Every finding on record at Lenoir Health Care Center

Based on observation, interview and record review, the facility staff failed to store food in a manner to prevent potential contamination, out-dated use and reuse of single-service containers. This failure had the potential to affect residents who dined in the Woods Central and Olive [NAME] units and residents who received modified textured diets. The facility census was 48. 1. Review of the facility's Food Storage Policy, revised [DATE], showed: -Inspect food regularly for damage due to spoilage; -Items that arrive in their original packaging with a manufacturer's expiration date will utilize that date for discard: a. Should an item be opened and stored in a different container, it will be labeled with an open date and discard date; -Food safety practices based on ServSafe Standards will be followed at all times. Review of the ServSafe Manager's Manual, 7th edition, Chapter 5 (The Flow of Food: Purchasing, Receiving, and Storage) showed: -Following good storage guidelines for food and nonfood items will help keep these items safe and preserve their quality. In general, you must label and date mark your food correctly; -All items that are not in their original containers must be labeled with the common name of the food or a statement that clearly and accurately identifies it unless it is easily identified by sight and clearly will not be mistaken for another item; -Refrigeration slows the growth of most bacteria, but some types grow well at refrigeration temperatures. When food is refrigerated for long periods of time, these bacteria can grown enough to cause illness. For this reason, ready-to-eat time/temperature control for safety (TCS) food must be marked if held longer than 24 hours. The label must indicate when the food must be sold, eaten, or thrown out; -Food must be stored in ways that prevent cross-contamination; -Store food in containers intended for food; -Use containers that are durable, leakproof, and able to be sealed or covered; -Food storage starts with wrapping or covering food. Review of the facility's Preventing Foodborne Illness-Food Handling Policy, revised [DATE], showed Food will be stored, prepared, handled, and served so that the risk of foodborne illness is minimized. All employees who handle, prepare, or serve food will be trained in the practices of safe food handling and preventing foodborne illness Observations on [DATE] at 9:42 A.M., showed the main kitchen walk-in refrigerator contained: -a five pound plastic container, previously used for manufacturer packaged grated parmesean cheese, dated ,d+[DATE] used to store cooked sausage patties. Observation showed the container did not contain a description or emblem to indicate the container was not a single-service container; -a five pound plastic container, previously used for manufacturer packaged grated parmesan cheese, dated ,d+[DATE] used to store cooked white gravy. Observation showed the container did not contain a description or emblem to indicate the container was not a single-service container; -a plastic container of pureed sausage dated [DATE] opened to the air. Observation on [DATE] at 7:15 A.M., showed two undated and unlabeled plastic resealable bags which contained different flavors of cookie dough rounds removed from their original packaging stored in the freezer in the Woods Central kitchen. During an interview on [DATE] at 7:15 A.M., Dietary Aide (DA) C said the bags of cookie dough should be labeled with the name of the item and the date is it opened and he/she did not know why they were not labeled or dated. Observation on [DATE] at 7:30 A.M., showed a large undated bag of sausage patties opened to the air stored in the freezer in the Olive [NAME] kitchen. Observations on [DATE] at 8:15 A.M., showed four five pound plastic containers, previously used for manufacturer packaged grated parmesan cheese, dated ,d+[DATE] used to store pureed sausage, pureed eggs, ground sausage with gravy, and gravy in the main kitchen walk-in refrigerator. Observations showed containers did not contain descriptions or emblems to indicate the containers were not single-service containers. During an interview on [DATE] at 8:15 A.M., the kitchen supervisor said the staff prepare batches of the modified textured breakfast foods in advance and stored them in the containers previously used for manufacturer packaged grated parmesan cheese. The kitchen supervisor said he/she did not know the containers were not approved for reuse for food storage. Observation on [DATE] at 9:00 A.M., showed the main kitchen walk-in refrigerator contained a plastic container of pureed sausage marked with a hand-written use-by date of [DATE]. During an interview on [DATE] at 9:30 A.M., the kitchen supervisor said previously prepared food items should be discarded after three days and opened or prepared food items should be stored in sealed containers labeled and dated with their open or made dates. The kitchen supervisor said he/she is responsible for the food storage in main kitchen, which he/she usually checks weekly, and the dining service supervisors are responsible for the food storage in the unit kitchens. The kitchen supervisor said he/she does not document his/her weekly food storage checks. During an interview on [DATE] at 10:43 A.M., the dining services manager (DSM) said: -Opened and previously prepared food items should be labeled, dated with the date made or opened and stored sealed in appropriate containers; -Staff are trained on how to date and label food items, but he/she did not know if staff were trained on what is an appropriate food storage container; -Staff should not reuse manufacturer packaged cheese containers for food storage and he/she did not know they did so; -Prepared food items should be discarded after three days; -The kitchen supervisor is responsible to monitor the food storage in main kitchen; -The weekend dining services supervisors are to monitor the food storage for proper placement, labels, dates, and covering in correct containers, fill out the checklist once completed and turn the completed checklist into him/her; -The last completed checklist he/she had is dated [DATE] and he/she did not know why he/she did not have others after [DATE]. Review of Supervisor Checklist, dated [DATE], showed staff are directed to check food storage for labeling and dating. Review showed the checklist did not direct staff to monitor food storage for the use of proper containers, ensure foods were covered or sealed in containers, and to check for out-dated or expired food items. During an interview on [DATE] 10:55 A.M., the dining services supervisor (DSS) said he/she was the weekend dining services supervisor and he/she did the task on the checklist, but he/she did not document his/her checks because he/she also worked the floor. The DSS said he/she spot checked the refrigerators and freezers on the units for proper food storage looking to see if the foods were labeled, dated, sealed and stored in appropriate places. The DSS said he/she threw away some out-dated food items, but he/she did not notice any other issues and he/she did not check everything. During an interview on [DATE] at 11:39 A.M., the administrator said opened and prepared food items should be labeled, dated and stored in approved, heat resistant containers and previously prepared food items should discarded after three days. The administrator staff are trained on these requirements and the DSM is responsible to monitor the food storage at least weekly. The administrator said the weekend dining services supervisors are also responsible to check all previously mentioned areas thoroughly and document their checks every week. The administrator said he/she did not know the dining services supervisors had not documented their weekly checks since [DATE], staff used single-service containers for food storage, did not date, label and seal opened and prepared food items and did not discard prepared food items after three days.

Based on observation, interview, and record review, facility staff failed to use enhanced barrier precautions (EBP) (an infection control practice that requires staff to wear personal protective equipment (PPE) for five residents (Resident #15, #25, #27, #40, and #14) of five sampled residents who required care. The facility census was 48. 1. Review of the facility policy titled Enhanced Barrier Precautions, dated 02/25/25, showed EBP are utilized to prevent the spread of multi-drug resistant organisms (MDRO)s (bacteria or fungi that have developed resistance to one or more classes of antimicrobial agents, making them difficult to treat) to residents. EBPs employ targeted gown and glove use during high contact resident care activities when contact precautions do not otherwise apply. Gloves and gown are applied prior to performing the high contact resident care activity (as opposed to before entering the room) for residents that have a wound or indwelling medical device, and secretions or excretions that are unable to be covered or contained. Signs are posted in the door or wall outside the resident room indicating the type of precautions and PPE required; PPE is available inside of the resident rooms. 2. Review of Resident #15's Quarterly Minimum Data Set (MDS), a federally mandated assessment tool, dated 02/26/25, showed staff assessed the resident as: -Intact cognition; -Feeding tube (tube placed directly in the stomach to provide nutrition); -Received 501 milliliters (ml) a day or more intake by artificial route seven out of seven days in the look back period. Review of the Physician Order Sheet (POS), dated April 2025, showed: -Osmolite 1.5 Calorie 240 ml, via enteral tube, can have five times daily; -Cholestyramine (used to lower bad cholesterol) four grams (gm) powder for suspension in packet, administer via G-tube. Mix 60 ml of water, flush tube with 40 ml of water before and after medications. Observation on 04/07/25 at 11:27 A.M., showed the resident in his/her room. The resident's room did not have an EBP sign posted outside, and did not have gowns in or by the room. Observation on 04/08/25 at 8:29 A.M., showed resident in recliner with his/her feeding tube exposed. EBP signs are not posted and did not have gowns in or by the room. Observation on 04/08/25 at 1:56 P.M., showed Licensed Practical Nurse (LPN) G entered the resident's room to provide a tube feeding to the resident. The LPN performed the ordered flushes and feeding without a gown on. During an interview on 04/09/25 at 1:53 P.M., Certified Nurse Aide (CNA) E said he/she does not wear a gown when he/she provides care to the resident. The CNA said EBP signs are not posted for the resident and there is not any gowns for the resident's care. During an interview on 04/09/25 at 2:10 P.M., Certified Medication Technician (CMT) I said he/she has not worn gowns during the resident's care because he/she has not been taught to. The CMT said there is not a sign posted for EBP and there is not gowns in the resident's room, or in the hallway. During an interview on 04/09/25 at 2:20 P.M., LPN G said he/she had not been made aware he/she needed to wear a gown for the resident's tube feeding. The LPN said the resident does not have EBP signs posted and there is not gowns inside or outside the resident's room for care. 3. Review of Resident #25's Admission MDS, dated [DATE], showed staff assessed the resident as: -Intact cognition; -One stage 4 pressure injury (full-thickness skin loss and tissue loss); -Four unstageable pressure injury (obscured full-thickness skin loss and tissues loss); -Surgical wound; -Open lesion on foot; -Indwelling urinary catheter (flexible tube ran directly in to the bladder to drain urine). Review of the POS, dated April 2025, showed: -Left heel blister & right ankle blister. Apply skin prep three times a day until healed. -Tailbone wound, Cleanse with wound cleanser, pat dry with 4 x 4 gauze, apply calcium alginate (wound dressing) and cover with foam boarder, change every three days and as needed. Observation on 04/07/25 at 11:43 A.M., showed the resident in his/her bed. The resident's room did not have an EBP sign posted outside, and did not have gowns in or by the room. Observation on 04/07/25 at 11:47 A.M., showed resident in his/her bed. The resident's room did not have an EBP sign posted outside, and did not have gowns in or by the room. Observation showed the resident with a indwelling catheter. During an interview on 04/07/25 at 11:47 A.M., the resident said he/she has open wounds on his/her bottom and heels. The resident said he/she has a urinary catheter. The resident said staff does not wear a gown when they provide wound care or catheter care. Observation on 04/08/25 at 2:19 P.M., showed the resident in his/her room. LPN G performed wound care to the resident's bottom, and CMT I positioned the resident. Observation showed LPN G and CMT I did not wear a gown when they completed wound care and repositioned the resident. During an interview on 04/09/25 at 1:53 P.M., CNA E said he/she has not been told to wear a gowns during wound care or catheter care, so he/she does not wear one. The CNA said the resident does not have an EBP sign posted and there is not gowns inside or outside of the resident's room. During an interview on 04/09/25 at 2:10 P.M., CMT I said he/she has never been told to wear a gown during catheter or wound care. The CMT said he/she did not wear a gown with the resident's care, because he/she did not know he/she needed to. During an interview on 04/09/25 at 2:20 P.M., LPN G said he/she is not in the habit of wearing a gown during the resident's wound care. The LPN said he/she doesn't know why CNAs aren't wearing gowns with care. The LPN said the resident's room does not have an EBP sign posted and there is not any gowns inside or outside the resident's room. 4. Review of Resident #27's Significant Change in Status Assessment (SCSA) MDS, dated [DATE], showed staff assessed the resident as: -Unable to complete Brief Interview for mental status; -Short term memory problems; -One Stage 3 pressure injury (full-thickness skin loss); -One arterial or venous ulcer; -Diagnoses of stroke, high blood pressure, diabetes, heart disease, seizure disorder; hemiplegia (muscle weakness or partial paralysis on one side of the body that can affect the arms, legs, and facial muscles), and peripheral vascular disease (a circulatory condition in which narrowed blood vessels reduce blood flow to the limbs). Review of the resident's POS, dated April 2025, showed: -04/07/25: Right lower leg: Apply Santyl Collagenase Ointment (used to remove damaged tissue from chronic skin ulcers) and Hydrofera Blue (dressings to promote natural wound healing by drawing in the body's natural healing agents while also killing bacteria) to wound bed cover with Aquacel (dressings that promote wound healing, absorb excess fluid, and maintain a moist wound environment) change every day; -04/07/25: Right outer heel wound: Apply Santyl and Hydrofera Blue to wound bed cover with Aquacel change every day; -04/07/25: Right inner heel: Apply Santyl and cover with Aquacel daily. Observation on 04/07/25 at 11:53 A.M., showed the resident's room did not have an EBP sign to alert staff of the need for EBP and did not have PPE inside or outside. Observation on 04/09/25 at 9:33 A.M., showed the resident in his/her room. LPN H performed wound care on the resident's right leg and heel and did not wear a gown during care. During an interview on 04/09/25 at 1:48 P.M., LPN H said he/she did not know what EBP was off the top of his/her head. LPN H said he/she did not receive any instruction or education on EBP. During an interview on 04/09/25 at 2:58 P.M., the Assistant Director of Nursing (ADON) A said he/she did not know what EBP was off of the top of his/her head, and had not received any instruction about it. ADON A said he/she did not know if there were any residents that should be on EBP in his/her neighborhood. 5. Review of Resident #40's SCSA MDS, dated [DATE], showed staff assessed the resident as: -Severe cognitive impairment; -Dependent on staff members for assistance with dressing, bed mobility and personal hygiene; -Frequently incontinent of urine; -Occasionally incontinent of bowel; -One unstageable pressure injury. Review of the resident's POS, dated April 2025, showed: -Pressure wound times four, cleanse with normal saline, pat dry, apply triple antibiotic ointment and cover with Aquacel dressing; -Change every three days and as needed for soiling, there is total of of three wounds on the back along the right and left of the spine. -Left heel and right ankle blister, apply skin prep three times a day until healed. Observation on 04/07/25 at 2:13 P.M., showed the resident's room did not have an EBP sign posted outside, and did not have gowns in or by the room. Observation on 04/07/25 at 2:20 P.M. showed CNA E, Nurse Aide (NA) D and NA F entered the resident's to room to provide incontinence care. CNA E, NA D and NA F provided direct resident care without gowns on. Observation on 04/07/25 at 2:30 P.M., showed LPN G entered the resident's room with wound care supplies. CNA E, NA D and NA F positioned while the LPN provided wound care to the resident's coccyx. The LPN, CNA and two NA's did not have gowns on during care. Observation on 04/08/25 at 8:19 A.M., showed the resident's room did not have an EBP sign posted outside, and did not have gowns in or by the room. Observation on 04/09/25 at 2:08 P.M., showed the resident's room did not have an EBP sign posted outside, and did not have gowns in or by the room. During an interview on 04/09/25 at 1:53 P.M., CNA E said he/she had heard of EBP and it is used to protect staff from resident infections and bodily fluids. The CNA said he/she had not been told to wear gown when he/she does wound or catheter care, so he/she doesn't. The CNA said he/she would assume EBP signs should be posted. The CNA said there is not any gowns in the resident's room for staff to wear and none outside in hall. The CNA said there is not any disposable gowns on the unit floor. During an interview on 04/09/25 at 2:10 P.M., CMT I said he/she did not know what EBP is and no one had ever explained it to him/her. The CMT said he/she has not been told to to wear gowns with catheter care, wound care or enteral feedings. He/She said if he/she had know he/she would have. The CMT said he/she thinks the DON is responsible to post EBP signs. The CMT said the resident does not have gowns in his/her room or outside the room. During an interview on 04/09/25 at 2:20 P.M., LPN G said he/she has not heard of EBP. The LPN said he/she would expect a sign posted outside the room like when resident is on Transmission Based Precautions (TBP) with PPE available. The LPN said he/she didn't think about wearing a gown during wound care with the resident, but he/she should have had a gown on. The LPN said the facility usually has paper gowns for wound care, but there are not available, so he/she just forgot about it. The LPN said he/she doesn't know why the CNAs aren't wearing gowns with care. The LPN said the facility had an infection control nurse, but doesn't know who took over when he/she left the position and is now in a weekend supervisor role. The LPN said the infection prevention nurse switched positions about 6 months ago and he/she is not sure who is doing infection control now. 6. Review of Resident #14's POS dated 04/08/25 showed an order for Calmoseptine to be applied to his/her coccyx wound two times a day and as needed. Observation on 04/09/25 at 1:11 P.M., showed the resident's room did not have an EBP sign posted outside, and did not have gowns in or by the room. RN J and CMT M provided wound care to the resident's coccyx and did not wear a gown. During an interview on 04/09/25 at 1:25 P.M., RN J said he/she did not know what EBP is and had not been instructed to wear a gown during wound care. 7. During an interview on 04/10/25 at 8:59 A.M., the Clinical Educator said resident who require EBP should have a sign posted on the outside of their door and staff should wear and gown and gloves during care. The Clinical Educator said staff had been educated on EBP at the end of last year. The Clinical Educator said residents with wounds require EBP but residents with feeding tubes and catheters do not. The Clinical Educator said residents who require EBP should have gowns and gloves outside their rooms. The Clinical Educator said he/she does not know why resident's with feeding tubes, catheters and wounds are not on EBP. The Clinical Educator said he/she is responsible for educating staff about EBP and the nurse manager is responsible for implementing EBP. During an interview on 04/10/25 at 9:18 A.M., the MDS Coordinator said he/she has not heard of EBP. He/She said the clinical educator is responsible for training staff about infection prevention. The MDS Coordinator said he/she is not aware of what EBP is, nor has the staff been doing it. The MDS Coordinator said staff are not doing EBP for residents because staff have not been taught about EBP or informed of it. During an interview on 04/10/25 at 11:19 A.M., the Director of Nursing (DON) said if a resident has secretions from the mouth, a wound, or staff are considered about urine splashing they should use EBP. The DON said EBP requires staff to use a gown, gloves, mask and goggles depending on the splash back. The DON said EBP is to protect staff resident secretions. The DON said staff haven't been doing EBP and the Clinical Educator and myself should have implemented it. The DON said he/she doesn't know why he/she didn't implement EBP in the facility. The DON said the PPE is kept in the basement with the supply manager but charge nurses or nurse managers can go down and get it. During an interview on 04/10/25 at 11:39 A.M., the administrator said staff should wear gowns and gloves if a resident has an indwelling medical device or wound. The administrator said signs should be be posted if a resident requires EBP. The administrator said EBP is to protect the employees. The administrator said staff do not have to use EBP for residents with catheters if the resident does not have a current infection. The administrator said EBP should be used for feeding tube care. The administrator said staff are following the facility policy, but the policy is written wrong. The administrator said staff have not been using EBP because they are misinterpreting the policy. The administrator said the Clinical Educator is responsible for educating staff on EBP and he/she does not know why staff does not know what EBP is. 45489 50361

