temperature of 134 degrees F. The Engineering Supervisor tested the water temperature with a multimeter. The temperature was 131 degrees F;-At 1:11 P.M., room [ROOM NUMBER] (unoccupied) had a sink water temperature of 137 degrees F. The Engineering Supervisor tested the water temperature with a multimeter. The temperature was 129 degrees F;-At 1:23 P.M., room [ROOM NUMBER] (resident occupied) had a sink water temperature of 132 degrees F and a bathroom sink temperature of 131 degrees F. The Engineering Supervisor tested the main room sink and bathroom sink water temperatures with a multimeter. The main room sink temperature was 127 degrees F. The bathroom sink temperature was 126 degrees F;-At 1:26 P.M., room [ROOM NUMBER] (resident occupied) had a sink water temperature and bathroom sink temperature of 131 degrees F. The Engineering Supervisor tested the main room sink and bathroom sink water temperatures with a multimeter. The main room sink temperature was 126 degrees F. The bathroom sink temperature was 127 degrees F;-At 1:30 P.M., room [ROOM NUMBER] (resident occupied) had a sink water temperature of 131 degrees F and a bathroom sink temperature of 132 degrees F. The Engineering Supervisor tested the main room sink and bathroom sink water temperatures with a multimeter. The main room sink and bathroom sink temperatures were 128 degrees F. Observation on [DATE], at 1:37 P.M., of the boiler/mechanical room showed the following:-The temperature valve set to the second to highest setting (temperature not indicated);-The mixing valve temperature gauge showed 110 degrees F. During an interview on [DATE], at 1:37 P.M., the Regulatory Affairs Safety Coordinator said the facility utilizes instant steam heaters for hot water. The water is initially higher than 120 degrees F to kill bacteria. The water circulates to the mixing valve to lower the water to an appropriate temperature for circulation to the building. The water management policy details the hot water requirements for the facility. The water temperature should be between 105 degrees F and 120 degrees F. The engineering department was responsible for monitoring water temperatures. He/She did not know if the policy showed how often staff should check hot water temperatures. During an interview on [DATE], at 1:38 P.M., the Engineering Supervisor said he/she did not know if staff checked the mixing valve temperature gauge for accuracy. Staff visually check the temperature valve and mixing valve gauge for anything unusual. During an interview on [DATE], at 7:31 A.M., Environmental Service Technician (EVS) E said he/she cleaned rooms daily. He/She did not know hot water temperature range requirements. He/She did not know who monitored hot water temperatures or how often. Staff should report concerns about hot water to the Environmental Services Manager and nurses on staff immediately. During an interview on [DATE], at 9:10 A.M., Licensed Practical Nurse (LPN) A said he/she did not know of any reports regarding excessively hot water. He/She did not know temperature range requirements or who monitored water temperatures. Staff should report water temperature concerns immediately to the Assistant Registered Nurse Director and document in the maintenance log system. During an interview on [DATE], at 9:16 A.M., Maintenance Staff F said maintenance monitors water temperatures at the mixing valve in the boiler room. He/She did not know how often monitoring occurred. He/She did not know if the facility had a process for monitoring water temperatures in resident rooms. Staff should input a work order in the maintenance log for any concerns. During an interview on [DATE], at 10:55 A.M., Registered Nurse (RN) B said he/she was unaware of concerns related to hot water. Staff should create a maintenance work order immediately for concerns related to hot water. During an interview on [DATE]., at 1:15 P.M., the Environmental Safety Officer said water temperatures should be according to the water management plan. The policy said water temperatures should be 125 degrees F. Staff monitor water temperatures at the boiler. He/She did not know if staff monitor water temperature at the sinks. The boiler water temperature should not exceed 125 degrees F. The sinks have mixing valves for adjusting the temperature of water received. Staff should contact the engineering department concerning issues with hot water temperatures. The engineering department was responsible for maintaining water temperatures. During an interview on [DATE], at 1:51 P.M., the Administrative Director of Engineering said the facility had recent water temperature fluctuations related to repairs of the hot water mixing valve. On [DATE], at 2:39 P.M., housekeeping staff notified the maintenance department during the weekend of hot water temperatures for 300 hall and 400 hall. Maintenance staff investigated at that time and found environmental services staff hung cleaning equipment on the mixing valve lever preventing proper function. On [DATE], the water recirculating pump did not function properly requiring replacement. Facility staff notified the maintenance department during the weekend of hot water temperatures. Maintenance staff investigated at that time and found environmental services staff hung cleaning equipment on the mixing valve lever preventing proper function. The facility maximum water temperature is 125 degrees F with resident room temperatures requiring temperatures between 105 degrees F and 120 degrees F. The Engineering Supervisor is responsible for compliance. During an interview on [DATE] at 4:34 P.M., the Manager said a hot water issue occurred over the past weekend, but she did not know about it until Tuesday morning ([DATE]). The engineering department was responsible for testing the water. She did not know how often staff check the hot water temperatures. It is important to check the hot water temperatures due to not having it too hot which could cause damage to a resident. During an interview on [DATE], at 4:36 P.M., the Administrator said the engineering department was responsible for monitoring hot water temperatures and checking to ensure proper temperature. Staff should report issues with water temperatures directly to the engineering department. She had not received any reports of concerns related to water being too hot.

Based on observation, interview, and record review, the facility failed to maintain an effective and complete infection control program when staff failed to implement Enhanced Barrier Precautions (EBP - an infection control intervention designed to reduce transmission of multidrug-resistant organisms (MDRO - microorganisms, predominantly bacteria that are resistant to one or more classes of antimicrobial agents. Although the names of certain MDROs describe resistance to only one agent, these pathogens are frequently resistant to most available antimicrobial agents) that employs targeted gown and glove use during high contact resident care activities) for one resident (Resident #5) who had a gastrostomy tube (G-tube - a surgically placed device providing direct access to the stomach for feeding, fluids, and medications when a person cannot eat enough by mouth) and a jejunostomy tube (J-tube - a long-term feeding tube surgically placed through the abdomen directly into the small intestine's middle section (jejunum) to deliver nutrients and medication). A sample of three residents was selected. The facility census was 7.Review of Centers for Disease Control and Prevention' (CDC) Implementation of Personal Protective Equipment (PPE) Use in Nursing Homes to Prevent Spread of MDROs, dated 04/02/24, showed the following:-MDRO transmission is common in skilled nursing facilities, contributing to substantial resident morbidity and mortality and increased healthcare costs;-EBP are an infection control intervention designed to reduce transmission of resistant organisms that employs targeted gown and glove use during high contact resident care activities;-EBP may be indicated (when Contact Precautions do not otherwise apply) for residents with any of the following: wounds or indwelling medical devices, regardless of MDRO colonization status, and infection or colonization with an MDRO;-Examples of high-contact resident care activities requiring gown and glove use for EBP include dressing, bathing/showering, transferring, providing hygiene, changing linens,changing briefs or assisting with toileting, device care or use of central line (a long, flexible tube inserted into a large vein in the chest, neck, or arm, with the tip ending close to the heart), urinary catheter (a thin, flexible, indwelling urinary tube inserted through the urethra into the bladder to drain urine continuously), feeding tube (a medical device used to deliver liquid food, fluids, and medications directly to the stomach or small intestine), tracheostomy (a surgical procedure that creates an opening, called a stoma, through the neck directly into the windpipe (trachea) /ventilator (a medical machine that helps a patient breathe or fully breathes for them)and wound care of any skin opening requiring a dressing.Review of the facility's policy titled Infection Prevention, reviewed 06/30/25, showed the following:-To reduce or prevent exposure to infectious agents among patients, healthcare workers, visitors, students and volunteers;-Healthcare workers caring for patients in EBP are to perform hand hygiene and don an isolation gown and gloves at the entry way of the patient's room, during high contact resident care activities;-EBP is indicated for residents with any of the following: infected or colonized with a multiple drug resistant organism (MDRO) without a wound, indwelling medical device or secretions or excretions that are unable to be covered or contained; has a wound or indwelling medical device, and secretions or excretions that are unable to be covered or contained and are not known to be infected or colonized with any MDRO; and has a wound or indwelling medical device excretions that are unable to be covered or contained and are not known to be infected or colonized with any MDRO;-For residents for whom EBP is indicated, EBP should be used when performing the following: dressing, bathing, showering, transferring, providing hygiene, changing linens or assisting with toileting, device care or use central line, foley catheter, feeding tube, tracheostomy, ventilator, and wound care (any skin opening requiring a dressing).1. Review of Resident #5's face sheet (admission data) showed an admission date of 03/31/26. Review of the resident's current care plan showed staff did not address or develop interventions for EBP. Review of the resident's admission Minimum Data Set (MDS-a federally mandated comprehensive assessment instrument completed by facility staff), dated 04/06/26, showed the following:-Cognitive skills intact;-Had a feeding tube. Review of the resident's current physician orders showed no orders for EBP.An observation and interview on 04/21/26, at 10:22 A.M., showed the following:-The resident sat in his/her wheelchair in his/her room;-The resident had a G-tube and a J-tube. Both insertion sites were covered with gauze dressing under his/her shirt;-No signage visible on the resident's door indicating EBP;-The resident said staff did not wear isolation gowns when providing care for his G-tube and J-tube.An observation on 04/21/26, at 12:57 P.M., showed the following:-No signage on the resident's door indicating EBP;-Licensed Practical Nurse (LPN) A entered the resident's room and administered medication through his/her G-tube, flushed both feeding tubes, and cleaned and dressed the tubes' insertion sites;-The LPN performed hand hygiene and donned gloves prior to performing G-tube and J-tube care. The LPN did not don an isolation gown.An observation on 04/21/26, at 5:17 P.M., showed the following:-No signage on the resident's door indicating EBP;-LPN A entered the resident's room to start the resident's continuous enteral feeding through his/her J-tube;- The LPN performed hand hygiene and donned gloves prior to performing G-tube and J-tube care. The LPN did not don an isolation gown.During an interview on 04/21/26, at 5:40 P.M., LPN A said the following:-The facility initiated EBP for residents who had indwelling ports (a small, surgical device placed under the skin for long-term, repeated IV access), wounds infected with MDROs, and certain wound appliances such as wound vacs (a medical device that uses suction to accelerate healing for chronic or large acute wounds);-They did not initiate EBP for residents with indwelling catheters or feeding tubes (G-tubes, J-tubes)'-If a resident required EBP, staff placed a sign on the resident's door explaining the precautions, and staff would don gloves and an isolation gown before entering the resident's room;-At that time, they had no residents who required EBP.Observations on 04/22/26 showed no signage on the resident's door indicating EBP.During an interview on 04/22/26, at 10:55 A.M., Registered Nurse (RN) B said the following:-Staff should implement EBP precautions all wounds, catheters, tube feeding, and inserted lines;-Resident #5 should have EBP in place but staff did not implement as required;-He/She did not know why staff missed implementation of EBP for Resident #5;-The Assistant Manager reviews resident status daily regarding need for EBP and should inform nursing staff;-The Assistant Manager and nurses were responsible for implementing EBP when required.During an interview on 04/22/26, at 11:40 A.M., the Assistant RN Director said the following:-They initiated EBP for residents with indwelling catheters, peripherally inserted central catheter (PICC) lines (a long, thin, flexible tube inserted through a vein in the upper arm and guided into a large vein above the heart), chronic (a condition, disease, or problem that persists for a long duration), infected, or deep wounds, and G-tubes and J-tubes.-Either the infection preventionist who assessed an infected wound or the resident's admitting nurse initiated EBP;-When a resident required EBP, staff wore gloves and an isolation gown when assisting the resident with personal care and transfers, and when caring for the tubes; -Resident #5 had a G-tube and J-tube and should have been on EBP. During an interview on 04/23/26, at approximately 9:00 A.M., RN D said the following:-Residents with PICC lines, drain tubes, G/J-tubes and indwelling catheters required EBP;-EBP consisted of staff donning gloves and an isolation gown when performing tasks with personal contact such as administering medications through a G/J-tube;-When a resident required EBP, the provider entered the order for EBP into the EMR. If there was not an order for EBP, the nurses could recommend initiation of EBP, however, usually the provider entered the order;-Resident #5 was not on EBP but met the requirements for EBP;-He/she may have forgotten the resident needed EBP. During an interview on 04/23/26 at 1:52 P.M., the Administrator said the following:-Staff should wear appropriate PPE when assisting residents who have PICC lines, catheters and wounds which make them more at risk for infection;-When staff entered an order for EBP into the new electronic medical record system, it prompted them to look for an infection. The facility has entered a (help) ticket for the software company to review this prompt.During an interview on 4/23/26, at 4:42 P.M., the RN director said she was not familiar with EBP procedures.

