Every finding on record at Farmington Presbyterian Manor

Based on interview and record review, the facility failed to ensure the Nurse Aide (NA) Registry check was completed prior to the employment start date for four employees out of 10 sampled employees. The facility census was 68.Review of the facility's policy titled, Abuse Prevention, Intervention, Reporting and Investigation-Staff Treatment of Residents, revised 08/07/25, showed:- Potential employees will be screened for a history of abuse, neglect, or mistreating residents by obtaining information from previous employers and/or current employers, checking with the appropriate licensing boards and registries, including the Missouri employee disqualification list and the national sex offender registry (www.nationalsexoffenderregistry.com);- Screening employees, volunteers and consultants - the community will not knowingly employ any individual convicted of resident abuse, misappropriation of resident property or reported abuse, as noted by licensure boards or registries;- Prior to a new employee starting a work schedule, the community's human resource director or designee will obtain reference checks in accordance with human resources hiring checklist; obtain a criminal background check; if the potential employee has been found guilty of or pled no contest to abuse, neglect, mistreatment, exploitation of resident, misappropriation of resident property he/she is not hired; and a query from the Nurse Aid Registry has been completed on all certified nursing assistants (CNA) in each state where the CNA has previously worked;- The policy did not address the need to complete the NA Registry check on all employees. 1. Review of Employee A's personnel file showed:- Hire date of 04/06/26;- The facility failed to complete the NA Registry check until 04/13/26. 2. Review of Employee B's personnel file showed:- Hire date of 08/08/25;- The facility failed to complete the NA Registry check. 3. Review of Employee C's personnel file showed:- Hire date of 02/04/25;- The facility failed to complete the NA Registry check.4. Record review of Employee D's personnel file showed:- Hire date of 02/03/25;- The facility failed to complete the NA Registry check until 02/04/25.During an interview on 05/06/26 at 6:29 P.M., the Administrator and Human Resources Director said they would expect NA Registry checks to be completed on all employees prior to their start date.During an interview on 05/12/26 at 8:40 A.M., the Human Resources Director said she was responsible for checking the NA Registry. NA Registry checks should be completed on all employees, and she typically did the checks after an offer had been made. For CNAs and Certified Medication Technicians (CMTs), she would do the checks before they were interviewed.

Based on observation, interview, and record review, the facility failed to document a complete and accurate Minimum Data Set (MDS - a federally mandated assessment instrument completed by the facility) for four residents (Residents #1, #3, #6, and #48) out of 17 sampled residents and three residents (Residents #2, #30, and #38) outside the sample. The facility's census was 68. Review of the facility's policy titled, MDS Data Accuracy, reviewed 02/03/25, showed: - It is the responsibility of those who complete sections of the MDS to ensure data entered accurately reflects the resident's status and is coded according to Resident Assessment Instrument (RAI) Manual guidelines. If MDS documentation inaccuracies or disparities are ascertained, the process of editing the documentation source, in addition to correcting the MDS, will be initiated; - Validating MDS data for accuracy, prevents any issues with supportive documentation not matching the MDS and can help protect against any documentation issues arising in surveys or audits; - RAI Coordinator will work with staff to ensure any erroneous data is corrected and MDS is accurate. Review of the RAI Manual, dated October 2025, showed: - N0415E1. Anticoagulant (medication that prevents or reduces the coagulation of blood, slowing down the time it takes for clots to form; e.g., warfarin, heparin, or low-molecular weight heparin): Check if an anticoagulant medication was taken by the resident at any time during the seven-day look-back period (or since admission/entry or reentry if less than seven days); - N0415I1. Antiplatelet: Check if an antiplatelet medication (medication that prevents blood cells (platelets) from sticking together and clumping; e.g., aspirin/extended release, dipyridamole, clopidogrel) was taken by the resident at any time during the seven-day observation period (or since admission/entry or reentry if less than seven days); - Do not code antiplatelet medications such as aspirin/extended release, dipyridamole, or clopidogrel as N0415E, Anticoagulant. 1. Review of Resident #1's medical record showed: - admitted on [DATE]; - Diagnoses of multiple sclerosis (MS - chronic disease of the brain and spinal cord that can cause symptoms like numbness, vision problems, and weakness), dementia (decline in mental ability severe enough to interfere with daily life, characterized by loss of memory, language, problem-solving, and other thinking skills), and anxiety disorder (excessive, persistent, and uncontrollable fear or worry that disrupts daily life, work, or relationships). Review of the resident's physician order sheet (POS), dated 05/05/26, showed: - An order for aspirin (antiplatelet) 81 milligrams (mg) one tablet by mouth one time a day for preventative, dated 02/09/26; - No current or discontinued order for an anticoagulant. Review of the resident's significant change MDS assessment, dated 02/12/26, showed: - N0415E1 marked yes for taking an anticoagulant; - N0415I1 marked no for taking an antiplatelet; - The facility failed to code aspirin as an antiplatelet and incorrectly coded aspirin as an anticoagulant. 2. Review of Resident #2's medical record showed: - admitted on [DATE]; - Diagnoses of cerebral palsy (neurological disorder that affects movement, posture, and muscle coordination, resulting from damage to the developing brain), chronic kidney disease (long-term condition where kidneys are damaged and gradually lose their ability to filter waste and excess fluid from the blood), and peripheral vascular disease (circulation disorder characterized by the narrowing, blockage, or spasms of blood vessels). Review of the resident's POS, dated 05/06/26, showed: - An order for aspirin 81 mg one tablet by mouth one time a day for preventative, dated 05/07/22; - No current or discontinued order for an anticoagulant. Review of the resident's MDS assessments showed: - A quarterly MDS assessment, dated 02/03/26, with N0415E1 marked yes for taking an anticoagulant; - A quarterly MDS assessment, dated 11/04/25, with N0415E1 marked yes for taking an anticoagulant; - A quarterly MDS assessment, dated 08/04/25, with N0415I1 marked no for taking an antiplatelet; - An annual MDS assessment, dated 05/07/25, with N0415I1 marked no for taking an antiplatelet; - The facility failed to code aspirin as an antiplatelet and incorrectly coded aspirin as an anticoagulant. 3. Review of Resident #3's medical record showed: - admitted on [DATE]; - Diagnoses of heart disease, aortic and mitral valve insufficiency (leaky heart valves), and chronic kidney disease. Review of the resident's POS, dated 05/05/26, showed: - An order for aspirin 81 mg one tablet by mouth one time a day for preventative, dated 10/14/25; - An order for Eliquis (anticoagulant) five mg one tablet by mouth two times a day related to atrial fibrillation, dated 08/21/25 and discontinued 10/14/25. Review of the resident's MDS assessments showed: - A quarterly MDS assessment, dated 03/17/26, with N0415E1 marked yes for taking an anticoagulant and N0415I1 marked no for taking an antiplatelet; - A quarterly MDS assessment, dated 12/16/25, with N0415E1 marked yes for taking an anticoagulant and N0415I1marked no for taking an antiplatelet; - A significant change MDS assessment, dated 09/15/25, with N0415I1 marked no for taking an antiplatelet; - The facility failed to code aspirin as an antiplatelet and incorrectly coded aspirin as an anticoagulant. 4. Review of Resident #6's medical record showed: - admitted on [DATE]; - Diagnoses of high blood pressure, hyperlipidemia (high concentration of fat in the blood), cardiac murmur (swishing sound heard during a heartbeat caused by rapid blood flow within or around the heart), and chronic ischemic heart disease (condition where the heart muscle doesn't receive enough oxygenated blood due to a buildup of plaque). Review of the resident's POS, dated 05/03/26, showed an order for aspirin 81 mg oral tablet delayed release one tablet daily as a preventative related to chronic ischemic heart disease, dated 09/04/24. Review of the resident's significant change MDS assessment, dated 03/27/26, showed: - N0415E1 marked yes for taking an anticoagulant and N0415I1 marked no for taking an antiplatelet; - The facility failed to code aspirin as an antiplatelet and incorrectly coded aspirin as an anticoagulant. 5. Review of Resident #30's medical record showed: - admitted on [DATE]; - Diagnoses of stroke, aphasia (a language disorder caused by brain damage that impairs a person's ability to communicate), and heart disease. Review of the resident's POS, dated 05/05/26, showed: - An order for aspirin 81 mg one tablet by mouth one time a day for preventative, dated 03/27/25; - An order for heparin (anticoagulant) one milliliter (ml) subcutaneously (below the skin) three times a day related to stroke, dated 03/27/25 and discontinued 04/09/25. Review of the resident's MDS assessments showed: - A significant change MDS assessment, dated 03/17/26, with N0415E1 marked yes for taking an anticoagulant; - A quarterly MDS assessment, dated 12/17/25, with N0415E1 marked yes for taking an anticoagulant; - A quarterly MDS assessment, dated 09/23/25, with N0415E1 marked yes for taking an anticoagulant; - The facility failed to code aspirin as an antiplatelet and incorrectly coded aspirin as an anticoagulant. 6. Review of Resident #38's medical record showed: - admitted on [DATE]; - Diagnoses of chronic kidney disease, atherosclerotic heart disease (buildup of plaque within the artery walls), atherosclerosis of the aorta (plaque buildup in the largest artery in the body), and artificial heart valve. Review of the resident's POS, dated 05/03/26, showed an order for aspirin 81 mg oral tablet delayed release one tablet once a day as a preventative, dated 01/16/25. Review of the resident's quarterly MDS, dated [DATE], showed: - N0415E1 marked yes for taking an anticoagulant; - N0415I1 marked no for taking an antiplatelet; - The facility failed to code aspirin as an antiplatelet and incorrectly coded aspirin as an anticoagulant. 7. Review of Resident #48's medical record showed: - admitted on [DATE]; - Diagnoses of atherosclerosis of the aorta, muscle weakness, and occlusion and stenosis of carotid arteries (narrowing and/or blockage due to plaque of the main neck arteries supplying blood to the brain). Review of the resident's POS, dated 05/05/26, showed: - An order for aspirin 81 mg one tablet by mouth one time a day for preventative, dated 01/19/24; - No current or discontinued order for an anticoagulant. Review of the resident's MDS assessments showed: - A quarterly MDS assessment, dated 04/13/26, with N0415E1 marked yes for taking an anticoagulant and N0415I1 marked no for taking an antiplatelet; - A quarterly MDS assessment, dated 01/16/26, with N0415E1marked yes for taking an anticoagulant and N0415I1marked no for taking an antiplatelet; - A significant change MDS assessment, dated 10/21/25, with N0415E1 marked yes for taking an anticoagulant and N0415I1 marked no for taking an antiplatelet; - The facility failed to code aspirin as an antiplatelet and incorrectly coded aspirin as an anticoagulant. During an interview on 05/06/26 at 2:00 P.M., the MDS Coordinator said she had been coding aspirin as an anticoagulant. She looked it up in her drug book and realized it was an antiplatelet. She believed she got confused when they added antiplatelet to the MDS assessment a while back. During an interview on 05/06/26 at 6:29 P.M., the Administrator said she would expect anticoagulants and antiplatelets to be coded correctly on MDS assessments.