Based on observation, interview, and record review, facility staff failed to use appropriate infection control procedures to prevent the spread of bacteria or other infectious causing contaminants when staff failed to perform appropriate hand hygiene and glove changes during incontinent care for three residents (Resident #32, #35, and #36), and failed to properly handle soiled linens for one resident (Resident #36). The facility census was 49. 1. Review of the facility's Hand Hygiene policy, reviewed 01/30/24, showed all personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infection to other personnel, residents, and visitors. Review showed: -Use an alcohol-based hand rub containing at least 60% alcohol, or, alternatively soap (antimicrobial or non-antimicrobial) and water for the following situations: a. Before and after contact with residents; b. Before moving from a contaminated body site to a clean body site during resident care; c. After removing gloves; -The use of gloves does not replace hand washing/jhand hygiene. Integration of glove use along with routine hand hygiene is recognized as the best practice for preventing health care associated infections. 2. Review of Resident #32's Quarterly Minimum Date Set (MDS), a federally mandated assessment, dated 12/22/23, showed staff assessed the resident as: -Severely cognitively impaired; -Frequently incontinent of urine and occasionally incontinent of bowel; -Dependent for toileting hygiene; -Diagnosis of Dementia. Observation on 03/08/24 at 09:53 A.M., showed Certified Nursing Assistant (CNA) L and Certified Medication Technician (CMT) M provided perineal care for the resident. CNA L and CMT M did not wash their hands after they removed their gloves or before they left the resident's room. During an interview on 03/08/24 at 10:00 A.M., CMT M said the normal routine was interrupted, they were anxious about being watched, and forgot to sanitize their hands before exiting the room. CMT M said staff should sanitize hands before exiting a resident's room if the resident or any items were touched. 3. Review of Resident #35's Quarterly MDS, dated [DATE], showed staff assessed the resident as: -Severely cognitively impaired; -Always incontinent of urine and always incontinent of bowel; -Dependent for toileting hygiene; -Diagnosis of Dementia and Alzheimer's Disease. Observation on 03/07/24 at 10:10 A.M., showed Registered Nurse (RN) O and CMT N provided perineal care for the resident. CMT N wiped bowel off the resident's buttocks, removed gloves, put on clean gloves and continued to wipe the resident and did not perform hand hygiene. During an interview on 03/07/24 at 10:21 A.M., CMT N said hands should be sanitized before entering and exiting a resident's room, and before touching a cleaner item after touching a dirtier item. CMT N did not realize he/she had changed gloves without sanitizing hands during the perineal care. 4. Review of the facility's Linen Handling policy, reviewed January 2024, showed: -Soiled laundry/bedding shall be handled in a manner that prevents gross microbial contamination of the air and persons handling the linen. All soiled linen is handled as contaminated linen; -All used linen shall be bagged at the point of use in a leak-resistant bag and placed in a hamper or taken to the linen holding area. 5. Review of Resident #36's Quarterly MDS, dated [DATE], showed staff assessed the resident as: -Cognitively impaired; -Required substantial/maximum assistance for dressing; -Toileting assistance was non-applicable; -Diagnosis of stroke. Observation on 3/7/24 at 10:26 A.M., showed Certified Nurse Aide (CNA) E and CNA F entered the resident's room to provide incontinence care and did not perform hand hygeine before they applied clean gloves. Observation showed CNA F pulled down the blankets, unsecured the soiled brief, placed the brief down between the residents legs, and cleansed the perineal area with wet wipes. CNA F's gloves became soiled he/she removed the gloves and reapplied new gloves. Observation showed the CNA F did not perform hand hygiene. CNA E and CNA F rolled the resident to the side, CNA E rolled the soiled brief under the resident, soiled his/her glove with bowel movement and put it in a plastic bag, removed his/her gloves and applied new gloves. CNA E did not perform hand hygiene. CNA E cleansed the buttocks and inner thighs, removed gloves and applied new gloves. CNA E did not perform hand hygiene. The resident was rolled to the opposite side and CNA F cleansed the buttocks and inner thighs, removed the soiled brief from under the resident, placed the brief in a bag and removed his/her gloves and applied new gloves and did not perform hand hygiene. CNA F opened the nightstand and obtained a tube of barrier cream and squirted some onto CNA E's glove. CNA E applied the barrier cream to the residents buttocks, removed the soiled linens from under the resident and placed them on the floor, applied a clean brief to the resident, picked up the soiled linen and placed it into a plastic bag, placed the bag on the bed and removed his/her gloves and did not perform hand hygiene. Both CNA's removed the residents gown, applied the resident's clean pants and shirt, positioned a mechanical lift sling under the resident, and attached the sling to the lift, transferred the resident removed their gloves and applied clean gloves and did not perform hand hygiene. CNA E touched the call light and handed it to the resident, took the soiled linen bag and trash bag with gloved hands out of the room to the soiled work room and returned to the room. CNA E did not perform hand hygiene before leaving the room or when returning to the room. CNA F washed the resident's face, applied a hand brace, applied clean linens to the bed, and left the room with the mechanical lift and did not perform hand hygiene before leaving the room. CNA E left the room and did not perform hand hygiene. During an interview on 03/07/24 at 11:00 A.M., CNA F said hands should be washed when going into a room, before leaving a room, before washing the residents face, before making the bed or touching clean linens, and between glove changes. He/She said he/she was nervous and usually does wash his/her hands to decrease the spread of infection to other people. During an interview on 03/07/24 at 11:03 A.M., CNA E said hands should be washed when going in a room, before leaving a room, and between glove changes. He/She said he/she should not have left the room with gloves on or thrown the linens on the floor because that is how germs are spread. He/She said if linens are on the floor, someone could step there and spread the germs around. He/She said he/she didn't wash his/her hands because it slipped his/her mind. 5. During an interview on 03/08/24 at 10:10 A.M., Licensed Practical Nurse (LPN) S said hands must be sanitized before entering a resident's room, when leaving the resident's room, between changing gloves, and when touching dirty to clean. LPN S said linens should be in a dirty linen bag, and the bag tied up before exiting the room and that soiled linens should never be placed on the floor. LPN S said these processes are necessary to prevent the spread of infection. During an interview on 03/08/24 at 11:55 A.M., the Director of Nursing (DON) said hands should be sanitized before perineal care is started, when moving from dirty to clean, if gloves are changed, and before leaving the room. Soiled linens should be in a dirty linen bag, tied up and never on the floor. If these infection control procedures are not followed, there is a risk of spreading an infection. During an interview on 03/08/24 at 12:36 P.M., the administrator said hands should be sanitized when entering a room, any time gloves are removed, and when leaving the room. Hands should be sanitized before touching clean item such as a fresh brief after touching a soiled brief or soiled clothes. No linens should be on the floor, and soiled linens should always be in a bag after removing them from the bed. If staff do not sanitize hands or put soiled linens on the floor, there is an infection control issue. 43327

Based on observation, resident and staff interview, and record review, facility staff failed to provide safe mechanical lift transfers for four (Resident #28, #29, #32, and #35) out of 13 sampled residents. Facility staff failed to provide safe medication storage for three residents (Resident #23, #36, and #8). The facility census was 49. 1. Review of the facility's Safe Lifting and Movement of Residents policy, dated 10/14/19, showed staff were directed as follows: -Staff responsible for direct resident care will be trained in the use of a mechanical lifting devices; -Staff will be observed for competency in using mechanical lifts and observed periodically for adherence to policies and procedures regarding the use of equipment and safe lifting techniques. Review of the mechanical lift manufacturer's manual, dated 10/01/18, showed a warming, the legs of the lift must be in the maximum open position for optimum stability and safety. If it is necessary to close the legs of the lift to maneuver the lift under a bed, close the legs of the lift only as long as it takes to position the lift over the patient and lift the patient off the surface of the bed. When the legs of the lift are no longer under the bed, return the legs of the lift to the maximum open position and lock the shifter handle immediately. 2. Review of Resident #28's admission Minimum Data Set (MDS), a federally mandated assessment tool used to plan care, dated 01/10/24, showed staff assessed the resident as follows: -Severe cognitive impairment; -Total dependence on staff for toilet transfers; -Total dependence on staff for shower transfers; -Diagnosis of Alzheimer's. Observation on 03/06/24 at 3:40 P.M., showed Certified Nurse Aide (CNA) A and CNA B used the mechanical lift to transfer the resident from his/her bed to the wheelchair. CNA B used the mechanical lift to move the resident off the bed and backed the mechanical lift away from the bed, and turned the lift without spreading the legs of the the mechanical lift . CNA B then move the resident across the room to the wheelchair. Staff did not widen the legs of the mechanical lift to provide safety while they transferred the resident. During an interview on 03/06/24 at 3:47 P.M., CNA B said the legs of the lift should remain closed until they are spread to clear a wheelchair. 3. Review of Resident #29's quarterly MDS, dated [DATE], showed staff assessed the resident as follows: -Severe cognitive impairment; -Toilet transfer total dependence; -Shower transfer total dependence; -Diagnosis of Alzheimer's. Observation on 03/07/24 at 10:30 A.M., showed CNA I and CNA J used a Hoyer lift to transfer the resident from his/her bed to the wheelchair. CNA I lifted the resident off the bed with the mechanical lift, backed away from the bed, and then turned the mechanical lift around to point it towards the wheelchair. The aide pushed the mechanical lift across the room and lowered the resident into the wheelchair. Staff did not widen the legs of the mechanical lift to provide safety while they transferred the resident. During an interview on 03/07/24 at 10:40 A.M., CNA I said the legs of the lift should be open but it is easier to get around the room if they are left closed. The CNA did not know the safety risks when not opening the legs. 4. Review of Resident #32's quarterly MDS, dated [DATE], showed staff assessed the resident as follows: -Severely cognitively impaired; -Toilet transfers required with substantial/maximal assistance from staff; -Shower transfers required with substantial/maximal assistance from staff; -Diagnosis of Dementia. Observation on 03/08/24 at 09:53 A.M., showed CMT M and CNA L used a mechanical lift to transfer the resident from the resident's chair to the bed. CNA L pushed the mechanical lift legs under the resident's wheelchair with the mechanical lift legs closed. CNA L raised the resident with the mechanical lift , backed the hoyer lift up and pivoted the lift toward the bed. CNA L then pushed the lift under the bed and lowered the resident onto the bed. Staff did not widen the legs of the mechanical lift to provide safety while they transferred the resident. Observation on 03/08/24 at 10:04 A.M., showed CMT M and CNA L used a mechanical lift to transfer the resident from the resident's bed to the wheelchair. CNA L pushed the hoyer lift under the resident's bed with the legs closed. The CNA transferred the resident in the hoyer lift to the wheelchair with the legs closed. Staff did not spread the legs of the mechanical lift to provide safety while they transferred the resident. During an interview on 03/08/24 at 10:09 A.M., CMT M said when using a mechanical lift, the legs should be open while moving the resident, but it does not happen all the time because the lift legs do not fit well under the beds. 5. Review of Resident #35's quarterly MDS, dated [DATE], showed staff assessed the resident as follows: -Severely cognitively impaired; -Toilet transfers were not applicable -Shower transfers were dependent; -Diagnosis of Dementia and Alzheimer's Disease. Observation on 03/07/24 at 10:10 A.M., showed CMT N and RN O used a mechanical lift to transfer the resident from the resident's chair to the bed. RN O pushed the hoyer lift legs under the resident's wheelchair with the lift legs widened. RN O raised the resident with the hoyer left, backed the hoyer lift up, closed the lift legs and pivoted the lift toward the bed. RN O then pushed the lift under the bed and lowered the resident onto the bed. Staff closed the lift's legs when they pivoted the resident and did not widen the legs of the mechanical lift to provide safety while they moved the resident from the wheelchair onto the bed. During an interview on 03/07/24 at 10:19 A.M., RN O said when using a mechanical lift, the legs should be open while moving the resident, but it was difficult due to the lack of space in the room. During an interview on 03/08/24 at 8:45 A.M., Licensed Practical Nurse (LPN) K said the legs of a lift should be open wide when transferring a resident. He/She said this is done for stability and safety. Additionally, he/she said they expect staff to always open the legs of the lift when transferring a resident because they are educated to do a lift in this manner. During an interview on 03/08/24 at 8:55 A.M., the Assistant Director of Nursing (ADON) said lifts are done with two staff. The ADON said one staff steadies the resident while the other operates the lift. Legs on the lift should be open to the widest position for stability while moving. He/She said there is a risk of the resident falling if the legs of the lift are not open. During an interview on 03/08/24 at 11:54 A.M., the Director of Nursing (DON) said two staff are used to perform a mechanical lift and transfer of a resident. He/She said one staff supports the resident and the other operates the lift and the legs should be open to their widest position for stability regardless of the lift manufacturer. The DON said staff should not be doing transfers without the stability of the legs open. During an interview on 03/08/24 at 12:36 P.M., the administrator said staff are trained to open the legs of lifts for stability. He/She said there isn't a reason for them not to open the legs as it is not safe due to the lack of stability. 6. Review of the facility's Administering Medications policy, reviewed January 2024, showed residents may administer their own medication only if the physician, in conjunction with the interdisciplinary care planning team, has determined the resident has the decision making capacity to do so safely. 7. Review of Resident #8's quarterly MDS dated [DATE] showed staff assessed the resident as cognitively intact. Review of the resident's Physician Order Sheet (POS), dated March 2024, showed the resident did not have an order for Calamine Clear Lotion or over the counter sore throat spray to be kept at bedside. Review of the resident's medical record did not contain documenation staff assessed the resident for his/her ability to have the capacity to safely self administer medications. Review of the nursing notes showed staff documented: -At 03:20 P.M., the resident called nurse to room, held up a bottle of calamine clear spray bottles within reach in the resident's bathroom. -At 03:25 P.M., items removed from the resident's room included: a body cleanser - two bottles of shampoo/conditioner, aloe vera & vitamin E baby oil, nail polish remover, over the counter sore throat spray, stress relieving moisturizing lotion, over the counter wrinkle release spray, two bottles of eye glass cleaner, liquid soap and hydrating Lotion. Observation on 03/05/24 at 10:40 A.M., showed the resident in his/her room. Observation showed a bottle of over the counter calamine clear lotion sat on the resident's bedside stand with [NAME] Wrinkle Release and Equate Lense Cleaner ught the bottle of calamine lotion was nutritional supplement and swallowed it by mistake. During an interview on 03/07/24 at 09:48 A.M., the resident said he/she tholotion and stated, I drank this. During an interview on 03/07/24 at 10:53 A.M., Housekeeper R said if housekeeping staff see any kind of medication in the resident's room, a nurse should be notified. Housekeeper R said he/she had never seen medications in a resident's room. During an interview on 03/07/24 at 11:05 A.M., Licensed Practical Nurse (LPN) Q said a physician must write an order for any over the counter (OTC) medication and the order should also state may keep at bedside. The resident should have a medication self-administration assessment, and should be instructed to keep all medications out of sight. LPN Q said families are instructed to turn in or take home any over the counter medications and not leave them with the resident. During an interview on 03/08/24 at 11:55 A.M., the Director of Nursing (DON) said if a resident has medication in their room, doctor orders must be obtained, and the interdisciplinary care planning team should assess if the resident had the decision making capacity to safely self administer medication and use the resident shmedication self-administration assessment tool. The resident must be alert and follow instructions to keep the medications in the bathroom, locked in a box. The DON said there are residents who wander and access the medications which could harm them. During an interview on 03/08/24 at 12:36 P.M., the administrator said he/she expects an order for self-administration of medications and the resident should be assessed to ensure safety. He/She said if the resident is not safe, an accidental overdose or poisoning may occur. 8. Review of Resident #23's quarterly MDS, dated [DATE], showed staff assessed the resident as moderately cognitively impaired. Review of the resident POS, dated March 2024, showed an order dated 02/20/24, for Chlorhexidine gluconate (antiseptic) 0.12% 15 milliliters (ml) twice a day for dry mouth. Swish and spit, do not swallow. Review of the resident's medical record did not contain documenation staff assessed the resident for his/her ability to have the capacity to safely self administer medications. Observation on 03/06/24 at 09:40 A.M., showed the resident in his/her room. Observation showed a bottle of Chlorhexidine gluconate 0.12% mouthwash on the counter in the bathroom. Observation at this time time showed another resident wandered into the room and staff redirected the resident out of the room. During an interview on 03/08/24 at 10:05 A.M., LPN C said if there are medications in a resident's room, there should be an order that states, may keep at bedside. He/She said he/she was not aware until 03/07/24 an assessment is needed to be completed for residents who wish to have the medications at bedside. LPN C said the resident is not oriented enough to be able to self-administer the medication and should not have it at the bedside. He/She said other nurses have been told before not to leave medications at bedside because there are other residents that wander on the unit and could get hurt if they take medications that are not theirs. He/She did not know why the medication was in the resident's room. During an interview on 03/08/24 at 11:46 A.M., the DON said the resident is not approved to have medication in his/her room. 9. Review of Resident #36's quarterly MDS, dated [DATE], showed staff assessed the resident as moderately cognitively impaired. Review of the resident's POS, dated March 2024, showed an order dated 12/16/23, for arthritis hot pain relief 15%-10% topical cream to right upper extremity/right shoulder. May keep at bedside and family may apply when here. Review of the resident's medical record did not contain documenation staff assessed the resident for his/her ability to have the capacity to safely self administer medications. Observation on 03/06/24 at 09:38 A.M., showed the resident in bed. Observation showed the over bed table with an over the counter pain relieving cream/gel on on top. Observation at this time showed another resident wandered into the room and staff redirected the resident out of the room. During an interview on 03/06/24 at 09:38 A.M., the resident said he/she could not tell what the medication was for or why it was in the room. During an interview on 03/08/24 at 10:05 A.M., LPN C said if there are medications in a room, there should be an order that states, may keep at bedside. He/She said was not aware until 03/07/24 there was an assessment needed to be completed for residents who wish to have the medications at bedside. LPN C said there are other residents who wander on the unit and could get hurt if they take other medications that are not theirs. He/She said there is only one resident on the unit who is able to self administer medication, and this resident is not that resident. He/She did not know why the medication was in the room. During an interview on 03/08/24 at 11:46 A.M., the DON said the resident is not approved to have medication in his/her room. During an interview on 03/08/24 at 11:46 A.M., the DON said in order for a resident to self administer medication there should be an order and assessment completed to ensure the resident is alert and oriented enough to take the medication safely. He/She said if they are, there is a cabinet in the resident's bathroom that can be locked for the resident to use and to keep other residents from accessing the medication. He/She said there are residents who wander and could potentially access the medication kept in other rooms and get hurt. During an interview on 03/08/24 at 12:36 A.M., the administrator said he/she is not aware of any resident approved to have medication at bedside. He/She expects an order to be obtained from the physician and an assessment to be completed before medications are allowed to be in a resident's room. The administrator said wandering residents could go into the room and take the medication and get hurt if the medication is not secured. 42484 43327