Based on record review, observation and interview the facility failed to obtain specific flush orders and dressing change orders and failed to ensure the physician orders specified which tube staff should administer medications through and which tube staff should administer feedings though for one resident (Resident #5) who had a gastrostomy tube (G-tube - a surgically placed device providing direct access to the stomach for feeding, fluids, and medications when a person cannot eat enough by mouth) and a jejunostomy tube (J-tube - a long-term feeding tube surgically placed through the abdomen directly into the small intestine's middle section (jejunum) to deliver nutrients and medication). The facility's census was 7. Review of the facility's policy titled Tube Feeding, undated showed the following:-Special instructions and procedures outlined below will be followed by licensed nurses upon receipt of a provider order when tube feedings are administered to provide adequate nutrition and fluids to patients with a functioning gastrointestinal (GI -t he body system responsible for digestion) tract but unable to ingest adequate nutrients orally;-Provider will order the type of formula, volume and frequency of feeding;-See specific physician order for Enteral/Tube Feeding Orders for flushing instructions;-Document any residual, flushes and tube placement checks in the gastrointestinal detail section in the electronic health record. 1. Review of Resident #5's face sheet (admission data) showed the resident was admitted to the facility on [DATE]. Review of the resident' care plan, dated 03/31/26, showed the following:-Altered nutrient intake;-Nutrient intake appropriate for improving, restoring or maintaining nutritional needs.(Staff did not care plan interventions related to his/her G-tube/J-tube and tube feedings.)Review of the resident's orders, dated 03/31/26, included the following:-An active order for gastric tube care, sterile water, flush feeding tube with 30 milliliters (ml) of water prior to medication administration, hold feeds. Give each medication separately via feeding tube and flush with 10 ml water between each medication. Flush feeding tube with 30 ml of water to clear residual medication before feeds are resumed;-An active order for wheat dextrin oral powder packet 2 packets, 3 times a day, Mix according to package directions. Can be administered orally or via feeding tube (the order did not specify which tube to use for medication administration).Review of the resident's medical record showed no orders for J-tube flushes or dressing changes to the insertion sites.Review of the resident's admission Minimum Data Set (MDS-a federally mandated comprehensive assessment instrument completed by facility staff), dated 04/06/26, showed the following:-Cognitively intact;-Had a feeding tube. Review of the resident's medical record showed an order, dated 04/13/26, for Jevity (calorically dense, fiber-fortified therapeutic nutrition that provides complete, balanced nutrition for long- or short-term tube feeding) 1.5 cal, 70 ml/hour for 12 hours from 6:00 P.M. to 6:00 A.M., daily. (The order did not specify which tube to administer the feeding through.)Review of the resident's Avatar flowsheet (for G-tube and J-tube flushes and dressing changes), dated 04/01/26 to 04/22/26, showed the following:-Staff documented flushing the resident's J-tube with sterile water 21 times (the resident did not have an order for J-tube flushes);-Staff documented completing the split gauze dressing intervention (changing the dressing) on the G-tube site six times (the resident did not have an order for the dressing change);-Staff documented completing the split gauze dressing intervention (changing the dressing) on the J-tube site two times.Observation and interview on 04/21/26, at 10:22 A.M., showed the following:-The resident sat in his/her wheelchair in his/her room;-The resident had a G-tube and a J-tube. Each tube insertion site was covered with a gauze dressing.-He/she did not have an appetite and received nutrition through one of the feeding tubes at night. An observation on 04/21/26, at 12:57 P.M., showed the following:-Licensed Practical Nurse (LPN) A entered the resident's room to administer medication through the resident's feeding tube and to change the dressings around the tube insertion sites;-The LPN said he/she administered the resident's medications through the G-tube and administered his/her feeding through the J-tube;-The LPN flushed the G-tube with 30 milliliters (ml) of sterile water before and after administering the medication, then flushed the resident's J-tube with 50 ml of water;-The LPN said they changed the T-sponges around each tube insertion site, every day;-The LPN changed the T-sponges from each tube site and dated the sponges.An observation on 04/21/26, at 5:17 P.M., showed the following:-LPN A entered the resident's room to start the resident's continuous enteral feeding;-The LPN prepared the Jevity bottle and tubing then inserted the tubing into the feeding pump; -He/she prepared another bag filled with sterile water for flushes;-The LPN said the resident received 30 ml of water every four hours during the continuous feeding;-The LPN connected the Jevity tubing to the resident's J-tube and set the pump for 70 ml/hour.During an interview on 04/23/26, at approximately 9:00 A.M., Registered Nurse (RN) D said the following:-If a resident admitted with a feeding tube, the provider wrote G-tube/J-tube care orders as well as the tube feeding orders. Sometimes the registered dietician would also write the tube feeding orders;-If a resident did not have orders for dressing or flushes, the nurse could reach out to the provider for those orders;-If the resident did not have orders for flushes or dressing changes, if the nurses completed one of those tasks, there would be nowhere for them to document the task;-If a resident had a G-tube and J-tube, the nurses passed on in reporter which tube to use for which task although there should be orders that instructed staff on the care and use of the tubes. for each;-Resident #5 had a G-tube and a J-tube. They used the G-tube to administer medications and the J-tube to administer his/her feeding;-The RN reviewed the resident's EMR and said he/she did not find an order for J-tube flushes.During an interview on 04/23/26, at 9:30 A.M., LPN A said the following:-The provider entered the orders for tube feedings, insertion site dressing changes and flushes;-On 04/22/26, the LPN asked the Nurse Practitioner (NP) for an order to change the T-sponges around the resident's tube insertion sites;-The LPN reviewed the EMR and did not find an order for J-tube flushes;-When a resident admitted , the nurses wrote report on a Situation, Background, Assessment, Recommendation (SBAR) form, then updated the form as the resident's care needs changed. The nurses used that form to give report to each other;-The LPN showed the surveyor the SBAR for Resident #5 which included specific notations regarding which tube to use for which task; G-tube for medications, J-tube for feeding;-The SBAR also noted a 30 ml water flush every four hours for the J-tube and a 50 ml water flush for the G-tube;-The LPN said when administering medications, they flushed the tube with 30 ml of water, then 10ml between each medication, finishing with a 30ml flush. The LPN did not know if this was entered as a task but knew those instructions did not pop up on their handheld screen when administering medications;-The LPN thought she read an order with instructions on which tube to use but when he/she looked in the medical record, he/she did not find it.During an interview on 04/23/26, at 2:25 P.M., the Assistant RN Director said the following:-When a resident admitted with a feeding tube, the dietician conducted a nutritional review of the resident then worked with the provider to set the feeding rate;-When a resident admitted , they admitted with discharge recommendations that the provider could approve;-The nurses could propose orders for the provider to review and accept or reject;-There should be orders for flushes, dressing changes, feeding type and rate;-The RN reviewed Resident #5's discharge summary and found instructions for staff to use the J-tube for feedings. There was no order for this.During an interview on 04/23/26, at 6:20 P.M., the Administrator/Director and RN Director said the following:-The RN Director said the provider entered orders for G-tube/J-tube care. If a resident had more than one tube, the order should be specific for each tube; -There should be orders for dressing changes and flushes;-The Administrator/Director said the previous medical record software had order sets which included multiple care orders related to a specific device or diagnoses such as feeding tubes.