Based on observation, interview and record review, the facility failed to maintain infection control practices to prevent the development and transmission of infection by not performing proper hand hygiene, not utilizing gloves appropriately, and by not wearing appropriate personal protective equipment (PPE-specialized clothing or gear that acts like a barrier to minimize infections) for enhanced barrier precautions (EBP-an infection control strategy in long term care that mandates gowns and gloves during high contact care to prevent the spread of multi drug resistant organisms (MDROs) during urinary catheter (a thin, flexible, hollow tube inserted into the bladder to drain urine) care for one resident (Resident #35) out of one sampled resident with a urinary catheter, by not performing proper hand hygiene or utilizing gloves appropriately during perineal (peri care - cleaning of the genital and anal areas) for one resident (Resident #45) out of 17 sampled residents and one resident (Resident #30) outside the sample and during blood sugar monitoring for five residents (Residents #8, #29, #32, #42, and #69) out of five sampled residents who had blood glucose monitoring. The facility census was 68.Review of the facility's policy titled, Hand Hygiene, reviewed 02/03/35, showed: - Indications for hand washing: before and after direct contact with residents, before and after contact with body fluids or excretions, mucous membranes, non-intact skin, and wound dressings, even if hands are not visibly soiled and when moving from a contaminated body site to a clean body site during resident care; - Before and after contact with inanimate objects including medical equipment in the immediate vicinity of the resident; after removing gloves, before and after medication administration; - An alcohol-based hand rub is the preferred method for hand hygiene in all situations except when your hands are visibly soiled or contaminated; - Gloves reduce hand contamination by 70-80 percent, prevent cross-contamination, and protect elders and health care personnel from infection. However, the use of gloves does not eliminate the need for hand hygiene; - Wear gloves when contact with blood or other potentially infectious materials including other body fluids, secretions and excretions, mucous membranes, non-intact skin and contaminated items will or could potentially occur; - Change gloves during elder care if moving from a contaminated body site to a clean body site; - Remove gloves promptly after use, before touching non-contaminated items and environmental surfaces, and before caring for another patient; - Decontaminate hands after removing gloves by appropriate hand hygiene; - Always discard contaminated gloves in plastic-lined trash containers or biohazard waste receptacles. Review of the facility's policy titled, Infection Control, revised 10/06/25, showed: - Enhanced Barrier Precautions (EBP) refers to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employ targeted gown and glove use during high contact resident care activities; - EBP are used in conjunction with standard precautions and expand the use of PPE to donning of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs to staff hands and clothing; - EBP are indicated for residents with any of the following: Infection or colonization with a Centers for Disease Control and Prevention (CDC)-targeted MDRO when Contact Precautions do not otherwise apply; or wounds and/or indwelling medical devices even if the resident is not known to be infected or colonized with a MDRO; - Indwelling medical device examples include central lines, urinary catheters, feeding tubes, and tracheostomies; - Enhanced Barrier Precautions include: Dedicate the use of resident-care equipment when possible; If equipment must leave the resident's room, a healthcare worker will remove the equipment; healthcare workers will don a new pair of gloves and disinfect all surfaces of the equipment with a hospital-grade disinfectant approved for the identified microorganism; The gloves will be removed and hands washed with antiseptic soap and water; and position a trash can inside resident's room and near exit for discarding PPE after removal, prior to exiting room, or before providing care to another resident in the same room; - All staff have a responsibility to ensure that the employee complies with the principles of standard infection control precautions; - All staff have a responsibility to be aware of local and national policies, procedures, and campaigns related to standard infection control precautions; - All staff are responsible for following hand hygiene protocols of this community and be able to demonstrate competency in hand hygiene at least annually. 1. Observation on 05/06/26 at 5:30 A.M., of Resident #45's peri care showed: - Certified Nurse Aide (CNA) E entered the resident's room, shut the door and pulled the curtain; - CNA E did not perform hand hygiene and put on gloves, placed a clean trash bag into the trash can, removed gloves and did not perform hand hygiene, and put on clean gloves; - CNA F entered the resident's room, did not perform hand hygiene, and put on clean gloves; - CNA E and CNA F loosened the resident's soiled brief. CNA E cleaned the resident's front peri area; - CNA E and CNA F rolled the resident to his/her right side. CNA E cleaned the middle of the resident's buttocks, removed gloves, did not perform hand hygiene, and put on clean gloves; - CNA E cleaned the right and left sides of the buttocks, tucked the soiled brief under the resident, and lay a clean brief on the bed; - With the same soiled gloves, CNA E and CNA F rolled the resident to his/her left side. CNA F removed the soiled brief and handed it to CNA E, who placed the brief in the trash can; - With the same soiled gloves, CNA E and CNA F placed the clean brief on the resident and pulled the blanket up around the resident's shoulders; - With the same soiled gloves, CNA F picked up several stuffed animals and placed them on the bed next to the resident; - CNA E took the trash to the soiled utility room, removed gloves and performed hand hygiene; - CNA F removed gloves and performed hand hygiene in the resident's room. During an interview on 05/06/26 at 2:30 P.M., CNA E and CNF F said they should wash their hands prior to providing peri care, should wash/sanitize their hands in between gloves changes, and they should remove soiled gloves before touching resident items, including bedding and stuffed animals. 2. Observation on 05/06/26 at 6:00 A.M., of Resident #30's peri-care showed: - CNA I and CNA J did not perform hand hygiene, put on gloves, and assisted the resident to stand with a sit-to-stand lift (mobility device designed to help individuals with limited mobility, but partial weight-bearing ability, transition from a seated to a standing position); - CNA I pushed the sit to stand lift into the resident's bathroom. CNA I and CNA J positioned the resident on the toilet; - CNA I removed gloves, and CNA J changed gloves and did not perform hand hygiene; - CNA J removed the resident's brief and shorts, put the brief in the trash can and the shorts in a plastic bag, removed the trash bag from the trash can and set the bags on the floor beside the trash can; - CNA J did not perform hand hygiene, changed gloves, obtained a clean brief and pants from the resident's closet. Without performing hand hygiene, CNA I, with bare hands, and CNA J placed the brief and pants on the resident; - CNA I and CNA J assisted the resident to a standing position over the toilet with the sit-to-stand lift; - CNA I did not perform hand hygiene, put on gloves and provided peri care for the resident; - CNA I removed gloves and did not perform hand hygiene, and CNA J pulled the resident's brief and pants up; - CNA I pushed the resident in the sit-to-stand lift to the wheelchair, and CNA J guided the resident into the wheelchair; - CNA J removed gloves, and CNA I took the trash bag out of the room with bare hands; - CNA J did not perform hand hygiene, put on gloves, obtained a pillow from the resident's recliner, positioned it on the resident's lap, moved the resident's right arm onto the pillow and put both the resident's feet on the wheelchair's foot pedals; - CNA J straightened the resident's bedsheets, removed gloves, and washed hands. During an interview on 05/06/26 at 6:24 A.M., CNA J said he/she should wash hands when entering the room, wash hands in between glove changes, and when exiting the room. He/She could use sanitizer instead of washing. During an interview on 05/06/26 at 2:38 P.M., CNA I said he/she should do hand hygiene before care, sometimes during care if he/she got something on him/her, like a large bowel movement, and after care. 3. Observation on 05/06/26 of resident blood sugar checks showed: - At 6:22 A.M., Licensed Practical Nurse (LPN) G performed hand hygiene and put on clean gloves while outside the resident's room at the nurse cart. LPN G touched the computer keyboard, ink pen, and paper. LPN G obtained Resident #42's glucometer (machine used to test a person's blood sugar), alcohol pad, gauze, container of test strips, and lancet (small sharp instrument used to obtain blood sample) from the cart, put a strip in the glucometer and, with the same gloves, obtained the resident's blood sugar, threw the strip and lancet away in the sharps container, removed gloves, and put the glucometer in cart; - At 6:25 A.M., LPN G obtained Resident #32's glucometer, container of test strips, and lancet from the cart and placed them on the cart without a barrier, performed hand hygiene, put on clean gloves, then opened the cart with the right gloved hand to obtain gauze and alcohol pad and placed items between fingers on left gloved hand while he/she put a strip in the glucometer, and obtained the resident's blood sugar at the resident's doorway, threw strip and lancet away in sharps container, removed gloves, and put the glucometer in the cart; - At 6:29 A.M., LPN G performed hand hygiene, put on clean gloves, obtained Resident #69's glucometer, alcohol pad, container of test strips, and lancet from the cart and closed the cart with a gloved hand, put a strip in the glucometer, entered the resident's room and obtained the resident's blood sugar, then walked back to the cart, threw strip and lancet away in the sharps container, put the glucometer in the cart and obtained an insulin pen from the cart, primed the pen and dialed up five units of insulin, returned to the resident's room with the insulin and alcohol pad, and gave the insulin in the resident's abdomen; - At 6:37 A.M., LPN G performed hand hygiene, put on clean gloves, obtained Resident #8's glucometer, alcohol pad, container of strips, and lancet from the cart, put a strip in the glucometer, entered the resident's room and obtained the resident's blood sugar, threw the lancet away in the sharps container, removed gloves, removed the used strip from the glucometer with a bare hand and threw it away in the sharps container; - At 6:40 A.M., LPN G performed hand hygiene, put on clean gloves, opened the cart and obtained Resident #29's glucometer, lancet, alcohol wipe, test strip, and gauze and placed the items on top of the cart without a barrier. With the same gloves, LPN G typed on the computer, opened the resident's door, and obtained the resident's blood sugar. LPN G removed gloves while in the resident's room and placed the soiled gloves in the trash can on the nurse cart. LPN G placed the used lancet into his/her bare hand and placed in the sharps container on the cart and performed hand hygiene. 3. Observation on 05/06/26 at 2:15 P.M., of Resident #35's urinary catheter care showed: - CNA H and CNA F entered the resident's room and did not put on a gown; - CNA H performed hand hygiene and put on clean gloves; - CNA F did not perform hand hygiene and put on clean gloves; - CNA H and CNA F lowered the resident's pants and brief; - CNA H cleaned the resident's front peri area and cleaned from the insertion site down the catheter tubing; - CNA H and CNA F rolled the resident to his/her right side, removed the soiled brief and CNA F placed it in the trash can; - With the same soiled gloves, CNA H and CNA F placed a clean brief on the resident, and pulled up the resident's pants; - CNA H removed gloves. With the same soiled gloves, CNA F assisted CNA H to pull the resident's blanket up around his/her shoulders; - CNA F took the trash to the soiled utility room and performed hand hygiene; - CNA H performed hand hygiene in the resident's room before leaving the room. During an interview on 05/13/26 at 7:56 A.M., CNA H said that he/she should change gloves when going from any dirty task to another task and should wash or sanitize in between glove changes. He/She should wear PPE when doing anything enhanced for the resident, such as changing the resident, looking at their skin, and for catheter care. He/She should wear a gown and gloves when providing catheter care. During an interview on 05/06/26 at 6:29 P.M., the Administrator said she would expect staff to wash and/or sanitize their hands prior to starting care, between glove changes, when going from dirty to clean tasks, and when completing care. She would expect staff to gather supplies prior to putting on gloves and starting care and for staff to wear gloves while handling used lancets and glucometer strips. During an interview on 05/12/26 at 8:56 A.M., the Director of Nursing (DON) said staff should wear PPE for EBP when caring for catheters, dressing changes, peripheral inserted central catheter lines (PICC - a thin flexible tube inserted into a vein in the upper arm and threaded to a large vein near the heart), and for care of any indwelling device. She would expect staff to wear gowns and gloves for catheter care.