Based on observations, interviews and record review, facility staff failed to review, revise and develop individualized interventions for one resident (Resident #5) who exhibited behaviors. The facility census was 49. 1. Review of the Facility Assessment, dated July 2023 through June 2024, showed: -Twenty-eight residents with a diagnosis of Alzheimer Disease (A progressive disease that destroys memory and other important mental functions); -Twenty-one residents with a diagnosis of unspecified dementia (A group of thinking and social symptoms that interferes with daily functioning). Review of the facility's Mood and Behavior policy, undated, showed: -To provide a plan of care that is individualized to the resident's needs based on the comprehensive assessment by the interdisciplinary team; -An initial care plan identifying resident mood and behavior needs will be completed and communicated to care givers; -Any mood and behavior symptoms will be documented by the Interdisciplinary Team while caring for the resident, as well as interventions attempted and outcome; -The community will assess and determine individualized behavioral care plan interventions for individuals with dementia; -Behavioral interventions are individualized approached that are provided as part of a supportive physical and psychosocal environment, and are directed toward understanding, preventing, relieving, and/or accommodating a resident's distress or loss of abilities; -Mood and behavioral tracking documentation will be completed by front line staff, based on comprehensive assessment outcomes, to identify any mood and behavior patterns, interventions attempted and outcome of approaches; -Mood and behavioral tracking will be reviewed by the Interdisciplinary Team to determine trends and effectiveness of care plan interventions. 2. Review of Resident #5's quarterly Minimum Data Set (MDS), a federally mandated assessment tool used to plan care, dated 1/12/24, showed staff assessed the resident as: -Severely cognitively impaired; -No behaviors or symptoms of delirium; -Diagnosis of Alzheimer dementia, anxiety, and depression. Review of the resident's care plan, dated 3/5/24, showed: -Use of psychotropic medication and will be free of signs and symptoms of drug-related cognitive impairment and behavioral impairment; -Monitor for effectiveness of psychotropic drug(s); -Has anxiety manifested by verbal distress; -Offer juice and/or snacks; -When experiencing episodes of anxiety by crying out, ask if would like to sit in a recliner in his/her room for a quieter environment; -Reassure during periods of distress/anxiousness; -Speak in a calm voice; validate feelings; -The record did not contain documentation or direction to staff regarding his/her need for frequent redirection when being repetitive and attempts to find out cause of anxiety. Review of the resident's nurse's notes, dated December 8, 2023 through March 8, 2024 showed: -1/27/24 clinical note: When brought to the dining room for dinner, began yelling somebody help me. Who is going to help me. The resident stated he/she wanted to move to a recliner in the living room. Informed he/she was sitting at the dining table because it was almost time for dinner and he/she understood. When staff walked away, the resident began yelling for help again. The resident needed frequent redirection while waiting for dinner. -2/10/24 clinical note: Sitting in the living room recliner after dinner, kept yelling Somebody come and help me, somebody come and get me, multiple times. Staff would check on the resident to see what he/she needed and the resident would state, I don't need anything. The nurse repositioned the resident in the recliner by elevating his/her feet and covering him/her with a blanket. -2/16/24 clinical note: Sitting in the living room, yelling out Somebody come get me, multiple times throughout the evening. Twice, when staff approached the resident to assist him/her, the resident yelled get away from me. Leave me alone. He/she was assisted to the bathroom and sat in his/her recliner in his/her bedroom this evening. He/she calmed down after using the bathroom and while watching television (TV) in his/her room. Review of the resident's Behavior Monitoring, dated 12/8/23 through 3/8/24, showed staff documented the resident cried: -December 2023, four of 23 days; -January 2024, 19 of 31 days; -February 2024, 18 of 29 days; -March 2024, seven of eight days. Review of the resident's Behavior Monitoring, dated 12/8/23 through 3/8/24, showed staff documented disruptive behaviors on January 21 and 23, February 27, and March 4, 2024. Observation on 3/5/24 at 10:30 A.M., showed the resident in a recliner in the living room with ten other residents. Observation showed the resident repeatedly said help me, take me over there loudly. Observation showed an unknown staff member said, in just a little bit. The resident in a loud voice said, my butt hurts. Observation on 03/05/24 at 10:56 A.M., showed a staff member ambulated the resident to the dining room chair and told the resident he/she would be eating soon. Observation showed staff did not assist the resident with his/her discomfort or offer any other interventions to assist the resident as directed in the residents plan of care. Observation on 03/05/24 at 11:23 A.M., showed the resident at the dining room table with 16 other residents in the area. He/She loudly repeated help me, help me, come and get me, so ready. Observation showed staff did not offer any other interventions to assist the resident as directed in the resident's plan of care. Observation on 3/5/24 at 02:27 P.M., showed the resident in a recliner in his/her room with the door open. In a loud voice the resident said help me to two different staff members as they walked by the room. Observation showed staff did not offer any other interventions to assist the resident as directed in the resident's plan of care. Observation on 3/6/24 at 08:04 A.M. through 09:08 A.M., showed: -At 08:04 A.M., the resident sat at the dining room table with a large group of peers during the breakfast meal. In a loud voice, he/she said, come and get me now, I'm ready, take me to the white chair, I'm choking, now I am, come and get me. -At 08:10 A.M., in a loud voice, said I'm ready, come and get me. -At 8:12 A.M., in a loud voice said, Im right here, come and get me. His/her voice increased in tone. An unknown staff member said, hang on, I'm with another resident. An unknown resident said, I wish they would come and get her. -At 08:37 A.M., in a loud voice, the resident said, come and get me, I'm cold. A staff member stopped and told the resident he/she would shower him/her. The resident replied ok. When the staff member walked away, the resident said in a loud tone, Not tomorrow but now, get the red blanket, I'm cold. -At 8:50 A.M., in a very loud tone said come and get me. An unknown resident said back to the resident, Oh shut up! A staff member approached the resident and asked him/her to finish his/her coffee and then he/she would receive a shower. When staff walked away, the resident said in a loud tone, help! Staff returned to remind resident to drink his/her coffee, the resident said to staff, I need my red blanket. Staff did not offer the blanket or retrieve a similar one. -At 09:01 A.M., the resident sat at the dining room table with chin to chest and eyes closed. -At 9:05 A.M., staff woke the resident as informed he/she would get clean clothing to go shower. As staff walked away, the resident yelled out, get me a blanket and clothes! -At 09:08 A.M., staff ambulated the resident to the shower room. Observation on 03/06/24 at 09:46 A.M., showed staff ambulated the resident to the living room and placed him/her into a reclining chair and placed the red blanket onto his/her lap. At 09:47 A.M., in a loud voice, the resident said, I cant breathe. An unknown resident said in a harsh tone, oh your breathing, just stop it. At 09:49 A.M., when the resident repeated I cant breath, two residents mocked the resident and said oh enough, you can breath. The two residents said to one another, the staff don't seem to help him/her, one of these days, I'm going to sit on him/her. During an interview on 3/8/24 at 09:47 A.M., Certified Nurse Aide (CNA) D said, there are residents that live at the facility that have behaviors such as the resident. He/She said the resident can be loud and repetitive at times and needs frequent redirection. He/She said he/she worked at the facility for a few months and does not remember having any dementia or behavior training. CNA D said when the resident is being disruptive or loud, he/she moves the resident to a quieter area, says nice things, and tries to calm him/her down. He/She is not aware of any other residents complaining of the resident's behaviors. During an interview on 3/8/24 at 10:05 A.M., the nurse manager said staff are encouraged to use non-pharmacological interventions when dealing with resident behaviors such as distraction or activity participation. He/She said recently the facility found out the resident has had a traumatic history and when staff see an increase in behaviors, it us usually due to too much stimulus or noise around him/her. The nurse manager said interventions that help the resident should be a part of the care plan so it is shared to all the staff on what works for the specific behaviors. He/She said there are some residents who have complained about this resident's behaviors, and when this resident is increasingly agitated or anxious, he/she is moved from the situation. He/She said he/she updated the care plan with interventions for behaviors. During an interview on 03/08/24 at 10:43 A.M., the administrator said the resident has a traumatic history and has behaviors. He/She said there are two residents that have complained about the behaviors. During an interview on 03/08/24 at 11:46 A.M., the Director of Nursing (DON) said the resident's behaviors are brought on by anxiety and staff are instructed to ask the resident if he/she needs anything. He/She said staff should offer food/fluids, or depending on what is going on in the area, can be overstimulating and may need to move the resident from the area. The DON said sometimes there are other residents who have issues with this resident's behaviors and staff have to calm them down. He/She said with anyone having behaviors or being disruptive, staff should try distraction and/or remove from situation. He/She said the resident should have specific interventions for specific behaviors in the care plan especially the interventions that work best. He/She said the nurse managers on the units and the MDS Coordinator are responsible to ensure the interventions are individualized on the care plans. During an interview on 3/8/24 at 12:36 P.M., the administrator said staff are trained on behaviors at hire and twice yearly. He/She said if there are staff who mishandle behaviors, then on-the-spot training is completed. The administrator said resident specific behaviors should be care planned with interventions for staff to follow that work for those specific behaviors.

Based on interviews and record review, staff failed to maintain a professional standard of care when staff failed to ensure one resident's (Resident #36) care plan for advanced directives (code status - decision to start or withhold Cardiopulmonary Resuscitation - CPR) matched the physician ordered advanced directive and failed to notify the physician for further direction when an ordered supplement was unavailable. The facility census was 49. 1. Review of the facility's Advanced Directives policy, reviewed [DATE], showed: -Prior to admission or upon admission of a resident, the Social Service Director (SSD) or designee will inquire of the resident and their representative about the existence of any written advanced directive; -Information about whether or not the resident has executed an advanced directive shall be displayed in the ribbon in the Electronic Health Record (EHR); -The plan of care for each resident will be consistent with their documented treatment preferences and/or advanced directives; -A nurse will notify the physician of advanced directives so that appropriate orders can be documented in the resident's medical record and plan of care; -Questions regarding advanced directives shall be referred to the SSD. 2. Review of Resident #36's quarterly Minimum Data Set (MDS), a federally mandated assessment tool used to plan care, dated [DATE], showed staff assessed the resident as moderately cognitively impaired with diagnoses of dementia and aphasia (language disorder affecting communication). Review of the resident's Physician Order Sheet (POS), dated [DATE], showed an order dated [DATE] for Do Not Resuscitate (DNR). Review of the resident's signed Outside the Hospital DNR form (OSHDNR) signed [DATE] showed DNR. Review of the resident's Care Plan, dated [DATE] showed: -Resident's advanced directive/code status wishes will be followed; -Resident is a Full Code - CPR will be initiated. During an interview on [DATE] at 02:37 P.M., the resident's family said CPR discussions occurred on admission and he/she informed the facility he/she wants the resident's code status to be DNR. During an interview on [DATE] at 10:05 A.M., Licensed Practical Nurse (LPN) C said the admitting nurse obtains advanced directive information, obtains an order, and puts the purple OSHDNR sheet in a binder at the nurse station. He/She said the SSD updates the care plan with the information and all information should match or a mistake could occur and the resident's wishes not followed. During an interview on [DATE] at 11:12 A.M., the SSD said advanced directives are completed on admission by either the nurse or the SSD. He/She said if an order needs obtained, it is the responsibility of the nurse and the SSD updates the care plan. He/She said after the initial care plan meeting, he/she double checks the care plan to make sure it is correct. The SSD was not aware the orders and signed OSHDNR did not match the care plan and said if the orders and care plan do not match, the resident may have unwanted treatment or lack of treatment. During an interview on [DATE] at 11:44 A.M., the Director of Nursing (DON) said the social worker is responsible for advanced directive information. He/She said the information is on the admission tab, on the face sheet, and in the orders in the EHR. He/She was not aware the orders did not match the care plan, but said they should or an incident could happen and wishes not followed. During an interview on [DATE] at 12:36 P.M., the administrator said the SSD goes over advanced directives during the admission process. He/She said the purple OSHDNR sheet goes in a binder at the desk and on a ribbon in the EHR. The administrator said until there is an order, the resident is a Full Code (CPR will be initiated). He/She said the only time the orders and care plan would not match is if there is a glitch in the EHR. He/She said the resident will not have their wishes followed if the documentation does not match. 3. Review of the facility's Change in Resident Condition policy, Administering medication policy, Labeling and Storage of Medications policy, and Adverse Consequences and Medication Errors policy dated [DATE] showed the documentation did not direct staff when to notify the physician when an ordered supplement is unavailable. 4. Review of Resident #36's quarterly MDS, dated [DATE] showed staff assessed the resident as: -Moderately Cognitively impaired; -Complained of pain or difficulty chewing and swallowing; -Had weight loss; -Fifty One (51) percent (%) of nutrition comes from a feeding tube; -Feeding tube; -At risk for skin breakdown; -Incontinent of bowel; -Diagnoses of aphasia, dementia, and stroke. Review of the resident's POS, dated February 2024, showed on [DATE] the physician ordered Banatrol TF 5 gram liquid (anti-diarrhea supplement) in a packet three times a day for diarrhea to start on [DATE], and to monitor for constipation. Review of the Medication Administration Record (MAR), dated February and [DATE] showed it did not contain documentation the staff administered the Banatrol. Review of the Nurse Notes dated [DATE] through [DATE] showed staff documented the following: -On [DATE], start Banatrol, 1 packet three times a day; Orders entered and sent to the pharmacy; -On [DATE], an order was recently received for resident to have scheduled Banatrol. The pharmacy states it needs to be ordered from another pharmacy, email sent to the facility's central supply; -On [DATE], called and spoke with central supply to get update on Banatrol order and central supply report they will get that completed; -The notes did not contain documentation of diarrhea, constipation, upset stomach, nausea, skin concerns, weight loss, hydration or appetite. Observation on [DATE] at 09:02 A.M., showed LPN H administered the morning medication to the resident. Additional observation showed the ordered Banatrol was unavailable to be administered. Observation on [DATE] at 10:26 A.M., showed Certified Nurse Aide (CNA) E and CNA F provide incontinence care on the resident. The resident was incontinent of a large soft bowel. During an interview on [DATE] at 09:02 A.M., LPN H said the medication is not available and he/she would have to check to see if it is in yet. During an interview on [DATE] at 10:05 A.M., LPN C said medications are typically ordered from the resident's pharmacy of choice or the facility pharmacy, then if it's the facility pharmacy, the facility will receive a phone call if the medication is not available and then other options will be considered. He/She said the facility pharmacy usually gets back within a day if there is a problem with an order. LPN C said the physician should be notified within 72 hours if the facility cannot get the ordered medication right away. He/She said staff should monitor the resident for adverse effects including bowel movements and skin integrity. He/She said the facility is trying to get the medication from another pharmacy for this resident and should notify the physician it is not available and there is difficulty getting it so further instructions/orders can be obtained. During an interview on [DATE] at 11:46 A.M., the DON said if there is a problem getting an ordered product from the pharmacy, the facility pharmacy usually informs the facility by the next day. Staff should notify the physician as soon as they hear from the pharmacy so further orders and instructions can be obtained. He/She expects staff to monitor the resident for skin breakdown and further diarrhea and document it in the EHR. During an interview on [DATE] at 12:36 P.M., the administrator said if medications are out or not available, staff should notify the physician by fax or other means for further instructions. He/She said if the medication is for diarrhea, then the staff should be monitoring for diarrhea, hydration issues, appetite, weight loss and skin issues. He/She expects the product or medication to be in the facility within 2 days or a hold order placed on the medication.