Based on observation and interview, the facility failed to provide dignity and respect to a resident during a wound care treatment when a staff member argued with one resident (Resident #4) who attempted to direct his/her own care. The facility census was 7.Review of the facility's policy titled Patient [NAME] of Rights, undated, showed the following:-The purpose of the Patient [NAME] of Rights is to inform patients and their family members of their rights and responsibilities;-The facility has defined patient rights and responsibilities to comply with the patient Self-Determination Act, (Health Insurance Portability and Accountability Act (Hippa) and Centers for Medicare and Medicaid Services (CMS) and other applicable regulations and organizational values;-Patients have the right to be treated with respect and dignity. Patients will be cared for in a safe environment that provides personal privacy, preserves dignity and contributes to a positive self-image;-Be involved in their care decisions including but not limited to participating in all decisions related to their health care;-Participate in the development and implementation of their plan of care including but not limited to being involved in care planning, treatment and discharge planning;-Patients have the responsibility to communicate with caregivers their desires and to ask questions to ensure they understand the plan of care being considered. 1. Review of Resident #4's face sheet (admission data) showed an admission date of 03/31/26. Review of the resident's admission Minimum Data Set (MDS-a federally mandated comprehensive assessment instrument completed by facility staff), dated 04/06/26, showed the following:-Cognitive skills intact;-The resident was independent with toileting and mobility. Review of the resident's care plan, revised 04/26/26, showed the patient/family able to effectively weigh alternatives and participate in decision making related to his/her treatment and care. An observation on 04/22/26, at 3:35 P.M., showed the following:-Skin Wound Ostomy Team (SWOT) Registered Nurse (RN) C and Licensed Practical Nurse (LPN) A entered the resident's room to perform wound care on his/her left leg;-The resident lay in bed with a Kerlix (a highly absorbent, 100% cotton fluff gauze with a crinkle-weave pattern, commonly used as a primary or secondary dressing to manage wound drainage) around his/her left leg with serous (a clear, thin, watery plasma that commonly appears during the early stages of wound healing) drainage approximately the size of an egg visible on the left side/back of the Kerlix dressing;-The resident told the RN and LPN the supplies they needed and where they should place the supplies;-The resident asked the nurses to place three disposable pads under his/her legs to catch the saline when they irrigated the wound;-The RN said they did not need to place that many disposable pads under his/her legs as he/she would not need that much saline;-The resident said you will need two bottles of saline and the 60 milliliter (ml) syringe and large plastic graduated container located on a counter in his/her room, to irrigate the wound;-The LPN looked at the container, syringe, and two opened bottles of normal saline and threw them in the trash as no opened date was visible on the items. One unopened bottle of saline remained on the counter along with a pink plastic basin that contained various supplies;-The resident told the nurses they needed the container they threw away to pour saline in when they irrigated the wound with the syringe;-The RN said he/she would not need that large container as he/she would not use that much saline;-The RN asked the resident if he/she could pour saline over the wound, and the resident said no, he/she did not want all of that saline on his/her bed and again requested more disposable pads;-The LPN found another syringe in the supply bucket and showed the RN. The resident said that syringe was not big enough and you need to irrigate it using the large syringe. The LPN looked and found another 60 ml syringe;-The resident said on Monday, the nurse practitioner changed the frequency of the dressing change to every three days. This (pointing to the visible drainage on the dressing) is the reason he/she could not go three days without a dressing change; -The resident again asked the nurses to get four 4X4 gauze and more saline, neither nurse acknowledged the resident's request;-The RN told the resident if the drainage was leaking through the dressing, they needed to change the Xeroform (a non-adherent wound dressing consisting of fine mesh gauze primarily used to maintain a moist wound environment for low-draining, chronic (continuing or occurring again and again for a long time) wounds). The resident said the absorbent dressing would stick to the wound. The RN said they could replace the ABD pad (thick, highly absorbent medical dressings designed for heavily draining wounds) with the more absorbent dressing. The resident said it would not need that if staff changed it every day; -The resident again asked the RN for four 4X4 gauze. The RN said he/she would not need three gauze; the resident said you will need four. -The RN grabbed his/her scissors and started to lift the Kerlix to cut off the dressing. The resident said do not start until you have all of the supplies assembled, four 4X4 gauze, more saline and a large container and syringe;-The resident then told the nurses to place a table at the end of the bed to set the supplies on. The RN slid out the bottom tray of the resident's bedside table. The resident said no, do not use that, it is dirty. The RN said he/she would clean it and wiped off the bottom tray of the bedside table with a sanitizing wipe. The resident said no, do not use that. They use the table near the window (pointing to a small table with various wound supplies). The LPN removed the items from the table near the window, moved it closer to the bed, but not at the foot of the bed as the resident requested, then cleaned it with a wipe. The LPN picked up supplies to place on the table, but the resident said you need to place something over the table before adding the supplies. The RN placed the pad on the table still wet from sanitizing wipe. The resident said no, you need to dry off the table before placing supplies on it as it could seep through and make the supplies wet. The nurses removed the disposable pad, dried the table with a paper towel, then covered the table with a new disposable pad;-The resident asked the nurses again to get a large container with a syringe to irrigate the wound. The nurse said he/she would not need it and this was what he/she was doing. The resident said you are not supposed to rub the wound and again insisted on the large container with syringe; -The RN disagreed with the resident several times about not needing the large container.-The resident said you could have gotten another one (from the supply room) instead of arguing with him/her;-The RN said, this is how we are doing the dressing change, is that okay? The resident said no, it was not okay;-The resident said ma'am, please, could you get the large container?-The RN and LPN left the room and returned a short time later with a sealed package. The RN opened the package and removed a large syringe and small container from the package;-The resident said please, get the proper materials. He/she did not know why he/she (the RN) was arguing with him/her. He/she (the resident) wanted a large container so they (the nurses) would not need to pour more saline in the container. The large container held enough fluid to complete the irrigation;-The RN said this one (pointing to the smaller container) would work fine;-The resident said it was too small and he/she needed to get one like he/she had;-The LPN said this one (pointing to the small container) was sterile and the one the resident kept requesting was not sterile and was packaged in bulk. The smaller container should work fine;-The resident said the large container was clean and when staff would bring it to him/her, it was covered with plastic; -The RN said he/she had been doing this (dressing changes) for 27 years and this container (pointing to the small container) would work fine. Could he/she just remove the resident's dressing. The resident said place another disposable pad under his/her legs;-The RN started unwrapping the kerlix covering the resident's wound, and the resident again told the nurses they needed to place another disposable pad under her legs. The RN told the LPN to place another pad under his/her legs if it made the resident happy. The LPN complied; -The RN told the resident he/she was sorry but this was his/her first time changing the resident's dressing. The resident said he/she knew that and that was why he/she was telling the RN how to do itl-The resident said ma'am could you just get the large container? The resident said I should not have to go through this;-The RN asked the resident if he/she could remove the dressing. The resident agreed then told the RN how to remove the tape and unwrap the three kerlix wrapped around his/her leg;-The RN filled the syringe with normal saline and turned to moisten the ADB dressing which had visible drainage that leaked through to the outside of the dressing. The resident said, do not saturate my dressing. The RN said he/she would like to wet it. The resident said no, it would come off; -The RN carefully removed the ABD pads and showed a large amount of serous, yellow and bloody drainage on the ABD. The resident said they saturate this pointing to the xeroform still covering the wound;-At approximately 4:05 P.M. (30 minutes after the RN and LPN entered the room), the SWOT Manager and another RN entered the resident's room. The resident looked at the four nurses standing in the room and said he/she did not want an entourage. LPN A left the room followed by the second RN;-The SWOT Manager introduced herself to the resident and RN C saturated the xeroform with saline. After saturating the xeroform, the resident said the RN needed to change his/her gloves. The RN said he/she was just going to remove the old dressing. The resident said no, change your gloves, you have been touching the syringe. The SWOT manager told the RN, Just do it.-The RN changed his/her gloves, and the SWOT manager took over the wound care;-The resident told the SWOT nurse to move the table containing the supplies to end of the bed and the trash can to the right of the SWOT manager. Neither nurse moved the table to the end of the resident's bed as requested;-The SWOT nurse removed the xeroform and showed a large red, open wound, which wrapped around the entire circumference of the resident's leg except for a small vertical strip of skin approximately two centimeters (cm) wide and the length of the wound;-The RN told the SWOT Manager that he/she discussed with the resident that a more absorbent dressing would be better, but the resident did not want that;-The SWOT Manager poured more saline in the small container. The resident told the SWOT Manager he/she wanted her to irrigate the wound vertically, starting at the top then moving down the leg. The SWOT Manager said she did not think that was a big deal, the resident said it was and repeated how he/she wanted the SWOT Manager to irrigate the wound. The SWOT nurse complied;-The resident said he/she needed two more disposable pads under his/her legs. The RN told the resident he/she already had one. The resident said he/she needed another as he/she did not want blood and drainage all over his/her sheets;- The resident looked at his/her wound and told the SWOT Manager that it appeared meaty because the NP changed the order. The SWOT nurse confirmed the NP's order and said they would talk to the NP or physician about the change;-The resident again said he/she wanted another disposable pad under his/her legs. The SWOT Manager asked the RN to get it for the resident;-After irrigating the wound per the resident's directions, the SWOT Manager began drying the wound by patting it with a 4X4 gauze, starting at the top working her way around the resident's leg in a circular. The resident told the SWOT Manager that she needed to start at the top and work her way down the leg. The SWOT Manager said she was going around the wound. The resident said no, go from the top down, vertically, to ensure the entire wound was dried. The SWOT Manager said she did but would do it the way he/she (the resident) wanted. The resident said that was not how he/she wanted it but how it was always done;-While the SWOT Manager performed the resident's wound care, the resident told the nurse, see, if you would have moved the table to where he/she asked (at the foot of the bed), you would not have to twist around, your supplies would be within easy reach;-The SWOT Manager then applied the xeroform per the resident's instructions and before she could start apply the ABD pad, the resident said, change your gloves. The SWOT Manager said the protocol was to change gloves after removing the dirty dressing before applying a clean dressing, and she was going from a clean dressing to another clean dressing. The resident said he/she did not care, the SWOT Manager's hands were sticky from the xeroform. The Manager complied with the resident's request.-The SWOT Manager completed the dressing change and RN C applied lotion to the resident's feet and legs.During an interview on 04/22/26, at 5:22 P.M., RN C and the SWOT Manager said the following:-RN C said he/she worked as a wound nurse for 27 years. The NP ordered staff to clean the resident left leg wound with saline, apply Xeroform, cover with ADB and wrap with kerlix, every 72 hours.;-The SWOT manager said she was RN C's manager. Resident #4 was very picky and not receptive to all plans of care (related to wound management). They had to find a plan that was appropriate for the wound and one that he/she (the resident) agreed with;-RN C said someone told him/her that the resident liked things a certain way. The resident became upset with him/her (RN C) because he/she was not doing things like he/she (the resident) wanted. The RN C said he/she probably did argue with the resident over the size of container;-The SWOT Manager said the RN used the sterile container because it was cleaner and thought the resident would prefer that;-RN C said he/she used a sterile container and syringe but did not use sterile technique, it was clean technique. The RN said after the interaction, he/she guessed the size of the graduate container did not matter. After he/she completed all of the wound care, he/she told the resident thank you. He/she thought the resident appeared calmer when he/she did as the resident saw fit;-The SWOT Manager said when the resident asked her to change her gloves after applying the xeroform, she tried to educate the resident but decided to just do it if it made the resident more comfortable and less anxious.During an interview on 04/23/26, at 9:46 A.M., the resident sat in his/her bed. The resident said the nurse did not want to use the table to organize his/her wound care materials. The resident informed the wound care nurse other staff organize the wound care material first. The resident did not feel the wound care nurse listened to him/her.During an interview on 04/23/26, at 9:30 A.M., RN D said the following:-Staff should not argue with residents;-If staff and a resident did not agree about a plan of care, staff should have a conversation with the resident, but resident could have their own opinion about their care, and they are allowed to refuse; -Staff should try to honor residents' preferences within reason.During an interview on 04/23/26, at 5:10 P.M., LPN A said the following:-RN C made a point when he/she did not comply with the resident; -We, as nurses, used the container we thought was appropriate for the situation;-The type of container did not necessarily matter but we did not want to compromise with her because where would it stop? He/she would think he/she was right, and we would have no say in the care we provided;-RN C used the type of container and syringe he/she thought the resident wanted, it was sterile and the resident was concerned with germs;-After discussing the incident further, the LPN said if a resident could not control their environment, they could control how other provided their care, and we are their advocates.During an interview on 04/23/26, at 1:52 P.M., the Director said she expected staff to honor resident requests and not argue with a resident regarding care. She expected staff to educate a resident if a request contradicted a physician order and staff should find a compromise to work with the resident. During an interview on 04/23/26, at 2:25 P.M., the Assistant RN Director said the following:-The nurse could not override the provider's orders if a resident did not agree with it. The resident had the right refuse the treatment;-The resident wanted staff to use four 4X4s because at one time, staff did not dry the wound well enough and left it too wet;-It was not okay for staff to be disrespectful or show no concern for a resident;-Resident #4 was very particular but the interaction between him/her and RN C did sound like a power struggle;-Sometimes it was easier to follow a resident's instructions as long as the instructions were not unreasonable such as not following a provider's order.During an interview on 04/23/26, at 4:20 P.M., the RN Director and Administrator/Director said the following:-The RN Director said it was not appropriate for staff to argue with a resident. If they had a disagreement, the two parties should communicate and discuss the issue and come to a reasonable agreement;-The Director said when in the facility, residents did not have a lot of choice and giving them a sense of control could mitigate problems and they may be willing to do things for you;-The RN Director said arguing with a resident is not what we expect of staff. Resident #4 knew his/her treatment. Complaint 2797590