Based on interview and record review, the facility failed to respond to or act upon the grievances and dietary recommendations for five residents (Resident #7, #17, #40, #45, and #62) out of 17 sampled residents, six residents (Resident #4, #6, #10, #28, #35, and #66) outside the sample and had the potential to affect all the residents in the facility. The facility's census was 67. Review of the facility's policy titled, Resident Council, revised January 5, 2023, showed: - Residents of each community within each level of living (independent, assisted, and skilled nursing) may organize and participate in resident councils. The resident council shall be composed of representatives from the designated living area (independent, assisted, and skilled nursing), officers of the council and chairpersons of the standing committees; - The purpose of the Resident Council will be to provide an orderly means of communication between residents and community administration; provide and receive necessary information for the benefit of all residents, including the interpretation of administrative policies to residents and conveying to administration suggestions regarding any phase of life and service of the community; assist with activities which will benefit resident of the community; and allow residents to retain part of the responsibility for certain action affecting their day-to-day living; - The Executive Director shall act upon the recommendations of the Council concerning proposed policy and operational decisions affecting resident care and life in the Community; - The Executive Director and other community staff members as determined by resident council and Executive Director will attend the resident council meetings; - Any issues/concerns identified by the resident council will be brought to the attention of the Executive Director or designee and addressed at the next resident council meeting for appropriate follow-up. 1. Review of the Resident Council Minutes, dated 11/20/24, showed: - Some residents are not seeing improvements in dietary; - Too much white rice on the menu and residents would like to see Spanish or flavored rice; - Over easy eggs are too hard; - Food was cold on Sunday; - Some items missing from trays if residents eat in their rooms; - Not enough staff in the dining room; - Residents ask staff for ice water of coffee and staff state that they will be right back but then never return; - Dietary Manager asked what food was missing and if kitchen staff were bringing missing items to the residents. - The facility did not document a response or assign a responsible staff member for follow up to other concerns. 2. Review of the Resident Council Minutes, dated 12/19/24, showed: - Some residents are not seeing improvements in dietary; - Too much white rice on the menu and residents would like to see Spanish or flavored rice; - Residents have not been getting dinner until after 6:00 P.M.; - Residents would like to see more soup on the menu during the colder months and would like more in their bowls as they are usually only half full; - Dietary Manager stated that he would inform dining staff to fill the bowls with more soup; - Staff are taking residents to the dining room too early and residents are having to wait on meals; - Residents are having to yell to get coffee because they are in the dining room too early; - Not enough staff in the dining room during mealtimes; - The facility did not document a response or assign a responsible staff member for follow up to other concerns. 3. Review of the Resident Council Minutes, dated 01/15/25, showed: - Some residents are not seeing improvements in dietary; - Too much white rice on the menu; - Residents would like to see more meat and less rice with meals; - Residents would like to see more soup and bigger bowls of soup; - Residents would like to see less cabbage on the menu; - Staff are still taking them too early to the dining room for meals; - Residents are still having to yell for dietary staff to get coffee; - The facility did not document a response or assign a responsible staff member for follow up to other concerns. During an interview on 01/27/25 at 1:14 P.M., Resident #7 said the food is cold sometimes. During an interview on 01/27/25 at 1:25 P.M., Resident #17 said the food is cold sometimes. During an interview on 01/27/25 at 1:29 P.M., Resident #10 said the chicken is poorly cooked. It is really hard on the outside and just doesn't have a good flavor. During an interview on 01/27/25 at 1:39 P.M., Resident #6 said the food needs help. The potatoes at lunch today were raw. His/Her sister was in the room and had to microwave them. Food is cold by the time he/she gets his/her hall tray and meals are consistently late. During an interview on 01/27/25 at 1:51 P.M., Resident #4 said food is warm most of the time when he/she gets it in his/her room. Staff will drop the tray off and leave without telling him/her, and when he/she realizes it's there, the food is cold. During an interview on 01/28/25 at 9:50 A.M., Resident #45 said the food is not good and sometimes it's not hot when he/she gets his/her hall tray. He/She always eats in his/her room. During an interview on 01/29/25 at 10:30 A.M., six members of the Resident Council (Resident #6, #28, #35, #40, #62, and #66) collectively said they would like to have extra people in the dining room to assist them and to help get refills and to help take other residents back to the room after eating. The food isn't perfect all the time, but it is good sometimes. Sometimes the food is cold even if it is served in the dining room. During an interview on 01/30/25 at 10:47 P.M., the Dietary Manager (DM) said there had been a few residents complain about food temperatures, but they were located at the end of the halls. He/She would expect food to be served to residents at a temperature within the recommended guidelines per regulation. During an interview on 01/30/25 at 2:20 P.M., the Administrator, Director of Nursing (DON), Assistant Director of Nursing (ADON), and Infection Preventionist (IP) collectively said the dietary manager is new, but they would expect food to be served to residents at a temperature within the recommended guidelines per regulation. During an interview on 02/07/25 at 10:44 A.M., the Administrator said if the issue is related to food, then the dietary manager would address it. The Social Services Designee follows up to make sure issues are addressed and reports to me.

Based on interview and record review, the facility failed to follow physician's orders for three residents (Resident #7, #9, and #36) out of 17 sampled residents. The facility's census was 67. The facility did not provide a policy regarding following physician's orders for weighing residents. 1. Review of Resident #7's medical record showed: - An admitted [DATE]; - Diagnoses of heart failure (a condition where the heart muscle is unable to pump enough blood to meet the body's needs), chronic respiratory failure with hypoxia (a serious condition where the body's respiratory system can't remove enough oxygen from the blood), and chronic obstructive pulmonary disease (COPD - a group of lung diseases that cause airflow obstruction and breathing problems). Review of the resident's Physician's Order Sheet (POS), dated January 2025, showed an order to weigh daily, dated 12/06/24. Review of the resident's weights summary and Treatment Administrator Record (TAR), dated December 2024 - January 2025, showed: - Staff were documenting weights in either the weights summary or the TAR; - No weights recorded in either location for 12/21/24, 12/22/24, 01/01/25, 01/11/25, and 01/12/25, for a total of five out of 54 opportunities missed. 2. Review of Resident #9's medical record showed: - admitted on [DATE]; - Diagnoses of Type 2 diabetes (the body has trouble controlling blood sugar), hypertensive heart and chronic kidney disease (chronic kidney disease caused by or significantly worsened by uncontrolled high blood pressure), emphysema (chronic lung disease), and heart failure (heart does not pump correctly). Review of the resident's POS, dated January 2025, showed an order for daily weights, weigh daily in morning for congestive heart failure (CHF), dated 11/09/24. Review of the resident's weights summary and Treatment Administrator Record (TAR), dated December 2024 - January 2025, showed: - Staff were documenting weights in either the weights summary or the TAR; - No weights recorded in either location for 12/3/24, 12/5/24, 12/6/24, 12/8/24, 12/9/24, 12/10/24, 12/11/24, 12/12/24, 12/13/24, 12/14/24, 12/15/24, 12/16/24, 12/17/24, 12/18/24, 12/19/24, 12/20/24, 12/21/24, 12/23/24, 12/25/24, 12/26/24, 12/27/24, 12/28/24, 12/29/24, 12/30/24, 12/31/24, 01/1/25, 01/2/25, 01/4/25, 01/5/25, 01/6/25, 01/7/25, 01/8/25, 01/9/25, 01/10/25, 01/11/25, 01/12/25, 01/13/25, 01/14/25, 01/15/25, 01/17/25, 01/18/25, 01/20/25, 01/21/25, 01/22/25, 01/23/25, 01/27/25, 01/28/25, for a total of 47 out of 62 opportunities missed. Review of Resident #9's progress notes showed starting on 12/11/24, notations saying the scale was broken, so weights were not being documented for the resident. 3. Review of Resident #36's medical record showed: - admitted on [DATE]; - Diagnoses of Type 2 diabetes, hypertensive chronic kidney disease, and edema (fluid retention). Review of the resident's POS, dated January 2025, showed an order for weekly weights every Friday, dated 12/13/24. Review of the resident's weights summary and Treatment Administrator Record (TAR), dated December 2024 - January 2025, showed: - Staff were documenting weights in either the weights summary or the TAR; - No weights recorded in either location for 01/03/25, 01/17/25, and 01/24/25 for a total of three out of six opportunities missed. During an interview on 01/30/25 at 11:06 A.M., Registered Nurse (RN) D said the previous Director of Nursing (DON) had been made aware of the lift not working. He/She had mentioned it more than once to the previous DON. During an interview on 01/30/25 at 11:38 A.M., the Infection Preventionist (IP) said he/she had seen notes saying the scale wasn't working, but when he/she worked that hall the other week the lift was working fine. The aides working the hall are responsible for completing the weights. Staff should know who needs weighed each day because it's listed on the daily sheet, is written on a white board in the nurses station, is on the TAR and it also lights up in the electronic charting. He/she did not know why the scale was listed as not working because it worked fine for him/her. The Assistant Director of Nursing (ADON) may know more about it. During an interview on 01/30/25 at 11:43 A.M., the ADON said there are two lifts. One of them is working, so staff should be able to weigh Resident #9. He/She would check the scale to make sure it's in working order. During an interview on 01/30/25 at 11:54 A.M., the ADON said he/she checked and the facility actually has four lifts, but one doesn't have a scale and two are not calibrated accurately, so they only have one that will weigh accurately. He/she will call the company and request the others be recalibrated and see if they can have a scale added to the one that doesn't have a scale. The aide working the hall should do the weight, but the staff work as a team, so any of the nursing staff can do it to help out. It's possible at times staff were grabbing the non-working scales not realizing there was a working one, but could not say for sure. He/She will move the non-working scales to a different area, so only the working one will be on that hall for staff to use since Resident #9 is the only resident requiring a lift. During an interview on 01/30/25 at 2:20 P.M., the Administrator, DON, ADON, and IP collectively said they would expect the staff to follow physician's orders and weigh residents as ordered. During an interview on 02/06/25 at 4:50 P.M., the Administrator said most of the time the aides document the weights under tasks, like vital signs. The nurse documents on the TAR also. When the nurse documents it on the TAR from the weight on the vital sign sheet, the paper sheet that the aides write their vitals on for the nurses, they may document it also. Staff are still learning this new system. Staff are having trouble seeing the notes the nurses wrote as to why a weight did not get done, resident out of building, refused, etc.