Based on observation, interview, and record review, the facility staff failed to properly store open food to prevent cross-contamination and outdated usage, to maintain kitchen equipment in a clean and sanitary manner, and to perform hand hygiene and change gloves as often as necessary to prevent cross contamination. This failure had the potential to affect all facility occupants. The census was 32. 1. Review of the facility's Food Storage and Safety Policies, dated 9/10/19, showed staff are directed to contain, store, label, and date everything properly. Observation on 2/1/23 at 12:20 P.M. in the Reach kitchen, showed a refrigerator contained: - Four uncovered cups of orange liquid not labeled, four uncovered cups of brown liquid not labeled, and four uncovered cups of clear liquid not labeled; - Multiple small bowls of citrus slices undated and not labeled; - One container of sliced white circles undated and not labeled. Observation on 2/1/23 at 12:25 P.M. in the Reach kitchen, showed the one opened container of cereal labeled Raisin Bran undated. Observation on 2/1/23 at 12:30 in the Woods Central kitchen, showed the pantry contained one open bag of cornflake cereal undated. Observation on 2/1/23 at 12:32 in the Woods Central kitchen, showed a freezer contained: - An open bag of waffles undated; - An open bag of whipped topping undated. Observation on 2/1/23 at 12:34 in the Wood Central kitchen, showed a refrigerator contained: - One container of a yellow mixture not labeled; - One container of a stew-like substance undated and not labeled. Observation on 2/1/23 at 12:51 P.M. in the [NAME] kitchen, showed a freezer contained: - One bag of round disks not labeled; - One bag of a round substance not labeled. Observation on 2/1/23 at 12:53 P.M. in the [NAME] kitchen, showed a refrigerator contained an open sliced yellow substance undated and not labeled. Observation on 2/1/23 at 1:06 P.M., showed the pantry in the basement contained one open bag of shell pasta undated. Observation on 2/1/23 at 1:10 P.M., showed the walk-in freezer in the main kitchen contained an open package of waffles undated. During an interview on 2/2/23 at 3:00 P.M., the administrator and the dietary manager said opened food items should be protected, labeled, and dated before they are returned to storage. The facility has a policy for food storage, and the dietary staff have been trained on the policy. The administrator and the dietary manager said it is expected staff are checking daily to ensure all items are stored correctly. 2. Review of the facility's Daily Cleaning Schedule, undated, showed: - Warmers/steamtables after each meal; - Wipe down the outside of fridge and freezer weekly or daily as needed; - Walls at least weekly or as needed; - Fridge/freezer including gaskets and outside clean weekly. Review of the facility's Weekly Cleaning List, undated, showed: - Clean walls in kitchen; - Clean bulk dry storage lids; - Top of oven/holding oven. Observation on 2/1/23 at 12:32 in the Woods Central kitchen, showed the bottom of the inside of both freezers visibly dirty with debris and drips. Observation on 2/1/23 at 12:51 P.M. in the [NAME] kitchen, showed: - The front of the refrigerator visibly dirty with drips and debris; - The front of the freezer visibly dirty with drips and debris. Observation on 2/1/23 at 1:15 P.M., in the main kitchen, showed: - Front of the oven visibly dirty with drips and debris; - Storage bins containing bulk food visibly dirty with debris; - Stand mixer with brown spots and food build-up on handle; - Sides and front of the fryer visibly dirty with splatters and debris; - Front of the stove with oven visibly dirty with drips and debris; - Sides and front of the griddle visibly dirty with drips and debris; - Table under the griddle visibly dirty with drips and debris; - The wall near the clean dishes storage rack visibly dirty with stains and drips. Observation on 2/2/23 at 8:23 A.M., in the main kitchen, showed: - Front of the food warmer visibly dirty with drips and debris; - Storage bins containing bulk food visibly dirty with debris; - Stand mixer with brown spots and food build-up on handle; - Sides and front of the fryer visibly dirty with splatters and debris; - Front of the stove with oven visibly dirty with drips and debris; - Sides and front of the griddle visibly dirty with drips and debris; - Table under the griddle visibly dirty with drips and debris; - The wall near the clean dishes storage rack visibly dirty with stains and drips. Observation on 2/2/23 at 11:23 A.M., in the [NAME] kitchen, showed: - The front of the refrigerator visibly dirty with drips and debris; - The front of the freezer visibly dirty with drips and debris. During an interview on 2/2/23 at 3:00 P.M., the administrator and the dietary manager said it is expected each dietary staff would clean their area after each shift. Anything that is easily cleanable should be cleaned at the end of shift. The administrator and dietary manager said dietary staff perform deep cleaning on a weekly basis. It is expected staff would clean drips, splatters, and debris at the end of their shift. 3. Review of the facility's Handwashing and Glove Usage policy, dated 7/21/11, showed: - All staff are to maintain proper hand hygiene when providing general care and services to the residents in order to minimize the risk of exposure to infectious disease; - Guidelines for hand washing: before starting work, before starting any new activity, after touching hair or face, after handling dirty dishes, before beginning food preparation, before putting on a pair of gloves used for food handling, after handling boxes or trash, and after taking off a pair of gloves. Observation on 2/1/23 at 2:50 P.M., showed Cook M prepared the resident's dinner meal. The cook took a thermometer to the dishwashing area, used the sprayer to clean the thermometer, returned to the food preparation area and touched various food related items in the preparation of dinner. Cook M did not perform hand hygiene after touching the sprayer in the dishwashing area and before he/she touched food related items. Observation on 2/2/23 at 8:49 A.M., showed Cook N prepared crab salad for the resident's lunch meal. The cook wore gloves and touched the shredded cheese with gloved hands. He/She continued to touch scissors, the visibly dirty handle on the stand mixer, drawer handle, and various utensils with the same gloved hands. The cook scooped the crab salad from the stand mixer into serving bowls. He/She touched the crab salad with the same gloved hands as he/she scooped it. Cook N did not change gloves and perform handwashing after he/she touched the shredded cheeseor before he/she touched the crab salad. Observation on 2/2/23 at 9:10 A.M., showed Cook N prepared macaroni salad for the resident's lunch meal. The cook used gloved hands to stir the macaroni salad. He/She continued to touch the mayonnaise container and the relish container with the same gloved hands. He/She touched the food processor bowls, packages of shredded cheese, and continued to stir the macaroni salad with the same gloved hands. Cook N did not change gloves and perform handwashing after he/she stirred the macaroni salad and before he/she touched ingredient containers. He/She did not change gloves and perform handwashing after he/she touched various food related items and before stirred the macaroni salad with his/her gloved hands. Cook N returned the mayonnaise and relish containers to the walk-in refrigerator without cleaning or sanitizing the containers. Observation on 2/2/23 at 9:29 A.M., showed Cook O used gloved hands to touch pie crust. The cook used the same gloved hands to pick up the box of pie crust and returned it the pantry, and he/she returned with a box of salmon patties. He/She used the same gloved hands to touch the salmon patties and place them on a baking sheet. Cook O did not change gloves and perform handwashing after he/she touched the pie crust and before he/she touched the boxes. He/She did not change gloves and perform handwashing after he/she touched the boxes and before he/she touched the salmon patties. Observation on 2/2/23 at 9:38 A.M., showed Dietary Aide P rinsed dirty dishes and put them into the dishwasher. He/She removed the dishes from the dishwasher and placed them on the drying rack to air dry. The dietary aid repeated the process multiple times. Dietary Aide P did not perform handwashing after he/she touched dirty dishes and before he/she touched clean dishes. During an interview on 2/2/23 at 3:00 P.M., the administrator and the dietary manager said it is expected the dietary staff would perform handwashing before putting on and after taking off gloves, when moving from a dirty process to a clean process, when changing tasks, after getting supplies, and when going in and out of the cooler. The administrator and dietary manager said dietary staff should change their gloves and perform handwashing after touching food and before touching anything else. The administrator and the dietary manager said the facility has a policy on handwashing and gloves use, and the dietary staff have been trained on the policy.

Based on observation, interview and record review facility staff failed to assess for risk of entrapment upon initiation and/or quarterly, and/or obtain informed consent for bed rails for two residents (Resident #23 and #288). The facility census was 32. 1. Review of the facility's Proper Use of Bed Assistive Devices policy, revised 9/16/22, showed: -An assessment will be made to determine the resident's symptoms or reason for using the bed assistive device upon initiation, quarterly, and as needed; -The use of bed assistive devices will be addressed in the resident's care plan; -Consent for using bed assistive devices will be obtained from the resident or resident representative and documented by community protocol; -When a bed assistive device is appropriate, the community should assess the resident's risk for entrapment, and ensure the bed's dimensions are appropriate for the resident's size and weight upon initiation, quarterly, and as needed. 2. Review of Resident #23's significant change Minimum Data Set (MDS), a federally mandated assessment tool, dated 12/3/22, showed staff assessed the resident as follows: -Required extensive assistance of one staff member for toileting, bed mobility, and locomotion on the unit; -Utilized a wheelchair for mobility; -Diagnosis aphasia and Parkinson's disease. Review of the resident's care plan, reviewed on 1/17/23, showed staff assessed the resident as not using bed assist bars. Review of the resident's physician's order sheet (POS), dated 2/1/23, showed the record did not contain an order for bed assist bars. Review of the resident's electronic medical record (EMR), showed the record did not contain a consent for the use of bed assist bars or a completed entrapment assessment. Review of the resident's fall report, dated 12/11/22, showed staff documented the resident was found face down on the side of his/her bed, with his/her right arm entrapped in the bed mobility rail. Review showed staff did not document any injuries to the resident, any new interventions, or any changes regarding the resident's bed mobility rail after this incident. Observation on 2/2/23 at 8:55 A.M., showed the resident in bed with bilateral assist bars in the upright position. During an interview on 2/6/23 at 4:01 P.M., Registered Nurse (RN) A said the resident has his assist rails up majority of the time. He/She sometimes uses them for repositioning. He/She said the resident is unable to lower the rails themselves and would require assistance to lower them. 3. Review of Resident #288's Entry Record MDS, dated [DATE], showed staff had not completed assessments of mobility or diagnoses in the document. Review of the resident's quarterly risk assessment, dated 1/20/23, showed staff assessed the resident as not having assist rails. Review of the resident's EMR, showed the record did not contain a consent for the use of assist rails or a completed entrapment assessment. Observation on 2/1/23 at 12:48 P.M., showed the resident in bed with both bed assist rails up. 4. During an interview on 2/6/23 at 4:00 P.M., the Director of Nursing said assist rails are used for mobility and positioning. He/She said the physician must order the assist rails. Entrapment assessments are completed quarterly for each resident, checking to make sure the bed assist rail is not a restraint, and for concerns of entrapment. Nursing staff does not take measurements for entrapment. The maintenance department checks the bed annually. During an interview on 2/6/23 at 4:01 P.M., Registered Nurse (RN) A said every bed has assist rails, but are not used for every resident. He/She said the residents who use assist rails must be assessed for them on the quarterly risk assessments. During an interview on 2/6/23 at 4:21 P.M., Licensed Practical Nurse (LPN) B said residents who have low cognition or cannot pull themselves up in bed, would not be appropriate to use assist rails. Residents are required to have risk assessments for all bed rails. The risk assessments are done quarterly or if a resident has a significant change. During an interview on 2/6/23 at 4:33 P.M., the administrator said bed assist rails have a protocol for use, which includes the assist rail assessment and safety, in addition to documenting verbal consent. He/She said the physician must order the bed assist rails, and if they are not to be used, the staff keeps the rails down. The administrator also said use of bed assist rails should be in the care plan. 47193

Based on interview and record review, facility staff failed to check the Certified Nurses' Assistant (CNA) Registry before hire for all staff in accordance with their policy to ensure they did not have a Federal Indicator (a marker given by the federal government to individuals who have committed abuse/neglect) for three employees (Housekeeper J, Dining Service K and Security L) out of ten sampled employees hired since the last survey. The census was 32. 1. Review of the Pre-Employment Screening Procedures Policy, Revised 3/6/20, showed the following: Background check -Concurrent to the candidate completing the pre-employment testing, the HR Representative will run all required background checks. The HR Representative will log into the background check vendor's site to order the appropriate background check. This includes: -Missouri Nurse Aide Registry (CNA). 2. Review of House Keeper J's employee file, showed the following: -Hire date of 6/20/22; -Staff did not document a CNA registry check was completed. 3. Review of Dining Services K's employee file, showed the following: -Hire date of 11/22/21; -Staff did not document a CNA registry check was completed. 4. Review of Security L's employee file, showed the following: -Hire date of 3/22/22; -Staff did not document a CNA registry check was completed. 5. During an interview on 3/6/23 at 4:22 P.M., the Human Resources Director said the CNA Registry should be checked prior to employment for every employee.