Based on interview and record review, the facility staff failed to ensure 100% of staff had been fully vaccinated for COVID-19 (a highly contagious virus that causes serious illness or death), or granted a qualifying exemption when one staff (Employee C) had not received the full primary vaccination series as of the start of the survey on 6/28/2022. The facility census was 14. Record review of the facility policy entitled Universal COVID-19 Vaccination (undated) showed the following information: -Vaccination is known to reduce the instance and severity of COVID-19 illness in the workplace. The facility has adopted this policy on mandatory vaccination to safeguard employees, providers, and patients from the hazards of COVID-19; -The facility requires all staff to be fully vaccinated for COVID-19 unless an exemption from this policy has been granted as an accommodation. Regardless of clinical responsibility or patient contact, the policy and procedures apply to covered workforce members, which includes employees, licensed practitioners, and individuals who provide care, treatment, or other services for the facility or its patients; -Individuals who fail to comply with policy requirements will not be allowed to work or provide services and will be subject to disciplinary measures, up to and including termination of employment, contracted services, or medical staff membership. Record review of the Centers for Disease Control and Prevention (CDC) Stay Up to Date with Your COVID-19 Vaccines, dated 06/24/2022, showed the following: - A person is considered full after two week after receiving the final dose of the primary series; -The primary series is two doses given three to eight weeks apart. 1. Record review of the facility's undated COVID-19 Vaccination Status - TCU Staff showed the following: -Total staff of 27; -Staff partially vaccinated: 0; -Staff fully vaccinated: 27; -Staff with medical exemptions: 0; -Staff with non-medical exemptions: 0. Record review of the facility's COVID-19 resident outbreak documentation showed no residents tested positive for COVID-19 for the past four weeks. Record review of Employee C's COVID-19 Vaccination Record Card showed the following: -The first dose COVID-19 two-step vaccination dose was administered 1/25/2022. (The card did not show documentation of a the second dose.) Record review of Employee C's facility COVID-19 Immunization Record showed the following information: -Employee received the first dose of a two dose COVID-19 vaccine series on 1/25/2022. (The record did not show the second dose was provided prior to the survey start on 6/28/2022.) During an interview on 6/30/2022, at 10:35 A.M., Employee C confirmed receiving the first dose of the COVID-19 vaccine on 1/25/2022. The employee said he/she did not like how he/she felt after receiving the first dose of the COVID-19 vaccine, so did not pursue obtaining the second dose. The employee said he/she had not requested or been granted an exemption from the mandatory vaccinations. During an interview on 6/30/2022, at 11:40 A.M., the Assistant Nurse Manager (ANM) said she was not aware that Employee C was not up to date on COVID vaccines. The employee health department of the facility's system tracked all COVID vaccinations. Employee C should not have worked if they were not in compliance with the facility policy.

Based on observation, record review, and interview, the facility failed to ensure a medication error rate of less than 5% when the facility staff made two errors out of 25 opportunities resulting in an error rate of 7.14% when staff failed to prime the insulin pens for one resident (Resident #3) during two medication pass observations. The facility census was 14. Record review of the [MEDICATION(S)] [MEDICATION(S)] (name brand for insulin [MEDICATION(S)] injection - fast acting insulin) manufacturer's website, dated [DATE], instruction for use included the following: -Pull off the pen cap and wipe the rubber stopper with an alcohol swab; -Attach a new needle, push and twist the needle on until it is tight; -Check the flow in the needle with an air shot of two units. Tap the pen a few time to make any air bubbles collect at the top. Press the push button all the way in and make sure that a drop appears, if not change the needle and complete the process again; -Select the dose - Make sure the dose selector is set at 0. Turn the dose selector to select the number of units you need to inject; -Give the injection. Insert the needle into the skin. Press and hold the dose button. After the dose counter reaches 0, slowly count to six before removing the needle from the skin; -Carefully remove the needle and place it in a disposal container; -Put the cap back on the [MEDICATION(S)] and store at room temperature. Record review of the [MEDICATION(S)] Pen (name brand for insulin [MEDICATION(S)] injection - long acting insulin) manufacturer's website, dated [DATE], instructions for use included the following: -Remove the pen cap with clean hands; -Wipe the pen tip (rubber seal) with an alcohol swab; -Remove the protective seal from the new needle, line the needle up straight with the pen, and screw the needle on; -Perform a safety test. Dial a test dose of two units. Hold pen with the needle pointing up and lightly tap the insulin pen so the air bubbles rise to the top of the needle. This will help get the most accurate dose. Push the injection button and ensure a drop of fluid is on the needle; -Select the dose. Make sure the window shows 0 and then select the dose; -Inject the dose. Clean skin site with an alcohol swab. Keep the pen straight, insert the needle into the skin. Press the injection button all the way down. When the number in the dose window returns to 0 while injecting, slowly count to 10 before removing. (Counting to 10 will make sure the full insulin dose is received.) Release the button and remove the needle from the skin. -Remove the needle, throw away in a sharps container, put the pen cap back on the pen and store in a safe place at room temperature. Record review of a facility document titled Insulin Pen Use, Home Care, dated [DATE], showed the following: -Observe the patient preparing the insulin pen for injection; -Ensure the patient obtains the correct insulin pen and appropriate size disposable needle; -Make sure that the patient inspects the pen to confirm that it is the correct insulin and that it is not expired; -Verify the patient removed the pen cap and attaches the needle to the pen according the manufacturer's instructions; -Confirm that the patient holds the pen vertically with the needle pointing up, dials one or two units on the dosage knob, and presses the injection button until a drop of insulin appears at the tip of the needle to prime the pen; -Verify the patient dials the dosage knob to the correct dose; -Confirm the patient holds the insulin pen and inserts the needle in one quick, smooth motion into the skin at a 90-degree angle to the skin's surface; -Verify the patient steadily pushes down the injection button at the back of the pen to inject the insulin; -Ensure the patient leaves the needle in the skin for 10 seconds to prevent leakage from the injection site and then pulls the needle out of the skin; -Verify the patient removed the needles according to the manufacturer's instructions, discards the needle in a puncture resistant sharps container, and replaces the pen cap on the insulin. 1. Record review of Resident #3's face sheet (brief resident information sheet) showed the following information: -admitted [DATE]; -diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the resident's [DATE] physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] -An order, dated [DATE], for [MEDICATION(S)] 100 units/ml Pen (insulin [MEDICATION(S)] - short-acting, manmade version of human insulin), administer per custom blood glucose (BG) correction scale five times per day; if BG is 160 milligrams(mg)/deciliter(dl) to 189 mg/dl administer 3 units; if BG 190 mg/dl to 219 mg/dl administer 6 units if BG is 220 mg/dl to 249 mg/dl administer 9 units; if BG is 250 mg/dl to 279 mg/dl administer 12 units. The order also stated to inject 1 unit [MEDICATION(S)] per 2 gram carbs (carbohydrates), three times per day with meals and inject 1 unit [MEDICATION(S)] per 3 gram carbs as needed with snacks; -An order, dated [DATE], for [MEDICATION(S)] 100 units/ml (insulin [MEDICATION(S)]) Pen administer 56 units twice per day. During an observation on [DATE], at 9:22 A.M., Registered Nurse (RN) A put on gloves, removed the cap from the [MEDICATION(S)] [MEDICATION(S)], wiped the stopper with an alcohol wipe, and put on a new needle. Without priming the pen, the RN turned the dial to the 22 indicator mark (3 units for BG 160 and 19 units for 39 gram carb breakfast). He/she entered the resident's room and used an alcohol wipe to clean the resident's abdomen. The RN injected 22 units of [MEDICATION(S)] in the resident's abdomen. He/she returned to the medication cart, removed the needle, and entered the required information into the resident's medication administration record. During an observation on [DATE], at 10:20 A.M., RN A began preparing medications for the resident. He/she took the [MEDICATION(S)] Pen from the medication cart, removed the cap, wiped the stopper with an alcohol wipe, and put on a new needle. Without priming the pen, the RN turned the dial on the pen to the 56 indicator mark. He/she entered the resident room and administered 56 units of [MEDICATION(S)] into the resident's abdomen. He/she returned to the medication cart, removed the needle, and entered the required information into the resident's medication administration record. During an interview on [DATE], at 10:30 A.M., RN A said for insulin injections the nurse should obtain the insulin pen, check the resident name on the pen, check the expiration date, scan the pen, open the cap, wipe the insulin stopper with alcohol, prepare the dose, and administer the insulin. The RN said nurses are supposed to prime the insulin before each use with one to two units to ensure no air bubbles, but he/she was in a hurry. During an interview on [DATE], at 1:10 P.M., RN B said the process for insulin administration included checking the physician orders, clean the insulin stopper with an alcohol wipe, prime needle with 2 units, then pull up the ordered dose. Take the insulin in to the room and explain to the patient. Clean the patient's skin, administer and ensure complete dose given before removing from the skin. During an interview on [DATE], at 1:20 P.M., Assistant Nurse Manager, said the process for insulin administration included to prepare insulin, wipe stopper with alcohol, put on a new needle, prime the pen with 1 to 2 units, then turn to ordered dose, verify the dose with patient, clean the skin and inject the dose. During an interview on [DATE], at 1:46 P.M., Administrator said that insulin is a high alert drug, staff should check blood sugar before meals, and should time insulin administration with foods. She was not familiar with insulin pens.