Based on observation, interview, and record review, the facility failed to follow physician's orders for supplemental oxygen therapy and oxygen tubing and humidifier changes for one resident (Resident #7) out of 17 sampled residents. The facility's census was 67. Review of the facility's policy titled, Oxygen Therapy, revised 10/08/21, showed: - Oxygen is treated as a medication ordered by the physician; - The order includes the amount per minute to be delivered, the device used for delivery, and during what times to deliver oxygen therapy; - Change tubing once a week or when soiled. Date, time, and initial tubing when changed; - Non-disposable refillable humidifier bottles are changed every seven days; - Date and initial each non-disposable refillable humidifier when changed every seven days or if contaminated; - Document on the Medication Administration Record (MAR)/Treatment Administration Record (TAR). 1. Review of Resident #7's medical record showed: - An admitted [DATE]; - Diagnoses of heart failure (a condition where the heart muscle is unable to pump enough blood to meet the body's needs), chronic respiratory failure with hypoxia (a serious condition where the body's respiratory system can't remove enough oxygen from the blood), and chronic obstructive pulmonary disease (COPD - a group of lung diseases that cause airflow obstruction and breathing problems.) Review of the resident's Physician's Order Sheet (POS), dated 01/29/25, showed: - An order for oxygen at two liters to maintain oxygen saturation above 92%, dated 12/06/24; - An order to change oxygen tubing and clean concentrator filter weekly every Sunday night shift, dated 12/06/24; - An order for oxygen tubing and humidifier change every Sunday night shift, dated 12/06/24. Review of the resident's MAR, dated January 2025, showed: - The resident received oxygen at two liters on day shift, evening shift, and night shift on 01/27, 01/28, and 01/29; - The resident received oxygen at two liters on day shift on 01/30. Review of the resident's TAR, dated January 2025, showed: - Oxygen tubing changed and concentrator filter cleaned on 01/05, 01/12, 01/19, and 01/26; - Oxygen tubing and humidifier changed on 01/05, 01/12, 01/19, and 01/26. Review of the resident's TAR, dated December 2024, showed: - Oxygen tubing changed and concentrator filter cleaned on 12/08, 12/15, 12/22, and 12/29; - Oxygen tubing and humidifier changed on 12/08, 12/15, 12/22, and 12/29. Observation of Resident #7 showed: - On 01/27/25 at 1:14 P.M., the resident sat on the side of the bed wearing oxygen at four liters per nasal cannula (a thin, flexible tube with two prongs that fit into the nostrils) with tubing dated 12/23/24 and humidity bottle dated 01/08/25; - On 01/28/25 at 1:23 P.M., the resident sat on the side of the bed wearing oxygen at four liters per nasal cannula with tubing dated 12/23/24 and humidity bottle dated 01/08/25. Resident removed the cannula from his/her nose while eating lunch; - On 01/29/25 at 2:11 P.M., the resident sat in a recliner using a second oxygen concentrator, wearing oxygen at two liters per nasal cannula, the humidity bottle dated 12/9 and no date on tubing. The concentrator by the resident's bed with tubing dated 12/23/24 and the humidity bottle dated 01/08/25; - On 01/30/25 at 9:21 A.M., the resident lay in bed wearing oxygen at four liters per nasal cannula with tubing dated 12/23/24 and humidity bottle dated 01/08/25. During an interview on 01/27/25 at 1:14 P.M., Resident #7 was unable to say if or when staff changed his/her oxygen tubing. During an interview on 01/30/25 at 1:24 P.M., Registered Nurse (RN) D said staff are supposed to change tubing every Sunday on night shift and they should be dating it when they change it. During an interview on 01/30/25 at 2:20 P.M., the Administrator said oxygen orders should be followed with the exception of a resident with low oxygen saturation. In that case, it would be nursing judgment to increase the oxygen liter flow and call the physician, but a resident should not be at an incorrect liter flow for an extended amount of time without a physician's order. The Director of Nursing (DON), Assistant Director of Nursing (ADON), and Infection Preventionist agreed that residents should receive oxygen as ordered and residents' tubing and humidity bottles should be changed on Sundays and dated with the date changed.

Based on observation and interview, the facility failed to provide a safe and functional environment for the residents by allowing items to be stored on top of over bed light fixtures for residents in ten resident rooms. Storing items on the over bed light creates a hazard of the items falling on the resident below and does not utilize the light fixtures as intended. The deficient practice had the potential to affect all residents and staff in the facility. The facility census was 67. The facility did not provide a policy for over bed lighting safety. 1. Observation on 01/29/25 at 12:26 P.M. of room [ROOM NUMBER] showed seven stuffed animals on top of the light fixture above the resident's bed. 2. Observation on 01/29/25 at 12:28 P.M. of room [ROOM NUMBER] showed four baseball caps on top of the light fixture above the resident's bed. 3. Observation on 01/29/25 at 12:30 P.M. of room [ROOM NUMBER] showed: - Six bird figurines and two birdhouses on top of the light fixture on the far right wall of the room; - Six glasses and a painting on top of the light fixture on the far left wall of the room. 4. Observation on 01/30/25 at 12:40 P.M. of room [ROOM NUMBER] showed a cup, pictures, and other [NAME] knacks on top of the light fixture above the resident's bed. 5. Observation on 01/30/25 at 12:44 P.M. of room [ROOM NUMBER] showed multiple framed photos on top of the light fixture above the resident's bed. 6. Observation on 01/30/25 at 12:50 P.M. of room [ROOM NUMBER] showed three painted canvas pictures on top of the light fixture above the resident's bed. 7. Observation on 01/30/25 at 12:55 P.M. of room [ROOM NUMBER] showed a framed painting, a Valentine heart decoration, and a Christmas flower arrangement on top of the light fixture to the right of the resident's bed. 8. Observation on 01/30/25 at 1:10 P.M. of room [ROOM NUMBER] showed a large painting on top of the light fixture above the resident's bed. 9. Observation on 01/30/25 at 1:10 P.M. of room [ROOM NUMBER] showed: - A stuffed animal and a white board on top of the light fixtures on the far right wall of the room; - Five stuffed animals on top of the light fixture on the far left wall of the room. 10. Observation on 01/30/25 at 1:12 P.M. of room [ROOM NUMBER] showed: - Five paintings on top of the light fixture above the resident's bed; - Three paintings on top of the light fixture across the room. During an interview on 01/30/25 at 2:20 P.M., the Administrator, Director of Nursing (DON), Assistant Director of Nursing (ADON) and Infection Preventionist (IP) collectively said items should not be placed on the light fixtures due to a possible hazard. 46555

Based on observation, interview and record review, the facility failed to implement a care plan with specific interventions to meet individual needs for two residents (Resident #8 and #60) out of 16 sampled residents. The facility's census was 62. Review of the facility's policy titled, Care Plan, dated 07/28/22, showed: - An appropriate plan of care with services and items the resident is to receive is developed to ensure the highest level of functioning the resident may be expected to obtain; - The plan of care is an ongoing, multi-disciplinary, resident incorporated care plan with services that are to be furnished with consideration of the resident's preference to attain or maintain the resident's highest practicable physical, mental, psychosocial well-being, and will also include the resident strengths, goals, life history. Interventions and goals will remain in the plan of care until problem is resolved. 1. Review of Resident #8's medical record showed: - admitted [DATE]; - Diagnoses of dementia (a disorder marked by memory loss, personality changes, and impaired reasoning that interferes with daily functioning), anxiety disorder (persistent worry and fear about everyday situations) and repeated falls. Review of the resident's quarterly Minimum Data Set (MDS, a federally mandated assessment instrument completed by the facility staff), dated 10/09/2023, showed hearing aid in use. Observations of the resident on 11/16/23 at 1:35 P.M., and on 11/17/23 at 9:35 A.M., showed the resident sat in a recliner with no hearing aid in place. The hearing aid sat in an open box on the top shelf of the resident's bookcase. Review of the resident's care plan, dated 10/18/23, showed it did not address the resident's hearing aid use. During an interview on 11/16/23 at 1:35 P.M., the resident said he/she had a hearing aid, but was not wearing it. The resident said multiple times that he/she could not hear what was being said. He/She wanted the hearing aid to be put in his/her ear. During an interview on 11/16/23 at 1:35 P.M., Certified Nurse Assistant (CNA) A said he/she had worked at the facility for three months and did not know the resident had a hearing aid. During an interview on 11/16/23 at 1:35 P.M., the resident's roommate said staff usually placed the hearing aid in the resident's ear when the resident got up in the morning. The hearing aid was kept on the top shelf of the bookcase. 2. Review of Resident #60s medical record showed: - admitted [DATE]; - Diagnoses of Alzheimer's disease (a progressive disease that destroys memory and other important mental functions), dementia with behavioral disturbances (a group of thinking and social symptoms that interferes with daily functioning), muscle weakness, and cognitive communication deficit (difficulty with thinking and how someone uses language); - A nurses note, dated 10/22/23, the resident fell into the staff's arms and had a seizure (a sudden alteration of behavior due to a temporary change in the electrical functioning of the brain) for two or more minutes; - The hospital documentation, dated 10/23/23, the chief complaint of the resident's visit was an altered mental status (change in mental function that stems from illnesses, disorders and injuries) and final diagnoses of transient alteration of awareness (a brief episode of losing normal awareness or behavior that can have many different causes: seizures, fainting, or one of a large number of physical problems) and syncope (fainting). Review of the resident's care plan, dated 10/23/23, showed: - Did not address the resident's change in condition; - Did not address the resident's or alteration of awareness; - Did not address the resident's syncope. During an interview on 11/17/23 at 1:00 P.M., the Administrator and Director of Nursing (DON) said they would expect a change in a resident's condition and a resident's hearing difficulty with a hearing aid to be addressed on the care plan and they would expect the care plan to reflect the current condition of the resident. 49754