Based on observation, interview, and record review, facility staff failed to maintain professional standards of practice by not completing neurological assessments (evaluation completed by staff for early detection of nervous system damage following head trauma) following unwitnessed falls, and falls with a known head injury, for five residents (Resident #6, #16, #20, #23, and #25). The facility census was 32. 1. Review of the facility's Fall and Fall Risk, Managing policy, dated September 2022, showed staff are directed as follows: -A fall without injury is still a fall; -Unless there is evidence suggesting otherwise, when a resident is found on the floor, a fall is considered to have occurred; -The staff, with the input of the attending physician, will implement a resident-centered fall prevention plan to reduce the specific risk factor(s) of falls for each resident at risk or with a history of falls; -If falling recurs despite initial interventions, staff will implement additional or different interventions, or indicate why the current approach remains relevant; -And the staff will monitor and document each resident's response to interventions intended to reduce falling or the risks of falling. Review of the facility's Neurological Evaluation policy, dated September 2022, showed staff are directed as follows: -Neurological assessments are indicated: -Upon physician order; -Following an unwitnessed fall; -Following a fall or other accident/injury involving head trauma; -Or when indicated by a resident's condition. -Perform neurological checks with the frequency as ordered or per falls protocol; -Determine resident's orientation to time, place, and person; -Observe resident's patterns of speech and speech clarity; -Take temperature, pulse, respirations, blood pressure; -Check pupil reaction by turning on a flashlight and observing the size and reaction of the resident's pupil; -Determine motor ability: -Have the resident move all extremities; -Ask resident to squeeze your fingers and note the strength bilaterally (both sides) -And have resident plantar (act of having a resident point their toes) and dorsiflexion (bending the foot back toward the body) and note the strength bilaterally (both sides). Ask resident if they have any numbness or tingling in extremities and document accordingly. Review of the facility's Post Fall Observation form showed, staff are directed to complete the form every 1 hour x 4; every 4 hours x 3; and every 8 hours x 7 after each fall. Review of the facility's Neurological Check Flow Sheet form showed, staff are directed to complete checklist at the following intervals: every 15 min x 4, every 30 min x 2, every 1 hour x 2, and every 8 hours x 72 hours for follow up for all unwitnessed falls or falls in which head is struck. Review of the facility's Clinical Documentation Standards, dated 2016, showed staff are directed as follows: -Complete adverse event Fall; -A separate Clinical Note must also be completed and follow up is every shift for 72 hours; -Neurochecks/Post Fall Observation completed 72 hours post fall for ALL unwitnessed or witnessed falls with head impact. 2. Review of Resident #6's quarterly Minimum Data Set (MDS), a federally mandated assessment tool, dated 11/20/22, showed staff assessed the resident as follows: -Required extensive assistance of one staff member for toileting and locomotion on the unit; -Required extensive assistance of two staff members for bed mobility and transfers; -Utilized a wheelchair for mobility; -Diagnoses of Parkinson's disease (a brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination), repeated falls, Apraxia (the brain is unable to make and deliver correct movement instructions to the body, caused by brain disease or damage), and Aphasia (loss of ability to understand or express speech, caused by brain damage). Review of the resident's fall report, dated 1/21/23, showed the resident had a fall that was not witnessed by a staff member. The resident was found with an abrasion and hematoma on his/her head. Further review of the report showed that staff contacted Emergency Medical Services (EMS) and the resident was transported to the hospital. Review of the resident's nurses' notes, dated 1/21/23, showed at 8:40 P.M. the resident returned from the hospital. Review of the resident's Post Fall Observation Form showed staff did not assess the following: -On 1/21/23 at 3:10 P.M., the vital signs, pupils, motor function of the upper and lower extremities, hand grasps, headache, seizure, ear and nose drainage, vomiting, pain scale, pain location, and change in injury; -On 1/21/23 at 5:10 P.M., the vital signs, pupils, motor function of the upper and lower extremities, hand grasps, headache, seizure, ear and nose drainage, vomiting, pain scale, pain location, and change in injury; -On 1/21/23 at 6:10 P.M., the vital signs, pupils, motor function of the upper and lower extremities, hand grasps, headache, seizure, ear and nose drainage, vomiting, pain scale, pain location, and change in injury; -On 1/21/23 at 10:10 P.M., the pupils, motor function of the upper and lower extremities, hand grasps, headache; -On 1/22/23 at 2:10 P.M., the vital signs, pupils, motor function of the upper and lower extremities, hand grasps, headache, seizure, ear and nose drainage, vomiting, pain scale, pain location, and change in injury; -On 1/23/23 at 3:10 P.M., the vital signs, pupils, motor function of the upper and lower extremities, hand grasps, headache, seizure, ear and nose drainage, vomiting, pain scale, pain location, and change in injury. 3. Review of Resident #16's annual MDS, dated [DATE], showed staff assessed the resident as follows: -Cognitively impaired; -Required extensive assistance with bed mobility, transfers, and toileting; -Utilized a wheelchair for mobility; -Diagnosis of dementia (is a group of conditions characterized by impairment of at least two brain functions, such as memory loss and judgment). Review of the resident's nurses note, dated 6/23/22, showed staff documented the resident had a witnessed fall, with head impact and a bump on the back of the head. Review of the resident's Neurological Check Flow Sheet showed staff did not document they assessed the following: -On 6/23/22 at 8:45 P.M. the level of consciousness (LOC), right and left pupil react, pupils equal, right and left pupil response, motor function upper extremity (UE) and lower extremity (LE), hand grasp, headache, seizure, Ear/Nose drainage, and vomiting; -On 6/23/22 at 10:00 P.M., the LOC, right and left pupil react, pupils equal, right and left pupil response, motor function UE and LE, hand grasp, headache, seizure, Ear/Nose drainage, and vomiting; -On 6/24/22 at 3:00 P.M., the resident refused, systolic and diastolic blood pressure (BP), pulse, respiratory rate, temperature, LOC, right and left pupil react, pupils equal, right and left pupil response, motor function UE and LE, hand grasp, headache, seizure, Ear/Nose drainage, and vomiting; -On 6/24/22 at 11:00 P.M., the resident refused, systolic and diastolic BP, pulse, respiratory rate, temperature, LOC, right and left pupil react, pupils equal, right and left pupil response, motor function UE and LE, hand grasp, headache, seizure, Ear/Nose drainage, and vomiting; -On 6/25/22 at 3:00 A.M., the resident refused, systolic and diastolic BP, pulse, respiratory rate, temperature, LOC, right and left pupil react, pupils equal, right and left pupil response, motor function UE and LE, hand grasp, headache, seizure, Ear/Nose drainage, and vomiting. 4. Review of Resident #20's quarterly MDS, dated [DATE], showed staff assessed the resident as follows: -Severe cognitive impairment; -Required total dependence for bed mobility, toileting, bathing, and locomotion on the unit; -Required extensive assistance of two staff members for transfers; -Utilized a wheelchair for mobility; -Diagnosis of dementia (is a group of conditions characterized by impairment of at least two brain functions, such as memory loss and judgment). Review of the resident's nurses note, dated 10/16/22, showed staff documented the resident was found on the floor, in the living room, laying on his/her side. Review of the resident's Post Fall Observation Form showed staff did not document they assessed the following: -On 10/16/22 at 6:30 P.M., the vital signs, pupils, motor function of the upper and lower extremities, hand grasps, headache, seizure, ear and nose drainage, vomiting, pain scale, pain location, and change in injury; -On 10/16/22 at 7:30 P.M., the vital signs, pupils, motor function of the upper and lower extremities, hand grasps, headache, seizure, ear and nose drainage, vomiting, pain scale, pain location, and change in injury; -On 10/16/22 at 8:30 P.M., the vital signs, pupils, motor function of the upper and lower extremities, hand grasps, headache, seizure, ear and nose drainage, vomiting, pain scale, pain location, and change in injury; -On 10/17/22 at 5:00 A.M., the vital signs, pupils, motor function of the upper and lower extremities, hand grasps, headache, seizure, ear and nose drainage, vomiting, pain scale, pain location, and change in injury; -On 10/17/22 at 9:00 A.M., the vital signs, pupils, motor function of the upper and lower extremities, hand grasps, headache, seizure, ear and nose drainage, vomiting, pain scale, pain location, and change in injury; -On 10/17/22 at 2:00 P.M., the of pupils, motor function of the upper and lower extremities, and hand grasps; -On 10/18/22 at 5:00 A.M., the pupils, motor function of the upper and lower extremities, hand grasps, headache, seizure, ear and nose drainage, vomiting, pain scale, pain location, and change in injury; -On 10/18/22 at 1:00 P.M., the vital signs, pupils, motor function of the upper and lower extremities, hand grasps, headache, seizure, ear and nose drainage, vomiting, pain scale, pain location, and change in injury; -On 10/18/22 at 9:00 P.M., the of pupils, motor function of the upper and lower extremities, hand grasps, headache, seizure, ear and nose drainage, vomiting, pain scale, pain location, and change in injury; -On 10/19/22 at 9:00 P.M., the vital signs, pupils, motor function of the upper and lower extremities, hand grasps, headache, seizure, ear and nose drainage, vomiting, pain scale, pain location, and change in injury. 5. Review of Resident #23's significant change MDS, dated [DATE], showed staff assessed the resident as follows: -Required extensive assistance of one staff member for toileting, bed mobility, and locomotion on the unit; -Utilized a wheelchair for mobility; -Diagnosis aphasia and Parkinson's disease. Review of the resident's nurses notes showed the following: -8/26/22 staff documented they responded to the resident's call light and found the resident on the floor beside his/her bed with the resident's wheel chair laying over his/her legs; -9/9/22 staff documented the resident was found lying on the floor next to his/her bed, when staff arrived to answer his/her call light; -9/16/22 staff documented the resident was found sitting on the floor next to his or her bed; -10/25/22 staff documented the resident was found on the floor between the recliner and his/her bed; -11/15/22 staff documented the resident was found on the floor next to his/her bed; -11/20/22 staff documented the resident was found on the floor by his/her bedroom door. The resident was in pain, cry, and grimacing when their neck was touched. He/She had a skin tear to the right arm; -12/11/22 staff documented the resident was found down on the side of his/her bed, face down with his/her right arm entrapped in the bed mobility rail; -12/16/22 staff documented the resident was found on the floor at the foot of the bed; -1/19/23 staff documented the resident was found lying on his/her right side, on the floor. Review of the resident's Neurological Check Flow Sheet showed staff did not document they assessed the following: -On 8/27/22 at 7:30 P.M., the pupils, motor function of the upper and lower extremities, and hand grasps; -On 8/28/22 at 3:30 A.M., the vital signs, pupils, motor function of the upper and lower extremities, hand grasps, headache, seizure, ear and nose drainage, vomiting, pain scale, pain location, and change in injury; -On 8/28/22 at 11:30 A.M., the pupils, motor function of the upper and lower extremities, and hand grasps; -On 8/28/22 at 7:30 P.M., the pupils, motor function of the upper and lower extremities, and hand grasps; -On 8/29/22 at 3:30 P.M., the pupils, motor function of the upper and lower extremities, and hand grasps. Review of the resident's Post Fall Observation Form showed staff did not document they assessed following: -On 9/9/22 at 5:30 A.M., the vital signs, pupils, motor function of the upper and lower extremities, hand grasps, headache, seizure, ear and nose drainage, vomiting, pain scale, pain location, and change in injury; -On 9/10/22 at 3:30 P.M., the vital signs, pupils, motor function of the upper and lower extremities, hand grasps, headache, seizure, ear and nose drainage, vomiting, pain scale, pain location, and change in injury; -On 9/11/22 at 11:30 A.M., the vital signs, pupils, motor function of the upper and lower extremities, hand grasps, headache, seizure, ear and nose drainage, vomiting, pain scale, pain location, and change in injury; -On 9/16/22 at 4:00 A.M., the vital signs, pupils, motor function of the upper and lower extremities, hand grasps, headache, seizure, ear and nose drainage, vomiting, pain scale, pain location, and change in injury; -On 9/16/22 at 4:00 P.M., the vital signs, pupils, motor function of the upper and lower extremities, hand grasps, headache, seizure, ear and nose drainage, vomiting, pain scale, pain location, and change in injury; -On 9/17/22 at 1:00 A.M., the vital signs, pupils, motor function of the upper and lower extremities, hand grasps, headache, seizure, ear and nose drainage, vomiting, pain scale, pain location, and change in injury; -On 9/17/22 at 8:00 A.M., the motor function of the upper and lower extremities, and hand grasps; -On 9/17/22 at 4:00 P.M., the motor function of the upper and lower extremities, and hand grasps; -On 9/18/22 at 1:00 A.M., the pupils, motor function of the upper and lower extremities, and hand grasps; -On 9/18/22 at 8:00 A.M., the motor function of the upper and lower extremities; -On 9/18/22 at 4:00 P.M., the motor function of the upper and lower extremities and hand grasps; -On 9/19/22 at 1:00 A.M., the vital signs, pupils, motor function of the upper and lower extremities, hand grasps, headache, seizure, ear and nose drainage, vomiting, pain scale, pain location, and change in injury; -On 10/26/22 at 4:30 A.M., the pupils, motor function of the upper and lower extremities, and hand grasps; -On 10/27/22 at 9:30 P.M., the vital signs, pupils, motor function of the upper and lower extremities, hand grasps, headache, seizure, ear and nose drainage, vomiting, pain scale, pain location, and change in injury; -On 10/28/22 at 12:30 P.M., the vital signs, pupils, motor function of the upper and lower extremities, hand grasps, headache, seizure, ear and nose drainage, vomiting, pain scale, pain location, and change in injury; -On 11/16/22 at 6:00 P.M., the vital signs and pain scale; -On 11/18/22 at 2:30 A.M., the vital signs, pupils, motor function of the upper and lower extremities, hand grasps, headache, seizure, ear and nose drainage, vomiting, pain scale, pain location, and change in injury; -On 11/20/22 at 4:00 A.M., the vital signs, pupils, motor function of the upper and lower extremities, hand grasps, headache, seizure, ear and nose drainage, vomiting, pain scale, pain location, and change in injury; -On 11/20/22 at 5:00 A.M., the vital signs, pupils, motor function of the upper and lower extremities, hand grasps, headache, seizure, ear and nose drainage, vomiting, pain scale, pain location, and change in injury; -On 11/20/22 at 6:00 A.M., the of vital signs, pupils, motor function of the upper and lower extremities, hand grasps, headache, seizure, ear and nose drainage, vomiting, pain scale, pain location, and change in injury; -On 11/20/22 at 4:00 A.M., the of vital signs, pupils, motor function of the upper and lower extremities, hand grasps, headache, seizure, ear and nose drainage, vomiting, pain scale, pain location, and change in injury; -On 11/21/22 at 6:00 P.M., the pupils; -On 12/11/22 at 6:50 P.M., the vital signs, pupils, motor function of the upper and lower extremities, hand grasps, headache, seizure, ear and nose drainage, vomiting, pain scale, pain location, and change in injury; -On 12/11/22 at 10:50 P.M., the pupils, motor function of the upper and lower extremities, and hand grasps; -On 12/12/22 at 6:50 A.M., the pupils, motor function of the upper and lower extremities, and hand grasps; -On 12/17/22 at 5:30 P.M., the vital signs, pupils, motor function of the upper and lower extremities, hand grasps, headache, seizure, ear and nose drainage, vomiting, pain scale, pain location, and change in injury; -On 12/19/22 at 1:30 A.M., the vital signs, pupils, motor function of the upper and lower extremities, hand grasps, headache, seizure, ear and nose drainage, vomiting, pain scale, pain location, and change in injury; -On 12/25/22 at 5:30 A.M., the vital signs, pupils, motor function of the upper and lower extremities, hand grasps, headache, seizure, ear and nose drainage, vomiting, pain scale, pain location, and change in injury; -On 12/25/22 at 9:30 P.M., the vital signs, pupils, motor function of the upper and lower extremities, hand grasps, headache, seizure, ear and nose drainage, vomiting, pain scale, pain location, and change in injury. 6. Review of Resident #25's significant change MDS, dated [DATE], showed staff assessed the resident as follows: -Severely cognitively impaired; -Required extensive assistance with bed mobility, transfers, and toileting; -Impairment of upper extremity one side; -Utilized a wheelchair for mobility; -Diagnosis of dementia, repeated falls, muscle weakness. Review of the resident's nurses note, dated 11/28/22, showed staff documented the resident had an unwitnessed fall, with head impact and a goose egg on the head. Review of the resident's Post Fall Observation Form showed staff did not document they assessed the following: -On 11/28/22 at 6:00 P.M., the resident refused, systolic and diastolic BP, pulse, respiratory rate, temperature, pupils' equal, motor function UE and LE, hand grasp, headache, seizure, Ear/Nose drainage, and vomiting, pain, pain location, and change injury; -On 11/28/22 at 7:00 P.M., the resident refused, systolic and diastolic BP, pulse, respiratory rate, temperature, pupils' equal, motor function UE and LE, hand grasp, headache, seizure, Ear/Nose drainage, and vomiting, pain, pain location, and change injury; -On 11/28/22 at 8:00 P.M., the resident refused, systolic and diastolic BP, pulse, respiratory rate, temperature, pupils' equal, motor function UE and LE, hand grasp, headache, seizure, Ear/Nose drainage, and vomiting, pain, pain location, and change injury; -On 11/28/22 at 9:00 P.M., the resident refused, systolic and diastolic BP, pulse, respiratory rate, temperature, pupils' equal, motor function UE and LE, hand grasp, headache, seizure, Ear/Nose drainage, and vomiting, pain, pain location, and change injury; -On 11/29/22 at 9:00 A.M., the resident refused, systolic and diastolic BP, pulse, respiratory rate, temperature, pupils' equal, motor function UE and LE, hand grasp, headache, seizure, Ear/Nose drainage, and vomiting, pain, pain location, and change injury; -On 11/29/22 at 1:00 A.M., the resident refused, systolic and diastolic BP, pulse, respiratory rate, temperature, pupils' equal, motor function UE and LE, hand grasp, headache, seizure, Ear/Nose drainage, and vomiting, pain, pain location, and change injury; -On 11/29/22 at 9:00 A.M., the resident refused, systolic and diastolic BP, pulse, respiratory rate, temperature, pupils' equal, motor function UE and LE, hand grasp, headache, seizure, Ear/Nose drainage, and vomiting, pain, pain location, and change injury; -On 11/29/22 at 5:00 P.M., the resident refused, systolic and diastolic BP, pulse, respiratory rate, temperature, pupils' equal, motor function UE and LE, hand grasp, headache, seizure, Ear/Nose drainage, and vomiting, pain, pain location, and change injury; -On 12/1/22 at 1:00 A.M., the resident refused, systolic and diastolic BP, pulse, respiratory rate, temperature, pupils' equal, motor function UE and LE, hand grasp, headache, seizure, Ear/Nose drainage, and vomiting, pain, pain location, and change injury; -On 12/1/22 at 9:00 A.M., the resident refused, systolic and diastolic BP, pulse, respiratory rate, temperature, pupils' equal, motor function UE and LE, hand grasp, headache, seizure, Ear/Nose drainage, and vomiting, pain, pain location, and change injury; -On 12/1/22 at 5:00 P.M., the resident refused, systolic and diastolic BP, pulse, respiratory rate, temperature, pupils' equal, motor function UE and LE, hand grasp, headache, seizure, Ear/Nose drainage, and vomiting, pain, pain location, and change injury. 7. During an interview on 2/6/23 at 4:00 P.M., the Director of Nursing said if a resident falls, a detailed protocol is followed which is located in the electronic medical record (EMR). Once the EMR is initiated, it will automatically populate the appropriate follow-up needed for the specific fall (unwitnessed, hit head, witnessed without head hit) and the type and frequency of follow up checks are needed. The staff are to print out this protocol to remind all caregivers to follow the protocol. Staff are to document follow-up on the printed copy as well as in the EMR, and some staff do not get this done. During an interview on 2/6/23 at 4:01 P.M., Registered Nurse (RN) A said when a resident has an unwitnessed fall or a witnessed fall where the resident hits his/her head, he/she initiates the fall protocol. The fall protocol assessments are done on residents every hour for four hours, every four hours times two, and then every eight hours after, totaling 72 hours. Fall interventions are also assessed and care plans updated. During an interview on 2/6/23 at 4:21 P.M., Licensed Practical Nurse (LPN) B said when a resident is found after a fall then staff immediately start the fall protocol. The fall protocol will be in effect for 72 hours. Nursing staff on every shift must fill out the post fall neuro checks. He/She said neuro checks are expected to be filled out fully every hour for four hours, every four hours times two, and then every eight hours after that, for the full 72 hours. All shifts will then provide input on what they believe would be good fall interventions for the resident. It is the RN's responsibility to then sign off on them and change the care plans. During an interview on 2/6/23 at 4:33 P.M., the administrator said when a resident falls, the nurse assesses the resident for injuries and takes vitals. The nurse also will attempt to determine what caused the fall, and eliminate any safety concerns. The proper people are informed, and the nurse enters the fall into the EMR and also make a hard copy. The fall will be added to the Quality Assurance report so nurse leaders review the falls. If the resident is a frequent faller, the committee attempts to determine the causes. Care plans do not always need to be updated; there is a prompt on the fall assessment to update the Care Plan should it need to be updated. 47193