Based on observation, record review, and interview, the facility failed to ensure residents were free of significant medication errors when staff failed to prime insulin pens for one resident (Resident #3) during two medication pass observations. The facility had a census of 14. Record review of the [MEDICATION(S)] [MEDICATION(S)] (name brand for insulin [MEDICATION(S)] injection - fast acting insulin) manufacturer's website, dated [DATE], instruction for use included the following: -Pull off the pen cap and wipe the rubber stopper with an alcohol swab; -Attach a new needle, push and twist the needle on until it is tight; -Check the flow in the needle with an air shot of two units. Tap the pen a few time to make any air bubbles collect at the top. Press the push button all the way in and make sure that a drop appears, if not change the needle and complete the process again; -Select the dose - Make sure the dose selector is set at 0. Turn the dose selector to select the number of units you need to inject; -Give the injection. Insert the needle into the skin. Press and hold the dose button. After the dose counter reaches 0, slowly count to six before removing the needle from the skin; -Carefully remove the needle and place it in a disposal container; -Put the cap back on the [MEDICATION(S)] and store at room temperature. Record review of the [MEDICATION(S)] Pen (name brand for insulin [MEDICATION(S)] injection - long acting insulin) manufacturer's website, dated [DATE], instructions for use included the following: -Remove the pen cap with clean hands; -Wipe the pen tip (rubber seal) with an alcohol swab; -Remove the protective seal from the new needle, line the needle up straight with the pen, and screw the needle on; -Perform a safety test. Dial a test dose of two units. Hold pen with the needle pointing up and lightly tap the insulin pen so the air bubbles rise to the top of the needle. This will help get the most accurate dose. Push the injection button and ensure a drop of fluid is on the needle; -Select the dose. Make sure the window shows 0 and then select the dose; -Inject the dose. Clean skin site with an alcohol swab. Keep the pen straight, insert the needle into the skin. Press the injection button all the way down. When the number in the dose window returns to 0 while injecting, slowly count to 10 before removing. (Counting to 10 will make sure the full insulin dose is received.) Release the button and remove the needle from the skin. -Remove the needle, throw away in a sharps container, put the pen cap back on the pen and store in a safe place at room temperature. Record review of a facility document titled Insulin Pen Use, Home Care, dated [DATE], showed the following: -Observe the patient preparing the insulin pen for injection; -Ensure the patient obtains the correct insulin pen and appropriate size disposable needle; -Make sure that the patient inspects the pen to confirm that it is the correct insulin and that it is not expired; -Verify the patient removed the pen cap and attaches the needle to the pen according the manufacturer's instructions; -Confirm that the patient holds the pen vertically with the needle pointing up, dials one or two units on the dosage knob, and presses the injection button until a drop of insulin appears at the tip of the needle to prime the pen; -Verify the patient dials the dosage knob to the correct dose; -Confirm the patient holds the insulin pen and inserts the needle in one quick, smooth motion into the skin at a 90-degree angle to the skin's surface; -Verify the patient steadily pushes down the injection button at the back of the pen to inject the insulin; -Ensure the patient leaves the needle in the skin for 10 seconds to prevent leakage from the injection site and then pulls the needle out of the skin; -Verify the patient removed the needles according to the manufacturer's instructions, discards the needle in a puncture resistant sharps container, and replaces the pen cap on the insulin. 1. Record review of Resident #3's face sheet (brief resident information sheet) showed the following information: -admitted [DATE]; -diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the resident's [DATE] physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] -An order, dated [DATE], for [MEDICATION(S)] 100 units/ml Pen (insulin [MEDICATION(S)] - short-acting, manmade version of human insulin), administer per custom blood glucose (BG) correction scale five times per day; if BG is 160 milligrams(mg)/deciliter(dl) to 189 mg/dl administer 3 units; if BG 190 mg/dl to 219 mg/dl administer 6 units if BG is 220 mg/dl to 249 mg/dl administer 9 units; if BG is 250 mg/dl to 279 mg/dl administer 12 units. The order also stated to inject 1 unit [MEDICATION(S)] per 2 gram carbs (carbohydrates), three times per day with meals and inject 1 unit [MEDICATION(S)] per 3 gram carbs as needed with snacks; -An order, dated [DATE], for [MEDICATION(S)] 100 units/ml (insulin [MEDICATION(S)]) Pen administer 56 units twice per day. During an observation on [DATE], at 9:22 A.M., Registered Nurse (RN) A put on gloves, removed the cap from the [MEDICATION(S)] [MEDICATION(S)], wiped the stopper with an alcohol wipe, and put on a new needle. Without priming the pen, the RN turned the dial to the 22 indicator mark (3 units for BG 160 and 19 units for 39 gram carb breakfast). He/she entered the resident's room and used an alcohol wipe to clean the resident's abdomen. The RN injected 22 units of [MEDICATION(S)] in the resident's abdomen. He/she returned to the medication cart, removed the needle, and entered the required information into the resident's medication administration record. During an observation on [DATE], at 10:20 A.M., RN A began preparing medications for the resident. He/she took the [MEDICATION(S)] Pen from the medication cart, removed the cap, wiped the stopper with an alcohol wipe, and put on a new needle. Without priming the pen, the RN turned the dial on the pen to the 56 indicator mark. He/she entered the resident room and administered 56 units of [MEDICATION(S)] into the resident's abdomen. He/she returned to the medication cart, removed the needle, and entered the required information into the resident's medication administration record. During an interview on [DATE], at 10:30 A.M., RN A said for insulin injections the nurse should obtain the insulin pen, check the resident name on the pen, check the expiration date, scan the pen, open the cap, wipe the insulin stopper with alcohol, prepare the dose, and administer the insulin. The RN said nurses are supposed to prime the insulin before each use with one to two units to ensure no air bubbles, but he/she was in a hurry. During an interview on [DATE], at 1:10 P.M., RN B said the process for insulin administration included checking the physician orders, clean the insulin stopper with an alcohol wipe, prime needle with 2 units, then pull up the ordered dose. Take the insulin in to the room and explain to the patient. Clean the patient's skin, administer and ensure complete dose given before removing from the skin. During an interview on [DATE], at 1:20 P.M., Assistant Nurse Manager, said the process for insulin administration included to prepare insulin, wipe stopper with alcohol, put on a new needle, prime the pen with 1 to 2 units, then turn to ordered dose, verify the dose with patient, clean the skin and inject the dose. During an interview on [DATE], at 1:46 P.M., Administrator said that insulin is a high alert drug, staff should check blood sugar before meals, and should time insulin administration with foods. She was not familiar with insulin pens.