Based on observation, interview, and record review, the facility failed to update and revise the care plan with specific interventions to meet individual needs of one resident (Resident #7) out of 16 sampled residents. The facility's census was 62. Review of the facility's policy titled, Care Plan, dated 07/28/22, showed: - An appropriate plan of care with services and items the resident is to receive is developed to ensure the highest level of functioning the resident may be expected to obtain; - The plan of care is an ongoing, multi-disciplinary, resident incorporated care plan with services that are to be furnished with consideration of the resident's preference to attain or maintain the resident's highest practicable physical, mental, psychosocial well-being, and will also include the resident's strengths, goals, and life history. Interventions and goals will remain in the plan of care until the problem is resolved; - The person-centered plan of care will be reviewed and revised quarterly (if needed), annually, and when significant changes occur; - When problems are no longer active, code as resolved. Review of Resident #7's face sheet showed: - admitted on [DATE]; - Diagnoses of congestive heart failure (CHF, an inability of the heart to pump sufficient blood flow to meet the body's needs), Type 2 diabetes mellitus (a condition that affects the way the body processes blood sugar), and chronic kidney disease (a condition in which the kidneys are damaged and cannot filter blood as well as they should). Review of the resident's Physician's Order Sheet (POS), dated 11/16/23, showed no orders for weekly weights, Accu-checks (blood sugar monitoring), or oxygen (a treatment that provides supplemental oxygen). Review of the resident's care plan, dated 10/04/23, showed: - The resident's weight will be taken weekly and PRN (as needed); - Blood sugars will be recorded per physician's orders; - Oxygen per physician's orders. During an interview on 11/16/23 at 1:35 P.M., the resident said he/she didn't have accuchecks performed. He/she hadn't received an accucheck since admission, and that at his/her last hospital visit prior to the admission, the physician discontinued the order. He/She had not used oxygen since admission. During an interview on 11/17/23 at 1:00 P.M., the Administrator and Director of Nursing (DON) said they would expect the care plan to be revised to reflect the current status of the resident.

Based on interview, observation and record review, the facility failed to keep one resident (Resident #1) safe when the resident got his/her head stuck between the transfer bar attached to the bed frame and the mattress out of three sampled residents. The facility census was 61. The administrator was notified on 06/14/23 at 2:45 P.M., of an Immediate Jeopardy (IJ) which began on 06/14/2023. The IJ was removed on 06/14/23, as confirmed by surveyor onsite verification. The facility did not provide a policy regarding use of mobility rails. 1. Review of Resident #1's medical record showed: - An admitted [DATE], with diagnoses of Alzheimer's disease (a progressive disease beginning with mild memory loss and possibly leading to loss of the ability to carry on a conversation and respond to the environment) with late onset, dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), chronic obstructive pulmonary disease (a group of diseases that cause airflow blockage and breathing-related problems), asthma (a disease that affects your lungs), obstructive sleep apnea (characterized by episodes of complete collapse of the airway or partial collapse with an associated decrease in oxygen saturation or arousal from sleep), and depression (a common and serious medical illness that negatively affects how you feel, the way you think and how you act). Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument required to be completed by the facility staff, dated 04/23/2023, showed: - Cognition intact; - Extensive assist of one staff for bed mobility, dressing, eating, and personal hygiene and bathing; - Extensive assist of two or more staff for physical assist with transfers and use of the toilet; - Incontinent of bladder and occasionally incontinent of bowel; - Two or more falls since admission. Review of the resident's Side Rail Assessment, dated 04/11/2023, showed: - Assessed for full half and quarter rails, not for positioning rails such as transfer, pivot or assist rails; - Rails indicated to assist with bed mobility. Review of the resident's June 2023 Physician Order Sheet (POS) showed: - An order the resident may use the transfer bar applied to the bed as a self-positioning device and to increase independence, dated 10/20/22 and discontinued on 06/01/2023. Review of the resident's Interdisciplinary notes showed: - On 06/01/2023, Certified Nurse Aide (CNA) C yelled for help down to the nursing station. Upon arrival to the resident's room, the resident lay on the floor at the side of the bed on his/her abdomen and right side; - CNA C said the resident's head was wedged between the mattress and the transfer bar with his/her body off the bed when he/she arrived to answer the resident call light. The resident's lips were blue when he/she arrived to the room. CNA C assisted the resident off the bed and lay him/her on the floor; - The nurse instructed other staff to call 911 for emergency medical services; - The nurse log rolled the resident onto his/her back while supporting his/her head, neck and shoulder. The resident was alert, conscious, breathing, able to answer questions appropriately, and denied any pain; - The resident explained to the nurse he/she rolled over and went too far; - The resident was transferred to the emergency room for evaluation. Records were not available for review. Review of the notes from the facility's Occupational Therapist, dated 06/05/2023, showed: - Resident #1 presented to the emergency room with near strangulation with examination for possible cervical spinal injury (the upper portion of the spine including the neck and just below the neck) and trachea (large membranous tube reinforced by rings of cartilage, extending from the larynx to the bronchial tubes and conveying air to and from the lungs) soft tissue injury; - The resident was cleared for no acute cervical injuries via x-ray and Magnetic Resonance Imaging (MRI) (a procedure that uses radio waves, a powerful magnet, and a computer to make a series of detailed pictures of areas inside the body); - History of falls when trying to transfer him/herself; - History of left shoulder dislocations multiple times; - Decreased active range of motion to the left shoulder, avoid pulling on the shoulder with poor endurance. During an interview on 06/14/2023 at 1:05 P.M., Registered Nurse (RN) A said he/she did not actually see Resident #1 until after CNA C removed the resident from the railing. When he/she arrived, the resident was responsive, talking, and did not complain of pain but was scared of what had just happened. During an interview on 06/14/2023 at 1:20 P.M., Resident #1 said he/she did not use the rail on the bed for getting up or positioning him/herself in the bed. He/she was in bed and rolled over one too many times and got the right side of his/her head stuck between the rail and the mattress. He/she was unable to get his/her head out due to rolling over on the left side and his/her left shoulder was too weak to move his/herself from the rail. His/Her body fell on the floor, leaving his/her head stuck, he/she was in pain in that position, was very scared and was having difficulty breathing, so just tried yelling until someone finally came by. He/She did not use the rail on the bed for getting up or positioning. During an interview on 6/14/2023 at 2:00 P.M., CNA D and CNA E both said the resident unable to support him/herself and was not able to use the mobility bar independently and would hold onto it only if directed to do so. During an interview on 06/14/2023 at 2:45 P.M., CNA C said he/she walked down the hall and saw Resident #1's call light on and heard him/her yelling. When he/she entered the room, he/she saw Resident #1 with his/her stomach on the floor, his/her back bent, and with his/her head and neck stuck between the rail and the mattress on the bed. His/her lips were blue, his/her eyes were set, and at that time, he/she was not responding. CNA C immediately, without thinking, grabbed Resident #1 by the shoulders and pulled him/her up and lay on his/her side. Resident #1 said, Thank God you're here, I had been so afraid. He/she immediately called out for help and additional staff came to assist. During an interview on 06/14/2023 at 3:00 P.M., the Director of Nursing and the Director of Clinic Operations said neither were aware that the Side Rail Assessment form did not clearly state what type of rails were being assessed. The form was incorrect and should not have been used to evaluate Resident #1. During an interview on 06/14/2023 at 3:10 P.M., Resident #1's Primary Care Physician (PCP) said he would expect the facility to evaluate each resident thoroughly before using any assistive devices. Based upon the information provided, the facility should have removed the transfer bars when the resident was no longer capable of using them. NOTE: At the time of the abbreviated survey, the violation was determined to be at the immediate jeopardy level J. Based on observation, interview and record review completed during the onsite visit, it was determined the facility had implemented corrective action to remove the IJ violation at the time. A final revisit will be conducted to determine if the facility is in substantial compliance with participation requirements. At the time of exit, the severity of the deficiency was lowered to the D level. This statement does not denote that the facility has complied with State law (Section 198.026.1 RSMo.) requiring that prompt remedial action be taken to address Class I violation(s). Complaint # MO219588

Based on observation, interview, and record review, the facility failed to ensure residents were transferred with safe transfer techniques for three residents (Residents #13, #45, and #55) out of 16 sampled residents and one resident outside the sample (Resident # 42). The facility census was 62. Record review of the facility's policy on Body Mechanics and Safe Resident Handling, Positioning and Transfers showed: - Staff should grasp the transfer belt (an assistive device placed around the resident's wait to aid in a safe transfer) at each side. Record review of the Certified Nurse Aide (CNA) Skills Checklist with a transfer/gait belt showed: - Staff should grasp the belt from underneath with two hands. Record review of the facility's policy on Lifting and Transferring Residents showed: - The facility will provide a safe work environment for resident care areas by providing and requiring the use of safety materials, equipment and training designed to prevent injury; - All residents must be lifted or transferred according to the determined procedure. 1. Record review of Resident #13's Significant Change Minimum Data Set (MDS), a federally mandated assessment required to be completed by the facility staff, dated 1/24/22, showed: - Required extensive assist of two staff for transfers, bed mobility, dressing, and personal hygiene; - Required extensive assist of one staff for toilet use. Observation of Resident #13 on 4/7/22 at 1:26 P.M., showed: - The resident sat in his/her wheelchair; - CNA E placed a gait belt around the resident's waist; - CNA E placed his/her right hand on the gait belt and his/her left hand under the resident's left axilla area; - CNA D placed his/her left hand on the gait belt and his/her right hand under the residents right axilla area and transferred the resident to his/her recliner. 2. Record review of Resident #42's Admission MDS, dated [DATE], showed: - Required extensive assist of two staff for transfers, bed mobility, dressing, and toileting; - Required extensive assist of one staff for personal hygiene. Observation of Resident #42 on 4/7/22 at 1:35 P.M., showed: - The resident sat in his/her wheelchair; - CNA E placed a gait belt around the resident's waist; - CNA E placed his/her right hand on the gait belt and his/her left hand under the resident's left axilla area; - CNA D placed his/her left hand on the gait belt and his/her right hand under the resident's right axilla area and transferred the resident to his/her recliner. 3. Record review of Resident #45's medical record, showed: - The resident required extensive assist of one staff for bed mobility, dressing, toilet use, and personal hygiene; - Required extensive assist of two staff for transfers. Observation of Resident #45 on 4/8/22 at 9:16 A.M., showed - The resident sat in his/her wheelchair; - CNA A placed a gait belt around the resident's waist; - CNA A placed his/her right hand on the front of the gait belt and his/her left hand through the back of the gait belt; - CNA B placed his/her left hand under the resident's left axilla area, his/her right hand on top of the resident's pants, pulled on the top of the resident's pants, and transferred the resident to his/her recliner. During an interview on 4/8/22 at 10:45 A.M., CNA C said staff should place both hands on the gait belt during a transfer and never under the resident's arms. During an interview on 4/8/22 at 10:48 A.M., CNA B said his/her hand should have been on the gait belt. CNA B said he/she was trying to balance the resident during the transfer. He/she said, I was taught to put my hands on the gait belt. During an interview on 4/8/22 at 11:28 A.M., CNA A said one hand should be placed in the front of the gait belt and the other hand in the back of the gait belt. During an interview on 4/8/22 at 11:30 A.M., the Director of Nursing (DON) said staff should place one hand in the front of the gait belt and one on the back of the gait belt. Staff should never put their arms or hands under the resident's arms or on the top of the resident's pants. 4. Record review of Resident #55 Quarterly MDS, dated [DATE], showed: - Required extensive assist of two staff for transfers, bed mobility, dressing, toileting, and personal hygiene. Observation of Resident #55 on 4/7/22 at 1:22 P.M., showed: - The resident sat in his/her wheelchair; - CNA D placed a gait belt around the resident's waist; - CNA E placed his/her right hand on the gait belt and his/her left hand under the resident's left axilla area; - CNA D placed his/her left hand on the gait belt and his/her right hand under the resident's right axilla area and transferred the resident to his/her recliner. During an interview on 4/7/22 at 1:37 P.M., CNA D said he/she was taught one hand could be placed on the gait belt and one under the arm to stabilize the resident. During an interview on 4/7/22 at 1:40 P.M., CNA E said both hands should be on the gait belt, not under the resident's arms. During an interview on 4/7/22 1:43 P.M., Licensed Practical Nurse (LPN) F said when a two-person gait belt transfer is completed, he/she would expect both hands to be placed on the gait belt, not under the resident's arms.