Based on observation, interview, and record review, facility staff failed to propel residents in wheelchairs in a manner to prevent accidents by failing to use foot rests, for four residents (Residents #4, #7, #17, and #24). The facility census was 32. 1. Review of the facility's policy titled Assistive Equipment Devices, dated 10/01/18, showed the community provides, maintains, trains, and supervises the use of assistive devices and equipment for residents. The policy shows staff will be trained and will demonstrate competency on the use of devices and equipment prior to assisting or supervising residents. Residents, family, and visitors will be trained, as indicated, on the safe use of equipment and devices. The Assistive Equipment Device policy does not address the use of foot pedals when propelling a resident in a wheelchair. 2. Review of Resident #4's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 1/23/23, showed the following: -Required extensive assistance of one staff with mobility and transfers; -Diagnosis of Dementia (a group of thinking and social symptoms that interferes with daily functioning), Stroke (damage to the brain from interruption of its blood supply). Observation on 1/31/23 at 12:50 P.M., showed CNA D propelled the resident in his/her wheelchair without foot pedals. Further observation showed the resident's feet slid on the floor. 3. Review of Resident #7's quarterly MDS, dated [DATE], showed staff assessed the resident as follows: -Required extensive assistance of one staff member for bed mobility, and locomotion on the unit; -Required extensive assistance of two staff members for transfers and toileting; -Utilized a wheelchair for mobility; -Diagnoses of Parkinson's disease (a brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination) and vertigo (A sudden internal or external spinning sensation, often triggered by moving your head too quickly). Observation on 2/1/23 at 1:23 P.M., showed Certified Nurse Aide (CNA) D propelled the resident from the dining room toward the resident's room, while his/her feet slid on the floor. As he/she passed by Life Enrichment Specialist (LES) G, CNA D asked if he/she knew where the resident's foot pedals were. Without stopping, CNA D continued to propell the resident down the hallway without foot pedals. 4. Review of Resident #17's MDS, dated [DATE], showed staff assessed the resident as follows: -Required limited assistance of one staff member for bed mobility and transfers; -Utilized a wheelchair for mobility; -Diagnosis aphasia, muscle weakness, difficulty walking, visual loss, and hemiplegia of the right side (paralysis of the right side if the body). Observation on 2/2/23 at 4:01 P.M., showed LES G propelled the resident from his/her room to the dining room, without foot pedals. Further observation showed the resident's feet slid on the floor. 5. Review of Resident #24's quarterly MDS, dated [DATE] showed staff assessed the resident as follows: -Extensive, one person assist with mobility, transfer and locomotion; -Uses a wheelchair. Observation on 2/2/23 at 9:31 A.M., showed Registered nurse (RN) H pulled the resident in his/her wheelchair without foot pedals from the hallway to the living room, by his/her right hand. 6. During an interview on 2/6/23 at 4:00 P.M., the Director of Nursing said the residents should to be safe at all times. If staff propel a resident in a wheelchair, the pedals should be placed on the wheelchair for the residents' feet. During an interview on 2/6/23 at 4:01 P.M., RN A said he/she would expect staff to propel residents with their feet properly placed on the foot pedals of the wheel chair. He/She said if foot pedals are not used it puts residents at risk of injury such as getting their feet run over, getting their feet caught up in the wheels of the chair, having their feet dragged across the floor, or getting knocked out of their wheel chair. He/She would expect staff members to go get the foot pedals before propelling the resident. He/She said staff are in-serviced regularly for wheel chair safety. During an interview on 2/6/23 at 4:15 P.M., CNA I said all residents that can not wheel themsleves should have foot pedals on their wheelchair. He/She said it is important to use foot pedals so the resident's feet don't drag on the floor, or scrape up their feet. During an interview on 2/6/23 at 4:15 P.M., CNA D said if a resident can not propel themselves then foot pedals should be used, to prevent accidents and so nothing gets broken. CNA D said all residents should have foot pedals for their wheelchair. During an interview on 2/6/23 at 4:21 P.M., Licensed Practical Nurse (LPN) B said she expects staff members to use the foot rests of the wheel chair when propelling residents down the hall. Failure to use the foot rests can result in injury such as causing the resident to topple out on to the floor or getting their feet hung up underneath. He/She said staff are educated on wheel chair safety upon hire and during quarterly in-services. During an interview on 2/6/23 at 4:33 P.M., the administrator said staff are expected to ensure the wheelchair pedals are used if they propel the resident. He/She said if the pedals are not used, a leg can get caught and the resident could have a horrible break, or the resident could get flipped out of the chair. 47193

Based on observation, interview, and record review, facility staff failed to provide appropriate personal hygiene care for six dependent residents (Resident #5, #6, #10, #17, #25, and #30). The facility census was 32. 1. Review of the facility's policies showed the staff did not provide a bath (shower) policy. 2. Review of Resident #5's quarterly Minimum Data Set (MDS), a federally mandated assessment tool, dated 11/19/22, showed staff assessed the resident as follows: -Required extensive assistance of one staff member for bed mobility, dressing, and personal hygiene; -Required extensive assistance of two staff members for transfers and toileting; -Totally dependent on staff for bathing; -Diagnosis of Alzheimer disease (a progressive mental deterioration that can occur in middle or old age, due to generalized degeneration of the brain) and polyosteoarthritis (Inflammation of five or more joints, causing pain and stiffness). Review of the resident's care plan, reviewed on 11/19/23, showed the care plan did not address showers or the resident's refusals of showers. Review of the resident's shower record dated November 2022 showed staff did not document they assisted the resident with a shower this month. Review of the resident's shower record dated December 2022 showed staff documented that they only assisted the resident with a shower five times, 12/12, 12/14, 12/15, 12/20, and 12/29. Review of the resident's shower record dated January 2023 showed staff documented that they only assisted the resident with a shower three times, 1/18, 1/23, and 1/26. Observation on 2/1/23 at 11:59 A.M., showed the resident sat at the dining room table, with his/her hair pulled back into a bun and appeared greasy. Observation on 2/2/23 at 8:49 A.M., showed the resident sat at the dining room, with his/her hair pulled back into a bun and appeared greasy. Observation on 2/6/23 at 2:00 P.M., showed the resident sat in his/her wheelchair in the living room, their hair appeared greasy, and pulled back into a small stiff ponytail. 3. Review of Resident #6's quarterly MDS, dated [DATE], showed staff assessed the resident as follows: -Required extensive assistance of one staff member for toileting and locomotion on the unit; -Required extensive assistance of two staff members for bed mobility and transfers; -Totally dependent for bathing; -Diagnoses of Parkinson's disease (a brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination), repeated falls, Apraxia (the brain is unable to make and deliver correct movement instructions to the body, caused by brain disease or damage), and Aphasia (loss of ability to understand or express speech, caused by brain damage). Review of the resident's care plan, reviewed on 2/1/23, showed the care plan did not address showers or the resident's refusals of showers. Review of the resident's shower record dated November 2022 showed staff documented that they only assisted the resident with a shower two times, 11/3 and 11/11. Review of the resident's shower record dated December 2022 showed staff documented that they only assisted the resident with a shower four times, 12/12, 12/14, 12/15, and 12/29. 4. Review of Resident #10's quarterly MDS, dated [DATE], showed staff assessed the resident as follows: -Required extensive, one person assistance with bathing, personal hygiene, toileting, and transfers; -Diagnoses of Parkinson's disease; -Does not reject care; -Always incontinent of bowel, and occasionally incontinent of bladder. Review of the resident's care plan, dated 2/3/2023 showed staff are directed to bathe-shower the resident two times weekly. Review of the resident's shower record dated November 2022 showed staff did not document that they assisted the resident with a shower this month. Review of the resident's shower record dated December 2022 showed staff documented they only assisted the resident with a shower four times, 12/19, 12/25, 12/28, and 12/29. During an interview on 1/31/23 at 2:10 P.M., the resident said he/she does not get a shower very often. He/She said they would like a shower more often but is lucky to get one, once a week or every couple weeks. 5. Review of Resident #17's annual MDS, dated [DATE], showed staff assessed the resident as follows: -Required extensive assistance of one staff member for dressing, personal hygiene, and toileting; -Required limited assistance of one staff member for bed mobility and transfers; -Required one staff member physical assistance for bathing; -Utilized a wheelchair for mobility; -Diagnosis aphasia, muscle weakness, difficulty walking, visual loss, and hemiplegia of the right side (paralysis of the right side if the body). Review of the resident's care plan, reviewed on 11/15/22, showed the care plan did not address showers or the resident's refusals of showers. Review of the resident's shower record dated November 2022 showed staff did not document they assisted the resident with showers this month. Review of the resident's shower record dated December 2022 showed staff documented that they only assisted the resident with a shower four times, 12/5, 12/14, 12/20, and 12/26. Review of the resident's shower record dated January 2023 showed staff documented that they only assisted the resident with a shower five times, 1/2, 1/5, 1/9, 1/23, and 1/30. 6. Review of Resident #25's significant change MDS, dated [DATE], showed staff assessed the resident as follows: -Required extensive, one person assistance with bathing, personal hygiene, toileting, and transfers; -Diagnoses of dementia (a group of thinking and social symptoms that interferes with daily functioning) and urinary incontinence; -Does not reject care; -Always incontinent of bowel and bladder. Review of the resident's care plan, dated 2/3/2023 showed staff are directed to bathe, tub or shower the resident two times weekly. Review of the resident's shower record dated November 2022 showed staff documented that they only assisted the resident with a shower two times, 11/5 and 11/19. Review of the resident's shower record dated December 2022 showed staff documented that they only assisted the resident with a shower one time, 12/7. Observation on 1/31/23 at 12:15 P.M., showed the resident sat at the dining room table, with uncombed hair which appeared greasy. 7. Review of Resident #30's admission MDS, dated [DATE], showed staff assessed the resident as follows: -Required extensive, one person assistance with bathing, personal hygiene, toileting, and transfers; -Diagnoses of Dementia, and Parkinson disease; -Does not reject care; -Occasionally incontinent of urine and frequently incontinent of bowel. Review of the resident's care plan, dated 2/3/2023 showed staff are directed to use consistent care routines. Review of the resident's shower record dated November 2022 showed staff documented that they only assisted the resident with a shower one time, 11/22. Review of the resident's shower record dated December 2022 showed staff documented that they only assisted the resident with a shower four times, 12/9, 12/27, 12/28 and 12/30. 8. During an interview on 2/6/23 at 4:00 P.M., the Director of Nursing (DON) said all residents should be offered showers two times a week. When a resident arrives, a resident is placed on the shower schedule. This schedule can be adjusted if a resident looks oily and requires more frequent showers. If a resident refuses a shower, staff is to walk away and try again later the same day. It is rare a resident refuses a second time. If this does happen, the oncoming staff on the next shift are notified, and they try to complete the showers. A refusal is documented in the Certified Nurse Assistant (CNA) charting. During an interview on 2/6/23 at 4:01 P.M., Registered Nurse (RN) A said residents are on a schedule to get two showers a week. If the resident is unavailable at that time or refuses a shower, staff tries to reschedule the shower for the next day. The nurse aides are in charge of giving and documenting the resident's showers. If a resident does not get a shower or refuses, it is charted on the shower sheet record and the aids let the nursing staff know. During an interview of 2/6/23 at 4:21 P.M., Licensed Practical Nurse (LPN) B said showers are done twice weekly, but if the resident would like it more often they try and accommodate them. Residents are on a scheduled rotation. It is the nurses' responsibility to ensure that residents get their two weekly showers. The nurse aides use shower sheets to track when they give the residents showers or when they are refused, then they turn them in and let the nurses know if showers are refused. During an interview on 2/6/23 at 4:33 P.M., the administrator said showers are ordered on the CNA charting tasks based on the care plan. They are scheduled two times a week unless there is a special consideration. If a resident is on hospice, the hospice staff provide a shower once a week and the facility provides the second shower. If a resident refuses, the staff should try again later. If the resident does not get the shower, it should be marked on the report sheet and the electronic chart. The administrator said she reaches out to two staff members who are especially good with resistant residents, and the resident is almost always convinced to take a shower. 47193

Based on interview and record review, the facility staff failed to ensure 100% of staff were fully vaccinated for COVID-19 (a highly contagious virus that causes serious illness or death). One employee, (Registered Nurse (RN) F), of eight employees sampled, had a medical exemption form that did not include an exemption recognized by the CDC. The facility Census was 32. 1. Review of the facility's COVID-19 Vaccination Policy, revised 8/17/22 showed: To protect residents, guests, clients, employees, family members and the community from Sars-Cov-2 (COVID-19) infection, all employees as well as regularly scheduled contracted personnel (e.g. rehab therapy staff) must be fully immunized against COVID-19. For purposes of this policy, fully immunized means all doses in the primary series and all recommended booster doses, when eligible, as required by law. Exemptions to the COVID-19 immunization requirement will be granted as an accommodation for medical reasons or sincerely held religious beliefs only, as outlined below. Exemptions to the COVID-19 vaccination requirement will be granted as accommodations for medical reasons or sincerely held religious beliefs only, as detailed below: Medical Exemptions - Employees requesting exemptions due to medical contraindications to the COVID-19 vaccine must complete Request for Medical Exemption form, which includes a request for supporting medical documentation from the employee's physician. The completed form and supporting medical documentation should be submitted to Human Resources. Standard criteria for medical exemptions will be established based upon recommendations for the Centers for Disease Control (CDC) and Prevention and will be utilized at each community/program. Review of the facility's employee vaccination tracking record, dated 2/3/23, showed 233 out of 234 employees (99.57%) were fully vaccinated for COVID-19, or had a pending request for, or had been granted a qualifying exemption, or had a temporary delay. Review of the facility's COVID-19 outbreak data, dated 2/3/23, showed the facility had 11 residents test positive for COVID-19 during the four weeks prior. Review of the facility's updated employee vaccination tracking record on January 31, 2023, showed the medical exemption for RN F with a clinical reason signed and dated by a licensed practitioner. The exemption did not contain a qualified medical precaution recognized by the CDC. During an interview on 01/31/23 at 1:14 P.M., the Infection Preventionist said COVID-19 vaccines are mandatory for staff. He/She said the Infection Preventionist was not responsible to monitor or implement COVID-19 vaccinations for staff and was handled by Human Resources. During an interview on 2/8/23 at 1:47 P.M., the Community Human Resources liason said when staff requests a medical exemption, they are required to have their physician state the medical reasoning the medical exemption should be granted; the request is forwarded to the organization's Clinical Excellence Team and this team assures the exemption follows CDC guidelines. At this point, the medical exemption is granted. He/She was not aware RN F's medical exemption was not within CDC guidelines for witholding the COVID-19 vaccine. During an interview on 2/10/23 at 1:30 P.M., RN F said his/her doctor filled out the medical exemption form provided by the facility and they approved it.