Based on observation, interview, and record review, the facility failed to provide wound treatments using accepted infection control standards for two residents (Resident #1 and #5). Seven sampled residents were reviewed in a facility with a census of 16. Record review of the Centers for Disease Control and Prevention (CDC, 2015) showed it advised healthcare providers adhere to [MEDICATION NAME] hand hygiene at key points in time to disrupt the transmission of microorganisms to patients including: -Before patient contact; -After contact with blood, body fluids, or contaminated surfaces (even if gloves are worn); -Before invasive procedures; -After removing gloves (wearing gloves is not enough to prevent the transmission of pathogens in healthcare settings). Record review of Infection Control Guidelines for Long Term Care Facilities, dated June 2005 and published by the Missouri Department of Health and Senior Services, showed handwashing remains the single most effective means of preventing disease transmission. Also, for body substance precautions, the guidelines state microorganisms adhere to the surface of a glove easier than the skin on the hand, and gloves must be changed between different body contacts with different body sites on the same resident. Record review of the facility's policy titled, Corporate Infection Prevention publish dated 12/31/13, review date 7/19/16, showed the following information: -Healthcare personnel are to clean their hands: before touching a patient, after touching patient surroundings, before clean/aseptic procedures, before and after wearing gloves. Record review of the pressure sore staging according to the U.S. Department of Health and Human Services Clinical Practice Guidelines #15 showed the following information: -Stage I pressure sore (a persistent area of skin redness without a break in the skin, which is nonblanchable); -Stage II pressure sore (a partial thickness loss of skin layers that presents as an abrasion, blister, or shallow crater); -Stage III pressure sore (full thickness skin loss involving damage or death of subcutaneous tissue that may extend down to, but not including bone); -Stage IV pressure sore (a full thickness skin loss with extensive tissue destruction, tissue death or damage to muscle, bone, or supporting structures). -When eschar (thick, leathery, necrotic, devitalized tissue) is present, a pressure ulcer cannot be accurately staged until the eschar is removed 1. Record review of Resident #1's admission Minimum Data Set (MDS), a federally mandated comprehensive assessment instrument completed by facility staff, dated 6/19/17, showed the following information: -admitted to unit on 6/13/17; -Cognitively intact; -[DIAGNOSES REDACTED]. -admitted with a stage IV pressure ulcer. Record review of the resident's care plan, dated June 2017, showed the following information: -Contact isolation; -Wound care. Record review of the resident's physician orders, dated 7/11/17, showed an order for [REDACTED]. Record review of the resident's progress note, dated 7/25/17, showed the following: -The wound measured 2.2 centimeters (cm) in length, 1.7 cm in width and 2.0 cm in depth. -The resident's wound had tunneling (open tunnels extending from the wound deeper into the tissue) at 12:00 o'clock 4.7 cm and at 2:00 o'clock 3.2 cm. -The resident's wound was a stage IV with no rough edges, moist, red, with bloody discharge. Observation on 7/26/17, at 2:35 P.M., showed the assistant unit manager provided wound care for the resident. The nurse donned personal protective equipment (PPE) before entering the resident's room. The nurse explained the procedure to the resident and gathered her supplies. The nurse removed her gloves, washed hands and donned new gloves and shut the resident's door. A CNA handed the nurse a green Chux (a disposable under pad) from the door, the Chux was placed down on the bedside table of the resident and supplies placed on top of the barrier by the nurse. The nurse removed the old bandage and examined the wound and drainage and removed her gloves. The nurse did not wash his/her hands at this time and donned new gloves. The nurse proceeded to touch the resident's bedside table, coffee cup and dressing supplies in the room. The nurse cleansed the wound with normal saline, applied Dakins to the gauze and used a cotton applicator to pack the tunneling wound, and covered with an abdominal dressing secured with tape. The nurses gathered up his/her trash, removed gloves/gown and washed his/her hands before exiting the resident's room. 2. Record review of the Resident's #5's care plan, dated June 2017, showed the following information: -Contact Isolation; -Wound care. Record review of Resident #5's physician orders, dated 7/20/17, showed daily dressing change to fill left ischial (back lower part of hip bone) ulcer with Dakins moistened 4X4 gauze, stretched out to a single layer, cover with a dry abdominal pad secured with tape. Record review of the resident's progress note, dated 7/25/17, showed the following: -The left buttock wound measured 1.5 cm in length, 0.9 cm in width and 1.2 cm in depth. -The wound was reported to be tunneling 5.4 cm with moist granulation tissue, pink/red in color with serosanguinous (containing or relating to both blood and the liquid part of blood (serum). It usually refers to fluids collected from or leaving the body) discharge. During an observation on 7/26/17, at 10:46 A.M., the assistant unit manager and Registered Nurse (RN) A performed wound care on the resident. The resident removed his/her underwear while the nurses washed their hands and donned gloves. The assistant unit manager removed the resident's old dressing and packing from the resident's pressure ulcer, examined the old dressing's drainage, removed his/her gloves, and re-gloved (no handwashing). The unit manager used a cotton applicator to apply the gauze with Dakins solution, covered and secured the bandage with tape. The supplies were left in the resident's room and both nurses removed their gloves, washed their hands and exited the resident's room. 3. During an interview on 7/27/17, at 10:34 A.M., RN B said during wound care he/she would wash his/her hands before starting the procedure, anytime he/she introduced anything new into the residents room, after removing the dirty dressing, at a minimum three times or more during the wound care. 4. During an interview on 7/27/17, at 11:48 A.M., the assistant unit manager said before wound care begins the nurse should wash his/her hands. The nurse said handwashing continues after the old dressing has been removed, when changing soiled gloves and before leaving the resident's room. 5. During an interview on 7/27/17, at 1:30 P.M., the Unit Manager said staff is expected to do handwashing with wound care. The unit manager said handwashing should happen before entering the resident's room, after removing a dressing or soiled gloves, and when the staff leave the residents room. The unit manager said handwashing would need to be performed more than that stated above if more procedures were performed for the resident by the staff.

Based on observation, interview, and record review, the facility failed to provide one resident (Resident #5) with privacy during personal cares when the staff failed to close the door, pull the privacy curtain, and close the window curtain when performing personal cares for the resident. Seven sampled residents were reviewed in a facility with a census of 16. Record review of the resident rights poster posted on the facility's West Hallway stated the following: -Residents have the right to be treated with respect and dignity; -Residents will be cared for in an environment that preserves dignity and contributes to a positive self-image. 1. Record review of Resident #5's care plan, dated 7/19/17, showed the following information: -admitted to the facility on [DATE]; -Need help for activities of daily living (ADL- dressing, grooming, bathing, eating, and toileting). Observation on 7/26/17, at 10:46 A.M., showed the assistant unit manager and Registered Nurse (RN) A provided wound care on the resident's pressure ulcer on the resident's left ischial area (back lower portion of the hip bone). Staff left open the resident's door, bedside curtain, and window curtain during the procedure. Staff exposed the resident's bottom and turned the resident's bottom toward the open window (window faces an open courtyard) for the wound treatment. The procedure transpired over a 32 minute time frame during which five visitors and staff members walked by the open door. Observation on 7/27/17, at 9:08 A.M., showed the assistant unit manager gathered supplies to provide suprapubic catheter (a thin tube that drains urine from your bladder that is inserted into the bladder through a small hole in the stomach) care for the resident. The assistant unit manager provided the catheter care and left the resident exposed. The resident's room door, bed side curtain, and window (facing open an court yard) remained open during the procedure. Observation on 7/27/17, at 11:48 A.M., showed the assistant unit manager and RN A provided wound care on the resident's pressure ulcer on the resident's left ischial area in the resident's room with the room door open, the bedside curtain not pulled around the resident's bed, and the room window curtain open. Staff and visitors could see the care provided to the resident from the hallway and courtyard. During an interview on 7/27/17, at 10:21 A.M., Certified Nursing Assistant (CNA) C said when personal care is provided to the residents the staff explain the procedures to the residents, close the resident's door, pull the curtains closed and keep the resident covered as much as possible to provide privacy to the resident. During an interview on 7/27/17, at 10:34 A.M., RN B said during catheter care he/she keeps the resident covered with a sheet to maintain dignity. The nurse said for privacy he/she shuts the door and pulls the curtains in the room shut. During an interview on 7/27/17, at 11:48 A.M., the assistant unit manager said dignity and privacy is provided to residents by asking visitors to step out of the room, pulling the curtains in the room closed and closing the resident's door. During an interview on 7/2717, at 1:30 P.M., the unit manager said staff are expected to pull the door closed to provide privacy and dignity for the resident. The staff are expected to close the resident's curtains, especially the curtains that face the courtyard.

Based on observation, interview, and record review, the facility failed to provide care for residents in a manner that enhanced each resident's quality of life and maintained their dignity when staff failed to keep a catheter bag (tube inserted into the bladder for draining urine into an external collection bag) covered for two residents (Resident #1 and #5). A sample of seven residents was selected for review in a facility with a census of 16 residents. 1. Record review of Resident #1's admission Minimum Data Set (MDS), a federally mandated comprehensive assessment instrument completed by facility staff, dated 6/19/17, showed the following information: -admitted to unit on 6/13/17; -Cognitively intact; -Extensive assistance needed for bed mobility; -Indwelling catheter. Record review of the resident's care plan, dated June 2017, showed the following information: -Ambulate by staff; -Catheter care. Observation on 7/25/17 at 11:37 A.M., showed the resident sitting in his/her wheelchair at the doorway of his/her room. The resident's catheter was underneath his/her wheelchair. The catheter bag was not in a dignity bag (a urinary drain bag cover to improve patient dignity that conceals fluid in the drain bag). Observation on 7/26/17 at 2:35 P.M., showed the assistant unit manager performed a pressure ulcer treatment to the resident. The resident's catheter bag was fastened to the bottom of his/her bed frame on the side of the bed facing the door. The catheter bag was not in a dignity bag. Observation on 7/27/17 at 7:37 A.M., showed the resident in his/her room drinking a cup of coffee. The resident's catheter bag was under his/her wheel chair in view from the hallway. The resident's catheter was not in a dignity bag. During an interview on 7/27/17 at 10:16 A.M., the resident said he/she was not aware of what a dignity bag was and did not think the facility had them or used them. 2. Record review of the Resident's #5's care plan, dated June 2017, showed the following information: -Catheter care. Observation on 7/25/17 at 2:20 P.M., showed the resident in his/her bed with a catheter bag fastened to the resident's bed frame with no dignity bag to cover the catheter bag. The resident's catheter bag was on the side of the bed facing the open door to the hallway. Observation on 7/26/17 at 7:59 A.M., showed the resident on his/her back eating breakfast. The resident's catheter was fastened to the resident's bed frame with no dignity bag to cover the catheter bag. The resident's catheter bag was on the side of the bed facing the open door to the hallway. Observation on 7/26/17 at 10:46 A.M., showed the assistant manager and Registered Nurse (RN) A performed wound care for the resident. The resident's catheter was fastened to the resident's bed frame with no dignity bag used to cover the catheter bag. The resident's catheter had leaked urine on the resident's floor the size of the bed. 3. During an interview on 7/27/17 at 10:21 A.M., Certified Nurse Aide (CNA) C said he/she had worked for the facility for five years and had never seen a dignity bag used at the facility. 4. During an interview on 7/27/17 at 10:34 A.M. RN B, said he/she had never heard of a dignity bag used to cover the resident's catheters. 5. During an interview on 7/27/17 at 6:50 P.M., the unit manager said the facility had never used privacy/dignity bags for catheters. The unit manager said it never occurred to her to use privacy/dignity bags and no one had ever asked for a privacy/dignity bag for their catheter.