Based on observation, interview, and record review, the facility failed to ensure appropriate placement of the indwelling catheter (a flexible tube inserted into the urinary bladder to drain the bladder) tubing and drainage bag of two residents (Resident #19 and #21) out of three sampled residents and one resident (Resident #42) outside the sample. The facility census was 62. Record review of the facility's procedure guidelines on Caring for Persons With Indwelling Catheters, undated, showed: - Allow urine to flow freely through the catheter or tubing, tubing should not have kinks, the person should not lie on the tubing; - Keep the drainage tube below the bladder to prevent urine from flowing backward into the bladder; - Do not let the drainage bag rest on the floor which can contaminate the system; - Do not let the drain on the drainage bag touch any surface. 1. Record review of Resident 19's medical record showed: - diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] - physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] - physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] - physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the resident's significant change Minimum Data Set (MDS), a federally mandated assessment instrument completed by staff, dated 2/7/22 showed: - Resident with an indwelling catheter. Record review of the resident's Care Plan, revised on 2/18/22, showed: - Indwelling catheter due to urinary retention and [CONDITION(S)]; - Catheter care every shift and as needed; - Ensure the catheter tubing and bag do not touch the floor; - Ensure the catheter appropriately positioned to prevent obstruction. Observations of the resident's catheter showed: - On 4/5/22 at 3:57 P.M., the resident lay in bed with the bed in low position on his/her right side with the foley tubing under his/her legs, and the collection bag lay on the floor; - On 4/5/22 at 2:28 P.M., the resident lay in bed with the bed in low position, and the collection bag lay on the floor; - On 4/7/22 at 1:10 P.M., the resident lay in bed with the bed in low position, the catheter bag hung on the bed frame with the foley tubing under his/her right leg, and the catheter bag touched the floor. 2. Record review of Resident 21's medical record showed: - diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] - physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] - physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the resident's annual MDS, dated [DATE], showed: - Resident with an indwelling catheter. Record review of the resident's care plan, revised on 2/18/22, showed: - Alterations in urinary elimination related to long term use of an indwelling catheter due to a history of a malignant neoplasm of the prostate, presence of urogenital implants (injections of material into the urethra to help control urine leakage), urinary retention, obstructive and reflux [CONDITION(S)] (when urine can not flow completely due to some type of obstruction), and [CONDITION(S)] stage 3 (kidneys with mild to moderate damage); - Ensure the catheter tubing and bag do not touch the floor or become elevated above the bladder. Observations of the resident's catheter showed: - On 4/5/22 at 11:56 A.M., the resident lay in bed with the bed in low position, the uncovered urinary catheter drainage bag hung from the side of bed and touched the floor; - On 4/7/22 at 2:20 P.M., the resident lay in bed with the bed in low position, the uncovered urinary catheter drainage bag hung from the side of bed and touched the floor. 3. Record review of Resident 42's medical record, showed: - diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] - physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] - physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] - physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] - physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the resident's admission MDS, dated [DATE], showed; - The resident with an indwelling catheter. Record review of the resident's care plan, revised on 3/16/22, showed: - Indwelling catheter due to urinary retention; - Catheter care every shift and as needed; - Ensure the catheter tubing and bag do not touch the floor. Observations on 4/7/22 showed: - At 1:30 P.M., the resident's catheter tubing dragged along the floor while being pushed by staff in wheelchair from his/her room; - At 1:35 P.M. the staff transferred the resident to his/her recliner and the catheter tubing lay under the the resident's leg and the bag touched the floor. During an interview on 4/7/22 at 1:37 P.M., Certified Nurse Aide (CNA) D said the catheter tubing should be off the floor and not dragging on the floor. During an interview on 4/7/22 at 1:39 P.M., CNA E said the catheter bag and tubing should be kept off the floor. He/she said with the bed being so low, it is hard to keep it off of the floor. During an interview on 4/7/22 at 1:41 P.M., Licensed Practical Nurse (LPN) F said he/she would expect staff to keep the catheter tubing and bag off of the floor. He/she said the tubing should not be placed under the resident's leg. During an interview on 4/8/22 at 9:40 A.M., the Director of Nursing (DON) said she would expect the catheter tubing to be placed properly and the drainage bag should not touch the floor.

Based on observation, interview, and record review, the facility failed to conduct testing in a manner that is consistent with current standards of practice for conducting Novel Coronavirus 19 (COVID-19, an infectious disease caused by severe acute respiratory syndrome Coronavirus 2 ([CONDITION(S)]-CoV-2). Common symptoms include fever, cough, fatigue, shortness of breath, and loss of smell and taste) tests by not using the recommended Personal Protective Equipment (PPE) during nasal testing of three residents (Resident #11, #14 and #15). The facility further failed to test a symptomatic resident (Resident #1) in a timely manner. The facility census was 59. Reference review by Center for Clinical Standards and Quality/Survey & Certification Group Ref: QSO-20-38-NH DATE: August 26, 2020 and revised 9/10/21 showed: - Conduct testing in a manner that is consistent with current standards of practice for conducting COVID-19 tests; - During specimen collection, facilities must maintain proper infection control and use recommended personal protective equipment (PPE), which includes an N95 (personal protective equipment that is used to protect the wearer from airborne particles and from liquid contaminating the face) or higher-level respirator (or facemask if a respirator is not available), eye protection, gloves, and a gown, when collecting specimens. Record review of the Center of Disease Control and Protection (CDC) Coronavirus Guidance for [CONDITION(S)]-CcV-2 Broad-Based Testing, updated March 29, 2021, showed: - Ensure that all staff involved in specimen collection are appropriately trained and wear PPE as appropriate to their role; - Staff should change or clean and sanitize eye protection when it is soiled or whenever they touch it or take it off; - Staff should change their respirators and masks whenever they are soiled or become wet or whenever they touch them or take them off. Record review of the facility's policy on Emergent Infectious Disease (EID) outbreak management, dated 10/12/21 showed: - Staff will be educated on equipment use, maintenance and supplies used during testing; - During testing of COVID-19 staff will wear transmission-based precaution PPE including N95 masks when obtaining samples and performing test. 1. Observation on 11/17/21 at 9:23 A.M., showed Registered Nurse (RN) A: - Wore a surgical mask, provided COVID-19 nasal swab testing for Resident #14, RN A exited the room and handed the testing swab to the assisting staff member; - RN A wore a surgical mask and provided COVID-19 nasal swab testing for Resident #15, RN A exited the room and handed the testing swab to the assisting staff member; - RN A wore a surgical mask and provided COVID-19 nasal swab testing for Resident #11, RN A exited the room and handed the testing swab to the assisting staff member; - During testing of the three residents, RN A did not wear the recommended PPE, which included an N95 and eye protection. During an interview on 11/17/21 at 2:03 P.M., RN A said he/she forgot to put a face shield on and said he/she was not sure what the facility policy stated in regards to PPE for testing. During an interview on 11/17/21 at 2:00 P.M., the Director of Nursing (DON) said when staff provides COVID-19 testing they should at least wear a surgical mask and definitely a face shield. She said the facility had a sufficient supply of all PPE. The DON said as of today, there were two additional residents that tested positive, making a total of four COVID-19 positive residents and three positive staff. She said the facility was testing twice weekly. 2. Reference review by Center for Clinical Standards and Quality/Survey & Certification Group Ref: QSO-20-38-NH DATE: August 26, 2020 and revised 9/10/21 showed: - Residents who have signs or symptoms of COVID-19, vaccinated or not vaccinated, must be tested immediately. Review of the CDC's Guidance titled Watch for Symptoms, dated February 2021, showed people with these symptoms may have COVID-19: -Fever or chills; -Cough; -Shortness of breath or difficulty breathing; -Fatigue; -Muscle or body aches; -Headache; -New loss of taste or smell; -Sore throat; -Congestion or runny nose; -Nausea or vomiting; -Diarrhea; This list does not include all possible symptoms. Record review of the facility's policy on Emergent Infectious Disease (EID) outbreak management, dated 10/12/21, showed: - Symptoms include: fever, cough, shortness of breath, muscle aches, sore throat, chills, headache, new loss of taste or smell, repeated shaking with chills; - Monitor residents for signs and symptoms. Record review of Resident #1's nurses notes, dated 11/4/21 through 11/11/21, showed: - On 11/4/21, the resident had a productive cough since last night with green to yellow phlegm, complains of mid back pain. Physician notified with new order for [MEDICATION(S)] (an antibiotic)100 (milligram) mg for 10 days; - On 11/5/21, the resident continued on the antibiotic, productive cough continued; - On 11/6/21, antibiotic continued for upper respiratory infection symptoms; - On 11/7/21 at 12:51 P.M., resident came to the nurse and stated, I can't taste or smell, can I be tested . Resident tested with positive results. Record review of Resident #1's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] - On 11/7/21, Transmission Based Precautions for COVID-19 infection until Infection Preventionist clears to discharge. During an interview on 11/17/21 at 2:00 P.M., the Director of Nursing (DON) said they test residents with any signs or symptoms of COVID-19 and was not sure why Resident #1 was not tested sooner. On 11/7/21 the resident was placed on isolation for COVID-19.