Based on observation, interview and record review, the facility failed to follow infection control protocols due to the ongoing COVID-19 pandemic, to help prevent the possible transmission of COVID-19, when facility staff failed to utilize facemasks appropriately, failed to maintain a social distance of at least six feet for residents and staff, and failed to wash or sanitize their hands per facility protocol. The facility census was 26. Review of the Centers for Disease Control and Prevention (CDC) recommendation dated 5/21/20, showed in order to prevent the spread of COVID-19, facility staff are to ensure all healthcare personnel (HCP) wear a facemask or cloth face covering for source control while in the facility. Additional review of the CDC recommendation titled How to Wear Face Coverings Correctly dated 5/22/20, showed staff are to place it over their nose and mouth and secure it under their chin. Further review of the CDC recommendation, titled Facemask Do's and Don'ts, dated 6/2/20, showed staff are not to touch or adjust their facemask without cleaning their hands before and after touching it. Review of the CDC's recommendation Strategies for Optimizing the Supply of Facemasks, dated 3/17/20, showed facemasks should be carefully folded so that the outer surface is held inward and against itself to reduce contact with the contaminated outer surface during storage. The folded mask can be stored between uses in a clean, sealable paper bag or breathable container. Review of the CDC's recommendation titled, Preparing for Covid-19 in Nursing Homes, updated 6/5/20, showed the potential for asymptomatic Severe Acute Respiratory Syndrome, [MEDICAL CONDITION] 2 ([DIAGNOSES REDACTED]-CoV-2; [MEDICAL CONDITION] that causes COVID-19) transmission underscores the importance of applying prevention practices to all patients, including social distancing, hand hygiene, and surface decontamination. Review of the facility's policy CDC Implement Extended Use of Facemask, undated, showed staff were directed as follows: -HCP must take care not to touch their facemask. If they touch or adjust their facemask they should immediately perform hand hygiene; -HCP should leave the patient care area if they need to remove the facemask; -The facemask should be worn the entirety of the HCP shift. Review of the facility's policy Personal Protective Equipment (PPE), dated 3/10/20, showed staff were directed as follows: -Do not touch the part of the mask that will cover the face. Hold the mask by the strings only; -Avoid any unnecessary handling of the mask; -Never touch the mask while it is in use; -Handle mask only by the strings. 1. During an interview on 7/1/20 at 11:13 A.M., the Director of Nursing (DON) touched her facemask multiple times. She did not wash or sanitize her hands after she touched her facemask. Observation on 7/1/20 at 11:47 A.M., showed Certified Nursing Assistant (CNA) A and CNA B delivered meal trays to resident rooms. CNA A took a tray into a resident's room and placed it on the bedside table. The CNA did not wear gloves, and touched the resident's bedside table. He/she uncovered the resident's food, obtained silverware from the cart in the hallway, gave it to the resident, and pushed the food cart to the next resident's room. CNA A did not wash or sanitize his/her hands after he/she touched the resident's bedside table with his/her bare hands or before he/she left the resident's room. Furthermore, the observation showed CNA B took a meal tray to a resident room, touched his/her facemask, and then touched the food cart and meal tickets with his/her bare hands. CNA B did not wash or sanitize his/her hands after he/she touched his/her facemask or after he/she opened the resident's door. Further observation showed, CNA A took a meal tray into a different resident's room. The CNA set the tray on the resident's bedside table, uncovered the food, adjusted his/her facemask, exited the room, and pushed the food cart. CNA A did not wash or sanitize his/her hands after he/she touched his/her facemask or after he/she left the resident's room. Observation on 7/1/20 at 11:54 A.M., showed CNA B propelled a resident in a wheelchair. CNA B touched his/her facemask multiple times while he/she propelled the resident. The CNA did not wash or sanitize his/her hands after he/she touched his/her facemask. Additional observation, showed Restorative Aide (RA) C passed out surgical facemasks to residents that sat in the common area. He/She touched his/her cloth facemask multiple times, but he/she did not wash or sanitize his/her hands. Further observation, showed RA C squatted down to speak to a resident in a wheelchair, and touched his/her facemask. He/she then touched the resident's wheelchair, the resident's arm, and the surgical facemasks he/she was handing out. RA C did not wash or sanitize his/her hands after he/she touched his/her facemask. Observation on 7/1/20 at 12:00 P.M., showed Licensed Practical Nurse (LPN) E stood closer than six feet to a resident in a wheelchair. LPN E pulled down his/her facemask to speak to the resident, placed his/her facemask over his/her nose, and opened the door to the soiled utility room. LPN E did not wash or sanitize his/her hands after he/she touched his/her facemask. Observation on 7/1/20 at 12:02 P.M., showed RA C stood in the hallway closer than six feet to a resident. RA C pulled down his/her facemask to speak to LPN E. RA C replaced her facemask over his/her nose and touched the facility phone at the nurse's station. RA C did not wash or sanitize his/her hands after he/she touched his/her facemask. Observation on 7/1/20 at 12:06 P.M., showed RA C went in a resident's room. RA C did not wash his/her hands before he/she entered the resident room or when he/she exited the resident's room. Observation on 7/1/20 at 12:09 P.M., showed CNA A entered a resident's room and assisted a resident. CNA A wore a facemask, but it did not cover his/her nose and mouth. He/she touched the resident's bedside table, dishes, doorknob, and door, with his/her bare hands. He/She did not wash or sanitize his/her hands before he/she left the resident's room. Additional observation, showed CNA A and LPN F returned to the resident's room and transferred the resident. LPN F and CNA A washed their hands and touched the doorknob when they left the resident's room. CNA A did not wash or sanitize his/her hands after he/she touched the doorknob. Observation on 7/1/20 at 12:17 P.M., showed five staff members sat in the Den (a room located on the hallway, used by residents and staff) and ate lunch. The staff members did not wear masks and sat closer than six feet apart. The door to the Den was open, and residents were present outside the room. Observation on 7/1/20 at 12:24 P.M., showed three staff members sat in the dining room and ate lunch. Two of the staff members sat at the same table, without masks, and were closer than six feet apart. Observation on 7/1/20 at 12:33 P.M., showed Floor Technician (FT) H entered the facility and walked to the employee check-in station. FT H did not sanitize his/her hands when he/she entered the facility. FT H wore a facemask, but it did not cover his/her nose and mouth. FT H adjusted his/her facemask, but he/she did not wash or sanitize his/her hands after he/she touched his/her mask. Additional observation, showed Cook I entered the facility and walked to the employee check-in station. Cook I did not sanitize his/her hands when he/she entered the facility. Additional observation, showed Housekeeper J entered the facility from the smoking area, and touched keys and the doorknob to a storage room. Housekeeper J did not wash or sanitize his/her hands after he/she entered the facility. Further observation, showed an unidentified staff member entered the facility and touched the doorknob to the maintenance room. The unidentified staff member did not wash or sanitize his/her hands after entering the facility. Additional observation, showed three unidentified staff members walked out of the facility, removed their facemasks and face shields, and walked to the smoking areas. The staff members held their personal protective equipment (PPE) (face shields and facemasks) against their uniforms while they smoked in the smoking area. Observation on 7/1/20 at 12:44 P.M., showed Cook K entered the facility and did not wash or sanitize his/her hands. He/she wore a facemask, but it did not cover his/her nose and mouth. Observation on 7/1/20 at 12:54 P.M., showed Dishwasher L entered the facility and did not wash or sanitize his/her hands. During an interview on 7/2/20 at 10:51 A.M. RA C said staff are expected to wash their hands when they enter and exit a resident's room. He/she said staff should put on gloves to deliver resident meal trays, and staff should remove the gloves and wash hands when exiting the resident's room. This should be done between each resident room. He/she said staff are to utilize face shields and facemasks at all times, and the face shield should cover the entire face. Additionally, he/she said the facemask should cover from the middle of the nose to under the chin. He/she said staff should wash or sanitize their hands whenever they touch their facemask, and should not pull their facemask down when speaking to a resident or staff member. He/she said the facility's social distancing policy says to maintain at least six feet of separation, and it applied to residents and staff members. He/she said the facility policy says staff are to eat their lunch in the staff break room, in the basement, and staff should maintain six feet distance while eating lunch. He/she said staff are not allowed to eat their lunch in resident care areas, which includes all areas of the building except the staff break room. Additionally, he/she said when going outside to smoke, staff are expected to maintain six feet of separation, and to sanitize their hands when re-entering the building. He/she said the staff cannot remove their face shield, and facemask until they are outside of the building. He/she said hand sanitizer and storage for PPE is not available outside of the building, and he/she holds his/her PPE while he/she is smoking. He/she said the staff must put their PPE back on before re-entering the building. During an interview on 7/2/20 at 11:15 A.M., LPN E said staff are expected to wash their hands when they enter and exit a resident's room. He/she said staff should wash or sanitize their hands after delivering a resident meal tray, and should do so between each resident's room. He/She said staff should wear the face shield so it covers all of their face, and staff should wear facemasks so they cover the nose and mouth and rests under the chin. He/she said staff are expected to wash or sanitize their hands whenever they touch their facemask. He/she said staff can remove their facemask to speak to residents who are hard of hearing. But some other options are to write on a white board or to move closer to the resident. He/she said staff have received training on facemasks, face shields, and hand washing. Furthermore, he/she said the facility policy on social distancing is to maintain at least six feet separation, and it applied to staff during meals and smoking. He/she said staff are allowed to eat meals in the Den on the Neighborhoods or in the employee break room in the basement, but the facility policy is to eat in the employee breakroom. He/she said nurses will eat in the Den in order to keep an eye on the residents, but it is expected that staff who eat in the Den, maintain six feet of separation, and close the door. Additionally, he/she said staff who go outside to smoke must exit the building before removing their facemask and face shield (PPE). He/she said staff must put on their PPE before re-entering the facility, and they must sanitize their hands when they get inside. Furthermore, he/she said hand sanitizer and storage for PPE is not available outside of the building, and he/she holds his/her PPE while smoking. During an interview on 7/2/20 at 11:37 P.M., the DON said it is expected that staff would wash their hands when exiting a resident room and sanitize their hands when they are in the hallway. He/she said this should occur between each resident room. He/she said staff should wash their hands and put on gloves before taking a meal tray into a resident room, and staff should remove the gloves and wash their hands when exiting the resident room. Additionally, he/she said facemasks should cover the nose and mouth and rest under the chin. He/She said cloth facemasks cannot be used on the Neighborhoods, and staff should wash or sanitize their hands whenever they touch their facemasks. He/She said face shields should be worn at the eyebrows so it is flush to the face, and should cover from the eyebrows to the chin. He/she said staff have been trained on handwashing/hand sanitizing, facemasks, and face shields. He/she said signs are posted throughout the facility, and the Infection Control Preventionist (ICP) conducts demonstrations and audits. He/she said he/she knows staff members pull down their facemask to speak to residents who have difficulty hearing. Additionally, he/she said staff could utilize a whiteboard. He/she said staff should not pull down their facemask to speak to staff or residents, and should maintain at least six feet of social distance, to include during meals and smoking. He/she said nursing staff will eat in the Den of their Neighborhood, but there should not be more than three staff in the Den so they can maintain six feet of distance. Furthermore, he/she said staff have been asked to close the door when eating in the Den. He/She said dietary staff can eat in the dining rooms of the Neighborhoods if there are no residents present, and should maintain at least six feet of separation in the dining room and should not sit more than one at a table. He/She said staff members who smoke are expected to exit the facility from the basement. He/she also said, the staff are expected to remove their facemask and face shield (PPE) once they are outside the building, and they must put on their facemask or shield before re-entering the building. Additionally, he/she said staff are expected to sanitize their hands when entering the building, and a dispenser is available inside the door. He/she said the expectation is for staff to put on their facemasks and then go into the bathroom to wash their hands. He/she said hand sanitizer is not available outside of the building, and he/she was not aware of the policy for PPE storage when going outside to smoke.

Based on interview and record review, facility staff failed to report an alleged misappropriation of resident property to the Department of Health and Senior Services (DHSS) as required for five of five residents. (Residents #1, #3, #4, #5, and #6). The facility census was 54. 1. Review of the facility's Procedure for Responding to Alleged/Possible Abuse, Neglect, or Mistreatment of [MEDICAL RECORD OR PHYSICIAN ORDER] -To report all allegations of abuse, neglect, exploitation or mistreatment , including injuries of unknown source and misappropriation of resident property immediately, but not later than two hours after the allegation is made if the events that cause the allegation involve abuse or resulting in serious bodily injury; or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury to the Administrator or the facility and to other officials including State Survey Agency; -The facility will ensure that all reports are made within 2 hours (abuse or serious bodily injury) or 24 hours (non -abuse). The 2-hour timeframe must be met even during the night shift or during the weekend. You may use the AFTER HOURS/WEEKEND SELF-REPORT FORM to fax in a report to meet the time frames for after hours and weekends. A follow-up call must take place as soon as the hotline or regional office is available to take the report. 2. Review of Resident #1's Admission Minimum Data Set (MDS), a federally mandated assessment tool, dated 9/27/19, showed staff assessed the resident as follows: -diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] -Received scheduled pain medication; -Received as needed pain medication; -Reports he/she has pain, and has frequent pain; -Reports his/her pain intensity at a score of a nine out of ten. Review of the facility's medication delivery receipt, dated 10/05/19, showed the pharmacy delivered thirty oxycodone (medication used for pain control) 5 milligram (mg) tabs for the resident. Further review showed Licensed Practical Nurse (LPN) A signed he/she received the medication from the pharmacy. Review of the facility medication log book showed it did not contain an entry the medication had been received from the pharmacy. 3. Review of Resident #3's Admission MDS, dated [DATE], showed staff assessed the resident as follows: -Dx of [CONDITION(S)] of the liver, and chronic pain; -Received as needed (PRN) pain medication; -Reports he/she has pain, and has almost constant pain; -Reports pain limits his/her daily activities, and interferes with him/her sleeping at night; -Reports his/her pain intensity at a score of 10 out of 10. Review of the facility's medication delivery receipt, dated 10/01/19, showed the pharmacy delivered two cards of thirty [MEDICATION(S)] (medication used for pain control) 5/325 mg for the resident. Further review showed LPN A signed he/she received the medication from the pharmacy. Review of the facility medication log book showed it did not contain an entry the medication had been received from the pharmacy. 4. Review of Resident #4's Admission MDS, dated [DATE], showed staff assessed the resident as follows: -diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] -Received scheduled pain medication; -Received as needed pain medication; -Reports he/she has pain, and has almost constant pain; -Reports pain makes it hard for him/her to sleep, and perform day to day activities; -Reports his/her pain intensity at a score of nine out of ten. Review of the facility's medication delivery receipt, dated 09/13/19, showed the pharmacy delivered two cards of thirty [MEDICATION(S)] 5/325 mg for the resident. Further review showed LPN A signed he/she received the medication from the pharmacy. Review of the facility medication log book showed it did not contain an entry the medication had been received from the pharmacy. 5. Review of Resident #5's Admission MDS, dated [DATE], showed staff assessed the resident as follows: -diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] -Received scheduled pain medication; -Received as needed pain medication; -Reports he/she has pain, and has frequent pain; -Reports pain limits his/her daily activities; -Reports his/her pain intensity at a score of 0 out of 10. Review of the facility's medication delivery receipt, dated 10/4/19, showed the pharmacy delivered two cards of thirty [MEDICATION(S)] 5/325 mg for the resident. Further review showed that LPN A signed for the medication as being received by the pharmacy. Review of the facility medication log book did not contain an entry the medication had been received from the pharmacy. 6. Review of Resident #6's Entry MDS, dated [DATE], showed staff assessed the resident as follows: -Hernia with obstruction, pain in left hip, and gout; -Pain was not assessed. Review of the facility's medication delivery receipt, dated 9/26/19, showed the pharmacy delivered two cards of thirty oxycodone 5 mg for the resident. Further review showed LPN A signed for the medication as being received by the pharmacy. Review of the facility medication log book showed it did not contain an entry the medication had been received from the pharmacy. 7. Review of the DHSS database for complaint and self-report investigations showed the facility did not report the misappropriation to the State Survey Agency, DHSS, until 11/13/18, six days after the investigation showed misappropriation had occurred with resident medications. 8. During an interview on 11/21/19 at 10:41 A.M., LPN C said missing medication is misappropriation which is a type of abuse and should be reported with in 24 hours. During an interview on 11/219 at 10:55 A.M., The Administrator said, It is my fault, I will take the blame, I know I am supposed to report it, I just didn't think about it because I was on vacation during that time. He/She said misappropriation of resident property should be reported to DHSS within 24 hours. MO 167

Based on interview and record review, facility staff failed to have interventions in place to prevent misappropriation of five residents' medication (Residents #1, #3, #4, #5, and #6) of five residents reviewed. The facility census was 54. 1. During an interview on 12/6/19 at 2:48 P.M., Registered Nurse (RN) D said the facility did not have a policy on how to ensure residents narcotic medication was accounted for when delivered to the facility. 2. Review of the facility's Procedure for Responding to Alleged/Possible Abuse, Neglect, or Mistreatment of [MEDICAL RECORD OR PHYSICIAN ORDER] -To report all allegations of abuse, neglect, exploitation or mistreatment , including injuries of unknown source and misappropriation of resident property immediately, but not later than two hours after the allegation is made if the events that cause the allegation involve abuse or resulting in serious bodily injury; or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury to the Administrator or the facility and to other officials including State Survey Agency; -The facility will ensure that all reports are made within 2 hours (abuse or serious bodily injury) or 24 hours (non-abuse). The 2-hour timeframe must be met even during the night shift or during the weekend. You may use the After hours/weekend self-report form to fax in a report to meet the time frames for after hours and weekends. A follow-up call must take place as soon as the hotline or regional office is available to take the report. 3. Review of Resident #1's Admission Minimum Data Set (MDS), a federally mandated assessment tool, dated 9/27/19, showed staff assessed the resident as follows: -diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] -Received scheduled pain medication; -Received as needed (PRN) pain medication; -Reports he/she has pain, and has frequent pain; -Reports his/her pain intensity at a score of 9 out of 10. Review of the resident's plan of care, dated 9/29/19, showed staff assessed the resident as having acute and chronic pain, with a goal that pain level will be acceptable by the resident. Interventions included pain medications as ordered, and report ineffective pain control to the physician. Review of the facility's medication delivery receipt, dated 10/05/19, showed the pharmacy delivered sixty oxycodone (medication used for pain control) 5 milligram (mg) tabs for the resident. Further review showed Licensed Practical Nurse (LPN) A signed he/she received the medication upon delivery. Review of the facility medication log book showed it contained an entry for thirty oxycodone. Further review showed it did not contain an entry that the additional thirty oxycodone had been received from the pharmacy. Review of the resident's narcotic count sheet showed the resident with 13 oxycodone tabs prior to the pharmacy delivery. Review showed staff documented the resident oxycodone 5mg at 43 after the pharmacy delivered the residents medication. Review showed the narcotic count did not include the additional thirty oxycodone delivered on 10/05/19. 4. Review of Resident #3's Admission MDS, dated [DATE], showed staff assessed the resident as follows: -diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] -Received as needed (PRN) pain medication; -Reports he/she has pain, and has almost constant pain; -Reports pain limits his/her daily activities, and interferes with him/her sleeping at night; -Reports his/her pain intensity at a score of 10 out of 10. Review of the resident's plan of care, dated 9/18/19, showed staff assessed the resident as having acute and chronic pain, with a goal resident and family will actively participate in assessment of pain, establishing pain management goals and plan. Interventions included assess for pain, obtain pain management history, use pain scale for reporting pain, educate in side effects of pain medication, and include resident in choices related to pain. Review of the facility's medication delivery receipt, dated 10/01/19, showed the pharmacy delivered sixty [MEDICATION(S)] (medication used for pain control) 5/325 mg for the resident. Further review showed LPN A signed he/she received the medication upon delivery. Review of the facility medication log book showed it contained an entry for thirty [MEDICATION(S)]. Further review showed it did not contain an entry that the additional thirty [MEDICATION(S)] had been received from the pharmacy. Review of the resident's narcotic count sheet, dated 10/01/19, showed staff documented the resident [MEDICATION(S)] 5/325 mg at 30. Review showed the narcotic count did not include the additional thirty [MEDICATION(S)] delivered on 10/01/19. 5. Review of Resident #4's Admission MDS, dated [DATE], showed staff assessed the resident as follows: -diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] -Received scheduled pain medication; -Received as needed (PRN) pain medication; -Reports he/she has pain, and has almost constant pain; -Reports pain makes it hard for him/her to sleep, and perform day to day activities; -Reports his/her pain intensity at a score of 9 out of 10. Review of the resident's plan of care, dated 9/13/19, showed staff assessed the resident as having a high risk for pain, with a goal that pain level will be acceptable by the resident. Interventions included pain medications as ordered, monitor resident for break through pain, assess pain and medication for effectiveness, and report ineffective pain control to the physician. Review of the facility's medication delivery receipt, dated 09/13/19, showed the pharmacy delivered sixty [MEDICATION(S)] 5/325 mg for the resident. Further review showed LPN A signed he/she received the medication upon delivery. Review of the facility medication log book showed it contained an entry for thirty [MEDICATION(S)]. Further review showed it did not contain an entry that the additional thirty [MEDICATION(S)] had been received from the pharmacy. Review of the resident's narcotic count sheet, dated 9/13/19, showed staff documented the resident [MEDICATION(S)] 5/325 mg at 30. Review showed the narcotic count did not include the additional thirty [MEDICATION(S)] delivered on 9/13/19. 6. Review of Resident #5's Admission MDS, dated [DATE], showed staff assessed the resident as follows: -diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] -Received scheduled pain medication; -Received PRN pain medication; -Reports he/she has pain, and has frequent pain; -Reports pain limits his/her daily activities; -Reports his/her pain intensity at a score of 0 out of 10. Review of the resident's plan of care, dated 10/7/19, showed staff assessed the resident complains of pain, with a goal pain level will be acceptable by the resident. Interventions included pain medications as ordered, and report ineffective pain control to the physician. Review of the facility's medication delivery receipt, dated 10/4/19, showed the pharmacy delivered sixty [MEDICATION(S)] 5/325 mg for the resident. Further review showed LPN A signed he/she received the medication upon delivery. Review of the facility medication log book showed it contained an entry for thirty [MEDICATION(S)]. Further review showed it did not contain an entry that the additional thirty [MEDICATION(S)] had been received from the pharmacy. Review of the resident's narcotic count sheet, dated 10/04/19, showed staff documented the resident [MEDICATION(S)] 5/325 mg at 30. Review showed the narcotic count did not include the additional thirty [MEDICATION(S)] delivered on 10/04/19. 7. Review of Resident #6's Entry MDS, dated [DATE], showed staff assessed the resident as follows: -diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] -Pain was not assessed. Review of the resident's plan of care, dated 9/21/19, showed staff assessed the resident as having pain, with a goal that pain level will be acceptable by the resident. Interventions included pain medications as ordered, and report ineffective pain control to the physician. Review of the facility's medication delivery receipt, dated 9/25/19, showed the pharmacy delivered sixty oxycodone 5 mg for the resident. Further review showed LPN A signed he/she received the medication upon delivery. Review of the facility medication log book showed it contained an entry for thirty oxycodone. Further review showed it did not contain an entry that the additional thirty oxycodone had been received from the pharmacy. Review of the resident's narcotic count sheet, dated 9/25/19, showed staff documented the residents oxycodone 5 mg at 30. Review showed the narcotic count did not include the additional thirty oxycodone delivered on 9/25/19. 8. During an interview on 11/21/19 at 10:41 A.M., LPN C said missing medication is misappropriation which is a type of abuse and should be reported with in 24 hours. During an interview on 12/6/19 at 2:48 P.M., Registered Nurse (RN) D said they don't have a policy for narcotics and that their normal procedure for narcotic delivery was that only one nurse received the medication to include narcotics when they come in from the pharmacy. He/She said the nurse should verify the medications with the delivery person, sign the delivery receipt, and give them a copy. Currently only the one nurse signs the medication in and no one is doing follow up to assure the medication was logged in the narcotic book and accounted for. MO 167