Based on observation, interview and record review the facility failed to provide catheter (a sterile tube inserted into the bladder to drain urine) care to two resident's (Resident #1 and #5) per current standards of practice and in a manner that would help prevent possible infection. A sample of seven residents was reviewed in a facility with a census of 16. Record review of Fundamentals of Nursing by Taylor, Lillis, LeMone and Lynn, seventh edition, 2011, urinary tract infections are the leading cause of systemic infections in older adults. Caring for individuals with an indwelling catheter require staff to always wash hands before and after caring for an individual with an indwelling catheter and always clean the perineal area thoroughly, especially around the meatus (the opening to the urinary tract) after each bowel movement. The staff should cleanse the catheter by cleaning gently from the meatus outward. The staff should be aware of the importance of thorough cleaning after having a bowel movement and thorough, frequent hand hygiene. Record review of the Nurse Assistance student Reference Manual, dated 2001, section 6-13 titled Procedures for giving peri care with a catheter said, Wash the catheter tubing from the opening of the urethra outward four inches or farther if needed. 1. Record review of Resident #1's admission Minimum Data Set (MDS), a federally mandated comprehensive assessment instrument, completed by facility staff, dated 6/19/17 showed the following information: -admitted to unit on 6/13/17; -Cognitively intact; -Extensive assistance needed for bed mobility; -Indwelling catheter and [MEDICAL CONDITION]; -[DIAGNOSES REDACTED]. Record review of the resident's #1's care plan, June 2017, showed the following information: -Contact Isolation; -Catheter care. Record review of the resident's physician orders [REDACTED]. An observation on 7/27/17 at 10:10 A.M., showed Certified Nurse Aide (CNA) C entered the resident's room to provide catheter care with the Regulatory Affairs nurse present. The CNA removed the sheet covering the resident and showed the indwelling catheter. CNA C cleaned the catheter tubing in a back-in-forth motion, possibly introducing bacteria into the resident's urinary tract. 2. Record review of the Resident's #5's care plan, June 2017, showed the following information: -admitted on [DATE]; -Contact Isolation; -Catheter care; -Wound care. Record review of the resident's physician orders [REDACTED]. An observation on 7/27/17 at 9:08 A.M., showed the assistant nurse manager knocked on the resident's door, washed her hands and applied a gown and gloves. The manager explained she would be performing catheter care on the resident and gathered supplies located inside the isolation room. The nurse removed the resident's dressing covering the suprapubic catheter (a hollow flexible tube that is used to drain urine from the bladder. It is inserted into the bladder through a cut in the stomach, a few inches below the belly button) opening, looked at the drainage on the 4X4 sponge, and discarded the old bandage into the resident's trash can. The nurse did not change her gloves or wash her hands at this time and proceeded to clean the resident's suprapubic catheter, possibly introducing bacteria into the resident's bladder. During an interview on 7/27/17 beginning at 6:50 P.M., the unit manager said staff should wash their hands before performing catheter care on residents. The staff should wear gloves, and staff should wipe down the tubing away from the insertion site. The unit manager said staff should wipe in a motion away from the genital area not in a back and forth motion.

Based on interview and record review, the facility failed to update written policies and procedures to report all allegations of abuse and allegations of neglect, exploitation or mistreatment, and misappropriation of resident property that result in serious bodily injury, immediately, but no later than 2 hours after an allegation is made, to the State Survey Agency in accordance with federal requirements. The facility census was 16. 1. Record review of the facility's (undated) departmental policy for the Transitional Care Unit titled, Allegation of Abuse/Neglect/Harassment or Assault on the Transitional Care Unit (TCU) showed the following information: -Purpose: Patients have the right to be free of abuse and protected if abuse and neglect is suspected; -Policy: The intent of the facility's policy is to ensure that all forms of mistreatment, neglect, or abuse, including injuries of unknown source, and misappropriation of resident property, whether from staff, other patients, or visitors are prohibited. Allegations should be reported to the Missouri Department of Health and Senior Services (DHSS) within 24 hours of the incident; -Procedure: Staff must report all allegations immediately to the nurse manager on the TCU. In absence of the Nurse Manager, the nursing supervisor on duty should be notified. The nurse manager should follow the same reporting requirements as listed in the system policy. The nurse manager, or his/her designee, should notify the Missouri Department of Health and Senior Services (DHSS) within 24 hours via the hotline number listed on their website that the allegation had occurred; (The facility's departmental policy for the TCU failed to instruct staff to report all allegations of abuse and allegations of neglect, exploitation or mistreatment, and misappropriation of resident property that result in serious bodily injury, immediately, but no later than 2 hours after an allegation is made.) During an interview on 7/26/17, at 9:02 A.M., the unit manager said allegations of abuse, neglect, injuries of unknown origin, and misappropriation of property should be reported with two hours. She said she expected staff to report any allegation of abuse or neglect to her within one hour so she could meet the two hour reporting time frame. The unit manager said the facility policy did not have the two hour reporting requirement and directed staff to report any allegation of abuse or neglect to DHSS within 24 hours.

Based on record review and interview, the facility failed to develop written policies and procedures for reporting mistreatment, neglect, and abuse of residents and misappropriation of resident property in accordance with federal requirements when the policies and procedures did not list specific time frames for conducting an investigation and reporting to the Department of Health and Senior Services (DHSS). The facility had a census of 14 residents. Record review of the State Operations Manual showed the following information in the F225 regulations and interpretive guidelines: -The facility must ensure that all alleged violations involving mistreatment, neglect, or abuse, including injuries of unknown source and misappropriation of resident property are reported immediately to the administrator of the facility and to other officials in accordance with State law through established procedures (including to the State survey and certification agency). -Immediately means as soon as possible, but ought not exceed 24 hours after discovery of the incident, in the absence of a shorter State time frame requirement. -The results of all investigations must be reported to the administrator or his designated representative and to other officials in accordance with State law (including to the State survey and certification agency) within five working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken. 1. Record review of the facility's System Policy titled, Suspected Abuse/Neglect and Assault (not dated) showed the following information: -Purpose: To ensure proper identification, reporting and referrals of the suspected or alleged abuse, neglect or assault to an elder (This may include suspected physical assault, sexual assault, and domestic violence); -Reporting of Suspected Abuse/Neglect/Assault: The facility will maintain a centralized record of all hotline calls made due to suspected abuse or neglect. Therefore, all facility employees who feel that a hotline call is warranted based on their professional assessment of the patient, should contact Social Services. When contacted by the facility staff of a possible elder abuse or neglect case the Social Worker will assess the situation and place a hotline call if they agree with the caregiver's assessment. If the social worker does not feel a hotline call is warranted, they will contact the facility employee who requested the hotline call and discuss their conclusions. The facility employee may make the elder abuse or neglect hotline call themselves if they still feel such is warranted. The Social Worker will document and log the hotline call. Document using objective, behaviorally specific terms. -The facility did not have specific time frames for reporting all allegations of abuse, neglect, misappropriation of property or injury of unknown origin to DHSS. -The facility's Investigation Guidelines did not instruct staff to report all allegations of mistreatment, neglect, abuse and misappropriation of resident property to DHSS within 24 hours and it did not instruct staff to report, to DHSS, the findings of the completed investigation within five days of the incident. During an interview on 09/08/16, at 1:40 P.M., the Director of Nurses (DON) said she reports any abuse or neglect situation to the Department of Health and Senior Services (DHSS) hotline, within one hour of her knowledge of the incident. The findings and conclusions of the facility's investigation are faxed to the DHSS regional office the next day.

Based on observation, interview and record review, the facility staff failed to follow proper nursing standards prior to and during administration of medications to one resident (Resident #1) who required tube feeding due to swallowing difficulties. Two residents were chosen for review out of three who required tube feeding. The facility census was 13. 1. Record review of Resident #1's medical record showed the resident was admitted to the facility on [DATE], following hospitalization as a result of a stroke. The resident had a percutaneous endoscopic gastrostomy (PEG) tube (a non-operative procedure in which a tube is inserted into the stomach through the abdominal wall to be used for long-term intermittent or continuous feedings) due to swallowing difficulties related to the stroke. Observation and interview on 01/04/12, at 8:55 A.M., showed LPN A entered the resident's room to administer his/her morning medications via the PEG tube. The resident sat in bed with his/her head up at a 45 degree angle. Wearing gloves, the LPN dissolved the crushed medications in 30 milliliters (ml) of sterile water and drew up the dissolved content into a 60 ml syringe. LPN A said he/she flushed the PEG tube with 200 ml of sterile water at 8:00 A.M. and checked the tube for placement at that time (55 minutes prior). Without rechecking the tube placement, LPN A connected the 60 ml syringe to the PEG tube and slowly plunged the 30 ml of the dissolved medication into the resident's PEG tube. The LPN then plunged 60 ml of a dissolved fiber supplement followed with a 60 ml sterile water flush. During an interview on 01/05/12, at 1:35 P.M., LPN A said he/she should have checked the resident's PEG tube for placement prior to administering the medications yesterday morning. Record review of the facility's tube feeding policy last revised on 11/08/11, showed that before beginning feedings, staff should check tube placement by aspirating [MEDICAL CONDITION] content. If unable to aspirate, inject approximately 10 ml of air and auscultate over appropriate area of abdomen associated with the feeding tube. Record review of the educational reference source Med-Pass regarding Enteral Tube Medication Administration revised 6/2011, showed in part the following information: -Turn off the feeding at least 30 minutes prior to medication administration;-Perform hand hygiene and apply gloves;-Prepare medications as ordered; -Position the head of the bed; -Check for proper tube placement;-Remove plunger from the 60 ml syringe and connect syringe to clamped tubing; -Put 15-30 ml of water in syringe and flush tubing using gravity flow. Clamp tubing after the syringe is empty; allowing water to remain in the tube; -Pour dissolved/diluted medication in syringe and unclamp tubing, allowing medication to flow by gravity.