Based on observation, interview, and record review, facility staff failed to serve food in a manner to reduce the risk of cross contamination and food borne illness by not washing/sanitizing their hands between serving individual resident's their trays. The facility census was 59. Record review of the policy and procedure titled Hand Sanitizers in Dining Room, last revised 2018, showed: - Train any individual who serves food on proper hand hygiene including handwashing and use of approved gel sanitizers; - All staff must wash hands in a designated hand sink prior to assisting residents/patients in the dining room. If hands are washed outside of the dining room, then staff must use a hand sanitizer when starting to assist residents/patients in the dining room, including passing resident/patient trays; - After proper hand washing, staff may utilize food grade safe hand sanitizer when assisting residents/patients to prevent the cross contamination of resident's food; - Staff will not have any bare hand contact with the resident's food. Deli wraps or utensils must be used to hold the food when assisting residents/patients; - Staff are allowed to use hand sanitizer when passing trays, after touching clothing protectors, assisting residents/patients, answering the telephone, touching resident/patient wheelchairs, etc; - If staff hands become visibility soiled, then the staff person must properly wash hands in a hand sink; - Follow FDA recommendations when using hand sanitizers. Observation on 11/16/21 at 12:12 P.M., on Magnolia Court showed: - Dietary Aide F removed a meal tray from the hall cart and carried it into Room 66-A, placed the tray on bedside table, provided set up, came out of room; - Dietary Aide F did not wash hands or use hand sanitizer, went back to hall cart, pulled out another tray and handed to Certified Nurse Aide (CNA) D to pass to a resident in Room 68. Observation on 11/16/21 at 12:20 P.M., on Dogwood Avenue showed: - CNA B served a meal tray to Rooms 43 and 48; - CNA B did not use hand sanitizer or wash his/her hands between entering and exiting either of the rooms. Observation on 11/16/21 at 12:26 P.M., on Dogwood Avenue showed: - Therapy staff C served a meal tray to Rooms 45 and 46; - Therapy staff did not use hand sanitizer or wash his/her hands between entering and exiting either of the rooms. Observation on 11/16/21 at 12:28 P.M., on Willow Terrace showed: - Therapy staff C served a meal tray to Rooms 38 and 40; - Therapy staff did not use hand sanitizer or wash his/her hands between entering and exiting either of the rooms. Observation on 11/17/21 at 12:16 P.M., on Dogwood Avenue showed: - Therapy staff C served a meal tray to Rooms 46 and 50; - Therapy staff did not use hand sanitizer or wash his/her hands between entering and exiting either of the rooms. During an interview on 11/17/21 at 12:25 P.M., Therapy staff C said staff should wash or sanitize their hands after delivering a meal tray and before touching another. Therapy staff C said he/she must have forgotten to sanitize between residents. During an interview on 11/17/21 at 2:25 P.M., CNA D said staff should wash their hands or use sanitizer after delivering each resident's tray, before reaching for another tray off the cart. If staff touch any item or the resident during the meal set up, staff should wash their hands prior to leaving the room. During an interview on 11/17/21 at 2:30 P.M., Licensed Practical Nurse (LPN) E said staff are expected to wash or sanitize their hands prior to getting a meal tray off of the cart and between each meal delivery. During an interview on 11/16/21 at 3:40 P.M., the Dietary Director said dietary staff are trained how to properly deliver hall trays when assisting the nursing department for meal time in resident rooms, and she would expect all staff to wash their hands or use hand sanitizer after delivering a meal tray to each resident. During an interview on 11/17/21 at 3:00 P.M. the Director of Nursing (DON) said staff should always wash or sanitize their hands when serving resident meal trays. Staff should always sanitize between each resident's meal tray.

Based on observation, interview, and record review, the facility failed to maintain an infection control program that provided a safe and sanitary environment for all residents during the Coronavirus Disease 2019 (COVID-19, an infectious disease caused by severe acute respiratory syndrome Coronavirus 2 ([CONDITION(S)]-CoV-2) pandemic when staff failed use to appropriate Personal Protective Equipment (PPE), failed to remove PPE upon exiting a COVID-19 positive resident's room, failed to post signage outside of a Covid-19 positive resident's (Resident #1) room on the use of specific PPE needed to provide care, failed to post signage at the facility entrances to alert visitors of current COVID-19 outbreak, and failed to ensure the door of a COVID-19 positive resident's (Resident #2) room remained closed to reduce exposure risk for residents residing on the hall who were COVID-19 negative. The facility census was 59. Record review of the facility's policy on Emergent Infectious Disease (EID) Outbreak Management, revised on 10/12/21, showed: - It is the policy of Presbyterian Manors of Mid America that emergent infectious disease (EID) outbreak measures will be instituted whenever there is evidence of an emergent outbreak in consultation with local and State Health Department(s). This community will include the possibility of EID threats to the all-hazard risk assessment for this community. Potential threats include but are not limited to: COVID19, Influenza, Norovirus, and Ebola, [NAME] virus and many others; - Appropriate notifications to the Medical Director, Designee, Executive Director, all departments, attending physicians, state and local agencies, staff members, residents and family members will take place immediately or as soon as possible after the outbreak has been identified via personal contact, community intranet as appropriate and signs around community; - Pandemic COVID19 refers to an outbreak of a respiratory illness caused by a new (novel) coronavirus; - As a new virus identified in 2019, much is unknown about COVID19. It spreads from person to person via respiratory droplets; - Symptoms include: fever, cough, shortness of breath, muscle aches, sore throat, chills, headache, new loss of taste or smell, repeated shaking with chills; - A single new case of [CONDITION(S)]-COV2 in any HCP or nursing home onset [CONDITION(S)]-COV2 infection in a resident is considered an outbreak; - Monitor residents for signs and symptoms; - Use standard precautions at all times; - Communication includes door signs (COVID19 Reopening Phase 1, 2, & 3 posters located in the COVID19 folder on the intranet) on individual infected residents will instruct visitors to check with nursing staff related to specific protective measures required; - COVID Positive Resident Care includes, Follow CDC Guidelines; - Isolate resident; - Appropriate transmission prevention and precautions; - Full PPE required in COVID19 positive areas; - Signage at the rooms, unit, designating need for eye protection, N95 masks, gowns, and gloves at all times; - If an outbreak is identified, nursing personnel will be responsible to: - Increase frequency of assessment of residents for signs and symptoms of the outbreak illness; - Use meticulous infection control practices; - Maintain transmission-based precautions and monitor compliance. 1. During an interview on 11/16/21 at 9:45 A.M., the Administrator said the facility currently has two COVID-19 positive residents. They are completing facility wide testing twice a week. Observations on 11/16/21 at 9:20 A.M., showed no signage posted at the facility entrance to alert visitors of the current COVID-19 outbreak in the facility. Observation on 11/17/21 at 8:00 A.M., showed upon entrance into the facility, no signage that alerted visitors of the current COVID-19 outbreak in the facility. During an interview on 11/17/21 at 9:20 A.M., the Director of Nursing (DON) said the facility had two additional COVID-19 positive residents for a total of four residents. 2. Record review of Resident #1's nurses notes, dated 11/4/21 through 11/7/21, showed: - On 11/4/21, the resident had a productive cough since last night with green to yellow phlegm, complains of mid back pain. Physician notified with new order for [MEDICATION(S)] (an antibiotic) 100 (milligram) mg for 10 days; - On 11/5/21, the resident continued on the antibiotic, productive cough continued; - On 11/6/21, antibiotic continued for upper respiratory infection symptoms; - On 11/7/21 at 12:51 P.M., resident came to the nurse and stated, I can't taste or smell, can I be tested . Resident tested with positive results. Record review of the resident's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] - On 11/7/21, Transmission Based Precautions for COVID-19 infection (COVID-19 positive) until Infection Preventionist clears to discharge. Record review of the resident's nurses notes, dated 11/13/21 through 11/15/21, showed: - On 11/13/21 at 12:42 P.M., resident still had cough and congestion and some anxiety related to COVID. Lung sounds coarse; - On 11/14/21 at 1:57 P.M., cough and congestion still present, lung sounds coarse; - On 11/15/21 at 11:56 A.M., congested cough continued, some labored breathing when talking, diminished lung sounds throughout. Observation of the resident's room on 11/16/21 at 11:45 A.M., showed: - No signage posted outside of the resident's room regarding the use of specific PPE upon entering room; - Certified Nursing Assistant (CNA) B exited the resident's room wearing a surgical mask, face shield, and gloves, and carried a bag of trash; - CNA B did not wear a N95 mask in the resident's room. Observation of the resident's room on 11/16/21 at 12:26 P.M., showed: - No signage posted outside of the resident's room regarding the use of specific PPE upon entering the room; - CNA B wore a surgical mask and face shield, donned (applied) a gown, and took the resident's lunch tray into his/her room; - CNA B exited the resident's room wearing the surgical mask. - CNA B did not wear a N95 mask in the resident's room. During an interview on 11/16/21 at 12:42 P.M., CNA B said he/she was agency staff. He/She had just returned to work today and didn't know what was required. Observation on 11/16/21 of Certified Medication Technician (CMT) M showed: - At 4:40 P.M., he/she donned N95 mask, gown, gloves and faceshield; - At 4:43 P.M., he/she entered Resident #1's room with medications and ice; - At 4:45 P.M., he/she exited the resident's room with face shield and N95 mask. The CMT removed the N95 mask and faceshield. He/she placed the faceshield in a brown paperbag; - At 4:51 P.M., CMT re-entered Resident #1's room wearing N95 mask, gown and faceshield; - At 4:52 P.M., CMT exited room, put the N95 in a paperbag and put the same faceshield back on his/her face; - At 4:55 P.M., the CMT was at the medication cart; - At 4:56 P.M., the CMT entered Resident #3's room (COVID negative), wearing the faceshield and administered eye drops to the resident. During an interview on 11/17/21 at 2:20 P.M., the DON said she would have expected staff to remove faceshield while still in room, leave in the COVID positive room and not wear it to care for other residents. 3. Record review of Resident #2's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] - On 11/15/21 tested with facility wide COVID-19 testing and tested positive. Review of the resident's medical record showed: - On 11/15/21 at 8:29 P.M., the resident had a temperature of 99.9 degrees; - On 11/16/21 at 7:16 P.M., the resident had a temperature of 100.2 degrees. Observations on 11/16/21 at 12:40 P.M., on the Memory Care Unit showed: - There were 17 residents residing on the Memory Care Unit, with isolation signage posted on the outside of one resident's (Resident #2's) room; - Resident #2 sat in a chair in his/her room, with the door open; - CNA K stood inside the open doorway and removed his/her shoe covers; - CNA K exited the room and left the door open. During an interview on 11/16/21 at 11:42 A.M., the DON said she would expect the door to a COVID-19 positive resident to be closed.

Based on interview and record review, the facility failed to document orientation for transfer to a hospital for four residents (Resident #51, #72, #76 and #81) out of 18 sampled residents. The facility's census was 82. 1. Record review of Resident #51's quarterly Minimum Data Set (MDS; a federally mandated assessment instrument completed by the facility), dated 7/15/19, showed: - Severe cognitive impairment; - Limited physical assistance of one staff for transfers, bed mobility, and toileting; - Extensive physical assistance of two staff for dressing. Record review of the resident's physician's orders [REDACTED]. - admitted on [DATE]; - [DIAGNOSES REDACTED]. Record review of the resident's Interdisciplinary Notes, dated 6/19/19, showed: - Resident sent to hospital; - The facility staff did not document orientation of the resident prior to the transfer. 2. Record review of Resident #72's admission MDS, dated [DATE], showed: - Cognition intact; - Extensive physical assistance of two staff for transfers, bed mobility, dressing, and toileting. Record review of the resident's POS, dated 9/11/19, showed: - admitted on [DATE]; - [DIAGNOSES REDACTED]. Record review of the resident's Interdisciplinary Notes, dated 7/29/19, showed: - Resident sent to hospital; - The facility staff did not document orientation of the resident prior to the transfer. 3. Record review of Resident #76's significant change MDS, dated [DATE], showed: - Severe cognitive impairment; - Extensive physical assistance of two staff for transfers, bed mobility, dressing, toileting, and bathing. Record review of the resident's POS, dated 9/11/19, showed: - admitted on [DATE]; - [DIAGNOSES REDACTED]. (a brain disorder that causes memory loss). Record review of the resident's Interdisciplinary Notes, dated 8/6/19, showed: - Resident sent to hospital; - The facility staff did not document orientation of the resident prior to the transfer. Record review of the resident's Interdisciplinary Notes, dated 8/14/19, showed: - Resident sent to hospital; - The facility failed to document orientation of the resident prior to the transfer. 4. Record review of Resident #81's quarterly MDS, dated [DATE], showed: - Severe cognitive impairment; - Total dependence of two staff for transfers, toileting, and bathing; - Extensive physical assistance of two staff for bed mobility and dressing. Record review of the resident's POS, dated 9/11/19, showed: - admitted on [DATE]; - [DIAGNOSES REDACTED]. Record review of the resident's Interdisciplinary Notes, dated 7/30/19, showed: - Resident sent to hospital; - The facility staff did not document orientation of the resident prior to the transfer. 5. During an interview on 9/13/19 at 10:27 [NAME]M., the Director of Nursing (DON) said she would expect there to be documentation that a resident has been oriented for transfer to a hospital. 6. Record review of the facility's policy titled Transfer/Discharge Notice, dated 4/26/19, showed the policy did not address orientation of the resident prior to transfer to a hospital.

Based on interview and record review, the facility failed to accurately code the Minimum Data Set (MDS; a federally mandated assessment instrument completed by the facility), for three residents (Resident #75, #76, and #77) out of 18 sampled residents. The facility's census was 82. 1. Record review of Resident #75's physician's orders [REDACTED]. Record review of the resident's significant change MDS, dated [DATE], showed Section J1400 (prognosis of a condition or disease that may result in a life expectancy of less than six months) coded No. 2. Record review of Resident #76's POS, dated 9/11/19, showed an order dated 8/14/19 for hospice services with a [DIAGNOSES REDACTED]. Record review of the resident's significant change MDS, dated [DATE], showed Section J1400 coded No. 3. Record review of Resident #77's POS, dated 9/11/19, showed an order dated 8/16/19 for hospice services with a [DIAGNOSES REDACTED]. Record review of the resident's significant change MDS, dated [DATE], showed Section J1400 coded No. 4. During an interview on 9/13/19 at 10:27 [NAME]M., the Director of Nursing (DON) said she would expect Section J1400 of the MDS to marked yes when a resident is receiving hospice care. 5. Record review of the facility's policy titled Resident Assessment Instrument (RAI) Process, dated 7/26/19, showed: - A nursing assessment is completed on each new admission, quarterly, annually, and when a significant change in condition occurs; - The MDS is used to record information obtained during the nursing assessment; - Sections of the MDS may have data gathered from completion of information by other staff. RAI Coordinator or the designated reviewer for that section of the MDS is responsible for ensuring accuracy.

Based on interview and record review the facility failed to update care plans for one resident (Resident #47) of 18 residents sampled. The facility census was 82. Record review of Resident #47's Physician Order Sheet (POS) dated 9/11/19 showed: - admitted on [DATE] with [DIAGNOSES REDACTED]. - An order dated 5/22/19 for [MEDICATION NAME] (a diuretic) 40 milligrams (mg) once daily; - An order dated 6/18/19 for multivitamin one daily; - An order dated 6/14/19 to add ice cream or equivalent favorite food item daily; - An order dated 7/29/19 for house supplement 120 milliliter (ml) twice daily for weight loss; - An order dated 8/27/19 for speech therapy three times a week for 30 days to address communication skills, dysarthria, dysphagia, diet modification; - An order dated 9/11/19 for regular mechanical soft solids, thin liquids in five ml flow control cup, may have coffee and naturally nectar liquids in a regular cup. Record review of the dietary note dated 8/16/19 showed significant weight loss, added super cereal for breakfast, house supplement twice daily. Record review of the resident's comprehensive care plan last updated 7/30/19 showed: - No supplements: - No new interventions of ice cream, super cereal and house supplements. During an interview on 9/12/19 at 4:18 P.M., the Director of Nurses (DON) said this resident has fluctuated with his/her weight but was unable to eat at all upon admission. The speech therapist worked with the resident and is at the point of being able to feed him/herself. The resident has made huge improvements, especially since he/she is able to drink from the controlled cup. Since the resident has been doing that he/she is drinking more and even eating more. During an interview on 9/13/19 at 10:27 [NAME]M., the DON said she would expect the nutritional care plan to be updated to included new interventions such as ice cream, house supplements and super cereal. Record review of the facility policy titled Care Plan, revised (MONTH) (YEAR), showed the following: - The plan of care is revised when client's health status, needs, or environment is significantly changed; - The Plan of Care will be reviewed every 62 days, at a minimum.

Based on observation, interview and record review, the facility failed to maintain infection control practices to prevent the development and transmission of infection for two residents (Residents #15 and #72) out of 18 sampled residents and for one resident (Resident #8) outside of the sampled residents. The facility's census was 82. 1. Observation on 9/12/19 at 11:00 [NAME]M., showed the following: - Registered Nurse (RN) A wore gloves, touched the treatment cart, and removed supplies from the cart; - RN A wore soiled gloves, touched Resident #15's cabinet, and removed the resident's glucometer; - RN A wore soiled gloves, touched the resident's finger, and pricked the resident's finger to obtain blood sugar. 2. Observation on 9/12/19 at 11:10 [NAME]M., showed the following: - RN A wore gloves, touched the treatment cart, and removed supplies from the cart; - RN A wore soiled gloves, touched Resident #72's cabinet, and removed the resident's glucometer; - RN A wore soiled gloves, touched the resident's finger, and pricked the resident's finger to obtain blood sugar. 3. Observation on 9/12/19 at 11:20 [NAME]M., showed the following: - RN A wore gloves, touched the treatment cart, and removed supplies from the cart; - RN A wore soiled gloves, touched Resident #8's cabinet, and removed the resident's glucometer; - RN A wore soiled gloves, touched the resident's finger, and pricked the resident's finger to obtain blood sugar; - RN A wore soiled gloves, touched the treatment cart, and removed a vial of insulin; - RN A wore soiled gloves and withdrew the insulin into a syringe; - RN A wore soiled gloves and administered the insulin to the resident. 4. During an interview on 9/12/19 at 11:25 [NAME]M.,. RN A said he/she should have put clean gloves on prior to checking blood sugars and before administering insulin to Resident #8. He/she said that wasn't very sanitary. During an interview on 9/13/19 at 10:27 [NAME]M., the Director of Nursing (DON) said she would expect staff to change their gloves and sanitize hands between dirty and clean areas/procedures. 5. Record review of the facility's policy titled Hand hygiene dated (MONTH) 2019, showed: - Staff to remove gloves promptly after use; - Before touching non-contaminated items and environmental surfaces; - Before caring for another patient.

Based on interview and record review, the facility failed to notify the resident and/or the resident's representative in writing of a facility-initiated transfer for four residents (Residents #7, #25, #50, #63) out of 18 sampled residents. The facility's census was 81. 1. The facility did not provide a policy for notification of hospitalization . 2. Record review of Resident #7's progress notes showed the resident transferred to the hospital on [DATE] and re-admitted to the facility on [DATE]. Record review of the resident's medical record did not contain documentation of a letter which notified the resident and/or the resident's representative of the resident's transfer to the hospital. 3. Record review of Resident #25's progress notes showed the resident transferred to the hospital on [DATE] and re-admitted to the facility on [DATE]. Record review of the resident's medical record did not contain documentation of a letter which notified the resident and/or the resident's representative of the resident's transfer to the hospital. 4. Record review of Resident #50's progress notes showed the resident transferred to the hospital on [DATE] and re-admitted to the facility on [DATE]. Record review of the resident's medical record did not contain documentation of a letter which notified the resident and/or the resident's representative of the resident's transfer to the hospital. 5. Record review of Resident #63's progress notes showed the resident transferred to the hospital on [DATE] and re-admitted to the facility on [DATE], and the resident transferred to the hospital on [DATE] and re-admitted to the facility on [DATE]. Record review of the resident's medical record did not contain documentation of a letter which notified the resident and/or the resident's representative of the resident's two transfers to the hospital. 6. During an interview on 7/25/18 4:05 P.M., the DON verified the facility does not send written notification of hospitalization s. They only verbally discuss the transfer with family and residents. The facility does not have a policy for notification of hospitalization .