Based on observation, interview and record review the facility failed to ensure staff implemented a safe and effective medication system when the staff did not keep two residents' (Resident #6 and #7) medications under direct observation or locked in the medication storage area/cart but left them unattended and available for anyone passing by. Seven residedts were sampled out of a facility census of 13 residents. Record review of the facility's policy for medication management dated 12/2011, showed in part the following information: -Storage: medications are stored to prevent unrestricted access and to ensure their integrity, stability and effectiveness;-Generally, all drugs should be kept in a locked room or container. If the container is mobile or readily portable, when not in use, it must be stored in a locked room, monitored location or secured location that will ensure the security of the drugs and biologicals; -All drugs removed from a medication storage area must be removed just prior to administration and only for one resident at a time. Once removed, the drug must remain with the individual at all times and may not be left unattended. 1. Observation on 1/4/12, at 9:15 A.M., showed licensed practical nurse (LPN) A stood at the medication cart preparing medications to administer to Resident #6. The medications included Pepcid (acid reducer) liquid in a syringe, Norvasc (for blood pressure), Lopressor (for blood pressure), Lantus (insulin) injection, Lisinopril (for blood pressure), HCTZ (diuretic),and a liquid multivitamin. LPN A carried the medications to the resident's room and placed them on a shelf inside the resident room. The shelf and medications were visible from the public corridor. LPN A exited the room and went to the medication cart near the nurses station. When LPN A returned to the resident's room, he/she said he/she thought the surveyor would watch the medications. 2. Observation on 1/5/12, showed the following information: -At 9:05 A.M., registered nurse (RN) B stood at the medication cart preparing medications to administer to Resident #7. Each medication was individually contained in heat sealed cellophane packets. RN B opened seven medications and placed them into a medication souffle cup; -At 9:06 A.M., RN B said he/she needed to have another nurse verify a medication dose. RN B left the medication cart in the public corridor outside of the resident's room and went to the medication room. The top of medication cart contained a bottle of saline eye drops, a bottle of Flonase (allergy medication) nasal spray, Lovenox (blood thinner) injection and the souffle cup with the seven medications. RN B did not remain in direct observation of the medication cart. RN B was behind the closed door in the medication room; -Between 9:06 A.M., and 9:10 A.M., staff, residents and visitors were in the hall corridor; -At 9:10 A.M., RN D walked up the corridor and past the unattended medication cart. RN D did not stop at the medication cart;-At 9:11 A.M., RN B returned to the cart with a narcotic pain medication. 3. During an interview on 1/6/12 at 12:00 P.M., LPN C said he/she does not turn his/her back on the medication cart, he/she kept the cart in his/her view. If he/she needed to step away from the cart, he/she locked the medication in the cart or would have another nurse watch the cart. 4. During an interview on 1/6/2012 at 12:30 P.M., the Director of nursing said staff should not leave medications unattended. Staff should keep the medications and the cart in their line of site.

Based on observation, interview and record review the facility staff failed to change contaminated gloves and wash hands appropriately after touching bio-hazard material for one resident (Resident #7). Staff failed to use universal precautions and apply gloves during the performance of injections for one resident (Resident #6). Staff failed to use aseptic (without contamination with bacteria or other microorganisms) technique when they touched one resident's (Resident #7) oral medications and two residents' (Resident #6 and #1) feeding tube medications with their bare hands before administering the medications to the residents. Seven residents were sampled out of a facility census of 13 residents. Record review of the facility's policy for injections dated 2011, showed in part the following information: -Equipment: disposable gloves;-Procedure:-Perform hand hygiene and apply gloves;-Cleanse site with antiseptic swab;-Administer injection;-Dispose of soiled supplies, remove gloves and perform hand hygiene. Record review of Perry and Potter 7th edition 2010, a reference source used by the facility showed in part the following information regarding safe medication preparation: -Implementation: follow the principles of safe and effective medication preparation and administration for each resident;-Pre-administration activities: use medical aseptic technique;-Perform hand hygiene before preparing a dose of medication;-Avoid touching tablets and capsules. 1. Record review of Resident #7's January 2012, physician's orders [REDACTED]. -[MEDICATION NAME] (anticoagulant) 40 unit injection;-[MEDICATION NAME] (insulin) 15 unit injection. Observation on 1/5/12, showed the following information: -At 9:05 A.M., registered nurse (RN) B stood at the medication cart preparing medications to administer to the resident. Each medication was individually contained in heat sealed cellophane packets. RN B opened seven medication packets one at a time. With his/her bare hands, RN B took each medication out of the packet and placed it into the souffle cup;-At 9:06 A.M., RN B left the medication cart and went to the medication room;-At 9:11 A.M., RN B returned to the cart with a narcotic pain medication. RN B touched the surface of the medication cart, and the handheld computer device (an electronic medication record). The nurse did not cleanse his/her hands with sanitizer. With his/her bare hands, RN B took the narcotic pain medication out of the packet and placed it into the souffle cup; -At 9:13 A.M., RN B applied gloves and entered the resident's room. The resident lay in the bed on his/her back. RN B exposed the resident's abdomen, cleansed the area with an antiseptic swab and administered the [MEDICATION NAME] injection. RN B cleansed another area with an antiseptic swab and administered the [MEDICATION NAME] injection. Still wearing the gloves, the nurse opened the biohazard container attached to the wall in the resident's room and placed the used medication syringes into the container. RN B did not perform hand hygiene and change his/her gloves;-At 9:18 A.M., with contaminated gloves, RN B touched the resident's left and right eye, using his/her thumb and index finger to spread open the resident's upper and lower eyelids and administered the eye drops as ordered. RN B did not perform hand hygiene and change his/her gloves;-At 9:20 A.M., with contaminated gloves, RN B touched the resident's face and nose and administered the nasal spray as ordered to the right and left nares. RN B did not perform hand hygiene and change his/her gloves;-At 9:22 A.M., with contaminated gloves, RN B touched the resident's telephone, drinking straw and administered the resident's oral medications. RN B removed the gloves, used sanitizer and exited the room. 2. Record review of Resident #6's January 2012, physician's orders [REDACTED]. -Naso gastric tube placement (a tube inserted through the nose and into the stomach used to administer nutrition and medications to someone who is unable to take in food, fluids, and medication orally). -[MEDICATION NAME] 30 unit injection;-[MEDICATION NAME] 20 unit injection;-[MEDICATION NAME] (for blood pressure) 25 milligram (mg) tablet, give ? tablet 12.5 mg per tube. Observation on 1/4/12, showed the following information: -At 9:15 A.M., licensed practical nurse (LPN) A stood at the medication cart preparing medications to administer to the resident. Each medication was individually contained in heat sealed cellophane packets. As LPN A opened the packet of [MEDICATION NAME], the pill fell on to the surface of the treatment cart. With his/her bare hands, the LPN picked up the medication and placed it into the pill splitter. After splitting the medication, LPN A removed the half tablet (12.5 mg) dose with his/her bare hands and placed it in the souffle cup with the other medications. The LPN crushed the medications; -At 9:30 A.M., the resident lay in the bed on his/her right side. The resident had the nasogastric tube placed in his/her nasal passage and secured with tape. LPN A entered the room with the crushed medications, the [MEDICATION NAME] and [MEDICATION NAME] injections. LPN A used hand sanitizer and applied gloves. LPN A added water to the crushed medications (including the [MEDICATION NAME]) and administered the medications to the resident via the tube;-At 9:45 A.M., LPN A removed his/her gloves and used sanitizer. LPN A did not apply new gloves. With his/her bare hands, LPN A cleansed the resident's left upper arm with an antiseptic swab and administered the [MEDICATION NAME] injection. With his/her bare hands, LPN A exposed the resident's abdomen, cleansed the area with an antiseptic swab and administered the [MEDICATION NAME] injection. LPN A cleansed his/her hands with sanitizer, applied gloves and finished administering the resident's medications. 3. Record review of Resident #1's medical record showed the resident was admitted to the facility on [DATE], following hospitalization as a result of a stroke. The resident had a percutaneous endoscopic gastrostomy (PEG) tube (a non-operative procedure in which a tube is inserted into the stomach through the abdominal wall to be used for long-term intermittent or continuous feedings) due to swallowing difficulties related to the stroke. Among the medications ordered by the physician was [MEDICATION NAME] (muscle relaxer) 5 mg to be given twice daily. Observation on 01/04/12, at 8:55 A.M., showed LPN A stood at the medication cart and prepared medications for the resident. Using a hand held computer device, the LPN scanned bar codes of each individually wrapped medication to be administered. After multiple failed attempts to register the medication on the hand held device, LPN A left the medication cart, obtained an alternate hand held scanner from an area behind the nurses station, then returned to the cart. Each medication was individually contained in heat sealed cellophane packets which the LPN tore open and placed in a souffle cup to be crushed. LPN A did not wash or sanitize his/her hands prior to returning to the medication cart. Among the medications the LPN prepared to administer was [MEDICATION NAME] 10 mg in which the LPN placed in a pill splitter (with his/her bare hands) to obtain the ordered 5 mg dose. After splitting the medication, LPN A removed the half tablet (5 mg) dose with his/her bare hands, placed it in the souffle cup with the other medications, and destroyed the remaining half tablet. The LPN crushed and dissolved the medications in water for administration via the resident's feeding tube. 4. During an interview on 1/6/12 at 12:00 P.M., LPN C said the following: -Staff have in-service training on the computer monthly and have yearly training on tube feedings. If a policy changed or was added then there would be a new in-service;-Staff should not touch medications with their bare hands;-Staff should change their gloves with each new treatment and body area;-Staff should wear gloves when giving an injection;-He/she used sanitizer a lot, staff should wash their hands when they exit the resident's room;-LPN A said he/she would change his/her gloves and wash his/her hands after touching any biohazard material. 5. During an interview on 1/6/12 at 12:30 P.M., Director of nursing (DON) said the facility had policy's and procedures in place and reference materials available at the nurse's station for staff to utilize. She expected the staff to follow the policy's and procedures and utilize the reference materials regarding infection control, hand hygiene and glove use.

Based on record review and interview, the facility failed to check if one (Certified Nurse Assistant A) out of two employees selected for the purpose of verifying the timeliness of the Employee Disqualification List (EDL), were on the EDL prior to having contact with residents in accordance with facility policy and state regulations. The facility census was 22 residents. 1. Record review of Patient Care Assistant I/ Certified Nurses Aid (CNA) A's employee file showed CNA A was hired on 06/21/10. Staff did not check the CNAs EDL until 11/30/10 (five months after employment). Record review of the Missouri Department of Health and Senior Services EDL quarterly addition dated 07/02/10, did not show the name of CNA A listed. During an interview on 12/01/10 at 3:00 P.M., the Nurse Manager and Administrator said the following: - It is the facility's policy that EDLs be ran and received prior to an employee being hired and working with patients; - CNA A worked part time; - It was an oversight by human resources regarding completing the EDL for CNA A prior to working; - Human resources checks the quarterly additions against all employees.