Based on interview and record review, facility staff failed to notify one resident's (Resident #1) physician of a change in condition of the resident's cognitive status. The census was 86. 1. Review of Resident #1's Minimum Data Set (MDS), dated [DATE], showed staff assessed the resident as follows: -No cognitive issues; -Required extensive assistance of one person for activities of daily living including bed mobility, transfers, ambulation, locomotion, toilet use and dressing; -Required limited one person assistance for bathing and personal hygiene; -Continent of bowel and bladder; -Venous ulcers (open sores); -Open [MEDICAL CONDITION]; -Skin tear; -Dressings and ointments. Review of the resident's plan of care, dated 6/26-7/25/19, showed [DIAGNOSES REDACTED]. Review of the resident's nurses' notes, dated 7/7/19 at 2:52 PM, showed Licensed Practical Nurse (LPN) B documented the resident's family reported the resident became confused and the resident started seeing things in the room that were not there. The LPN documented the family member was concerned about the resident's state of health. LPN B did not document he/she completed an assessment of the resident or notified the resident's physician regarding the change in the resident's condition. During an interview on 7/25/19 at 2:50 P.M. LPN B said the family member reported concerns the resident was hallucinating, he/she was concerned for the resident and requested they contact the doctor. The LPN said he/she assessed the resident and he/she found no evidence of hallucination and made a judgement call not to notify the physician. Review of the resident's nurses' notes, dated 7/8/19 at 9:37 [NAME]M., showed Registered Nurse (RN) A spoke with the resident's family member who expressed concerns and wanted the resident to go to the hospital for evaluation. The RN documented he/she assessed the resident and found no distress. Review showed the RN documented the resident able to state name, date of birth, and city. Expressed to resident the family member's concern of dehydration and confusion. Resident reported they always worry about that. The resident reported he/she would go to hospital if that's what the family member wanted. Review of nurses note, dated 7/8/19 at 2:18 P.M., showed staff documented in the morning when entering resident's room the resident said he/she experienced hallucinations last night, somebody shot my windows out, I heard high powered gun shots, and saw police. The resident was able to state name, date of birth, year and president. The family member requested resident go to emergency room for evaluation. Staff documented they notified the physician who directed staff to send the resident to the emergency room . Staff transferred the resident to the emergency room at 1:00 PM. Review of the resident's hospital records, dated 7/8/19 through 7/11/19 showed the physician's history and physical dated 7/9/19 2:56 [NAME]M. showed the resident was very confused and frail, recognized family and oriented to self only. Additional review showed: -Assessment and plan: 1.[MEDICAL CONDITION] (severe infection) secondary to bilateral lower extremity [MEDICAL CONDITION] (skin infection) - continue antibiotics; 2. Acute [MEDICAL CONDITION] (brain disease, damage, or malfunction) - likely associated with resident'[MEDICAL CONDITION], possibly complicated with hepatic (liver function) [MEDICAL CONDITION]; 3. Chronic [MEDICAL CONDITION] Fibrillation ([MEDICAL CONDITION]). During an interview on 7/25/19 at 3:45 PM the administrator said she would have expected the nurse to notify the physician when family reported hallucinations and changes in mental status, and requested the physician be notified. The resident is on a short term care unit and family would be more aware of changes in cognitive status. MO 489

Based on observation, interview, and record review, facility staff failed to develop a person centered baseline care plan within 48 hours of admission for five out of 12 sampled residents (Residents #10, #137, #235, #236, and #239). The facility census was 38. 1. Review of the facility's policy titled Care Plans - Baseline, dated 12/20/17 and reviewed 02/05/18, shows the baseline plan of care to meet the resident's immediate needs shall be developed for each resident within forty-eight hours of admission. The baseline care plan will be used until the staff can conduct the comprehensive assessment and develop an interdisciplinary person-centered care plan. 2. Review of Resident #10's medical record showed the following: - admission date of [DATE]; - [DIAGNOSES REDACTED]. - Prescribed Eliquis 2.5 milligram (mg) twice a day and aloprazolam 0.25 mg. Review of the resident's baseline careplan, dated 9/23/18, showed the following: - Behavior/Mood symptoms goal: decrease behavioral/mood symptoms during stay. No documentation of behavior exhibited, mood symptoms, or interventions. No documentation regarding the use of antianxiety medication; - Cardiac: Not applicable. Does not include pacemaker or pacemaker care; - Respiratory: Not applicable. Does not include dependence on supplemental oxygen; - Infection goal: infection will resolve. Type of infection and interventions: no information documented; - No documentation regarding use of blood thinner medication. 3. Review of Resident #137's admission record showed the resident admitted to the facility on [DATE]. Review of the resident's Baseline Care Plan, dated 10/22/18, showed staff did not address the following: -A complete assessment of wounds on the resident's skin and interventions for care; -Pain, location, and interventions; -Direction and care for [MEDICAL TREATMENT]; -Care and direction for the resident's oxygen use and nebulizer treatments; -Direction and care for diabetes management; -Direction for renal and diabetic diet. 4. Review of Resident #235's medical record, on 10/29/18, showed the following: - admission date of [DATE]; - [DIAGNOSES REDACTED]. - Fall on 10/25/18; - Wound to right buttock on admission. Review of the resident's baseline care plan, dated 10/21/18, showed the following: - Fall risk was not updated to include fall on 10/25/18; - Communication decline goal: resident will have needs met. Interventions: Did not include instructions on communicating with resident; - Skin integrity: Wound on buttocks. Type of wound not specified. Interventions: as ordered, see comments. No information for wound care in the comment section; - On hospice. 5. Review of Resident #236's medical record, on 10/29/18, showed the following: - admission date of [DATE]; - [DIAGNOSES REDACTED]. - Incontinent of bowel and bladder; - Required extensive assistance with bathroom use and personal hygiene; - Prescribed [MEDICATION NAME] 40 mg once a day (antidepressant) and Luipropio HCI SR 100 mg (antidepressant). Review of the resident's baseline care plan, dated 10/25/18, showed the following: - Bowel function: Incontinent of bowel; - Bladder function: Continent of bladder; - [MEDICAL CONDITION] drug use: Not applicable; - On hospice; - No documentation of history of UTIs. 6. Review of Resident #239's medical record, on 10/29/18, showed the following: - admission date of [DATE]; - [DIAGNOSES REDACTED]. - Sacral wound on admission; - Mechanical soft diet with nectar thick liquids. Review of the resident's baseline care plan, dated 10/19/18, showed the following: - Skin integrity: wound on bilateral buttocks. Type of wound: moisture associated skin damage. Interventions: as ordered, see comments. No information for wound care in the comment section; - Infection goal: infection will resolve. Type of infection and interventions: no information documented; - Oral/Dental: resident will be able to consume food. No interventions or comments documented; - Nutrition: optimal nutrition related to disease progress. Interventions: weekly weights and diet as ordered. Comments: able to voice own preference. No documentation of mechanical soft diet with nectar thick liquids; - No documentation of long term use of anticoagulants; - No documentation of amputation of right leg above the knee. 7. During an interview on 11/01/18 at 12:50 P.M., the Director of Nursing (DON) said the baseline careplan should be completed within the first 24 hours. The DON said the baseline care plan should accurately reflect the status of the resident and provide nursing staff with directions for caring for the resident, including activities of daily living (ADLS), resident preferences, wound care, pain, oxygen, [MEDICAL TREATMENT], whatever is necessary to meet the resident's needs. The DON said he/she expects the baseline careplan to be specific because some of the residents admitted for rehabilitation may not be in the facility long enough for a comprehensive care plan to be developed.

Based on interviews and record reviews, the facility failed to keep resident petty cash separated from facility petty cash. This had the potential to affect all residents for which the facility held funds. The census was 46. 1. Review of the facility's Resident Trust Petty Cash Fund Policy, dated 2/18/16, showed the following: - The facility will hold a petty cash fund up to fifty dollars for each resident who requests such a service; - A petty cash fund of up to fifty dollars per resident will be maintained separately from the facility funds. 2. Review on 11/1/18 at 6:30 A.M., showed the resident fund monthly reconciled bank statements did not list the residents' petty cash. 3. During an interview on 11/1/18 at 9:25 A.M., the Director of Community Finance (in charge of resident funds) said they do not have a petty cash fund for the residents. He/She said they keep money in the administrator's office for residents when they request it, however, it is the facility's money. The resident's money in kept in the bank. She said she is not aware of any regulations which said the residents' petty cash had to be separated from the facility petty cash. 4. During an interview on 11/1/18 at 1:00 P.M., the administrator said the residents' petty cash should come from the residents' trust rather than the facility's operating money. He/She said the residents' petty cash balance should appear on the reconciled bank statements.

Based on observation, interview and record review, facility staff failed to follow acceptable standards of practice for four residents out of 12 sampled residents (Resident #8, #18, #20, and #239). Staff failed to check placement of a percutaneous endoscopic gastrostomy (PEG) tube (tube passed into the stomach through the abdominal wall, used for feeding) prior to medication administration and properly store oxygen tubing. The facility census was 38. 1. Review of the facility's Administering Medication Through an External Tube Policy, dated 8/15/2017, showed staff is directed to confirm placement of tube, to notify provider of suspected improper placement, check gastric residual volume and record in the medical record, and notify care provider of abnormal amounts. Review of the facility's Gastric Tube Care Policy, dated 09/10/18, showed the steps staff is directed to confirming placement of feeding tubes is as follows: -Attach 60 milliliter (ml) syringe to end of catheter tube; -Aspirate stomach contents (GRV); -If the stomach content cannot be aspirated, pull back slightly on the tube to reposition. If the tube is still not patent, withhold medication and notify the physician; -If acceptable GRV has been verified, flush tubing with at least 30 ml warm sterile water (or prescribed amount). 2. Review of Resident #20's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 10/04/18, showed the following: -Required extensive assistance of two staff with mobility, transfer, locomotion, dressing, toileting and hygiene; -Tracheotomy; -PEG tube for feeding. Observation on 10/29/18 at 08:32 A.M., showed Licensed Practical Nurse (LPN) C did not check the PEG tube placement prior to medication administration. Observation on 11/01/18 at 08:50 A.M., showed LPN C did not check PEG tube placement prior to medication administration. 3. During an interview on 11/01/18 at 10:50 A.M., showed LPN E said staff should check placement of the PEG tube before giving medications, put 10 cc of air in a syringe and listen for an air sound. During an interview on 11/01/18 at 12:32 P.M., the administrator and the Director of Nursing (DON) said facility staff should check PEG tube placement by aspirating and auscultating prior to administering medications. 4. Review of Resident #239's entry tracking MDS, dated [DATE], showed an admission date of [DATE]. Observation on 10/29/18 at 12:40 P.M. and 10/31/18 at 12:30 P.M., showed the resident's oxygen concentrator in the bathroom with the oxygen tubing and nasal cannula on the floor of the bathroom. 5. During an interview on 10/31/18 at 3:27 P.M., CNA I said the resident's oxygen tubing should be stored in a plastic bag when not in use. He/She said the tubing and nasal cannula should not be on the floor. The CNA said staff should pick up the tubing and nasal cannula if they see it on the floor. During an interview on 10//31/18 at 3:30 P.M., LPN J said facility staff should try to keep the resident's oxygen tubing off the floor and the tubing and the nasal cannula should be stored in a plastic bag when not in use. He/She said all staff is responsible for picking up the tubing and nasal cannula off the floor. 6. Observation on 11/01/18 at 10:43 A.M., showed Resident #8's oxygen tubing wrapped around the portable oxygen tank and unbagged. 7. Observation on 10/31/18 at 01:32 P.M., showed Resident #18's oxygen tubing wrapped around the oxygen tank on the back of the wheelchair, undated and unbagged. 8. During an interview on 11/01/18 at 12:32 P.M., the administrator and the Director of Nursing (DON) said oxygen tubing and nasal cannulas should not be stored on the floor. They said it is their expectation staff would pick the tubing and nasal cannula up off the floor and change it out for a new one.

Based on observation, interview and record review, the facility staff failed to properly assess and care for one facility acquired pressure ulcer for one resident (Resident #9) of eleven sampled residents. The facility census was 42. 1. Review of the facility's policy titled "Pressure Ulcer Protocol", dated 2/21/13, showed: -A skin inspection will be conducted each time the resident is bathed and when clothing is changed; -The neighborhood nurse leader or neighborhood nurse will assess and record the status of the pressure ulcer in the clinical record at least once a week; -Weekly assessment will include wound measurements; -Neighborhood nurse leader or neighborhood nurse will notify the resident's physician/Nurse Practitioner and the Director of Nursing (DON) (or designee) if: -The ulcer shows signs of deterioration (i.e. increase in stage, new presence of tunneling or undermining); -The ulcer fails to show progress in healing in any two week period; -The ulcer shows signs of increased bio-burden as evidenced by increase redness to periwound edges, increases drainage, presence of odor. 2. Review of the National Pressure Ulcer Advisory Panel guidelines for Pressure Ulcer Stages/Categories showed the following: -A Stage I pressure ulcer is defined non-blanchable [DIAGNOSES REDACTED] of intact skin with non-blanchable redness of a localized area usually over a bony prominence. The area may be painful, firm, soft, warmer or cooler as compared to adjacent tissue. May indicate "at risk" persons. - A Stage II pressure ulcer is defined as partial thickness loss of dermis (skin) presenting as a shallow open ulcer with a red pink wound bed, without slough (dead, white,yellow, green or brown tissue). May also present as an intact or open/ruptured serum (fluid) filled or sero-sanguinous (blood and fluid) filled blister. Presents as a shiny or dry shallow ulcer without slough or bruising. - A Stage III pressure ulcer is defined as full thickness tissue loss in which subcutaneous fat may be visible but bone, tendon, or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. -A Stage IV pressure ulcer is defined as full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar (dead, leathery, brown or black tissue) may be present. The depth of a Stage IV pressure ulcer varies by anatomical location. Exposed bone/muscle is visible or directly palpable. - An Unstageable pressure ulcer is defined as full thickness tissue loss in which actual depth of the ulcer is completely obscured by slough and/or by eschar in the wound bed. Until enough slough and/or eschar are removed to expose the base of the wound, the true depth cannot be determined, but it will be either a Stage III or IV. 3. Review of Resident #9's MDS, dated [DATE], showed staff assessed the resident as follows: - Severe cognitive impairment; - Extensive assistance of two or more for transfers, ambulation, dressing, and personal hygiene; - Frequently incontinent or bowel and bladder; - Has a stage 1 pressure ulcer or greater; - Is at risk for development of pressure ulcers; - Has 1 or more unhealed pressure ulcer stage 1 or higher; - Has 1 unstageable pressure ulcer. Review of the resident's care plan, dated 9/9/14, showed the staff were directed to care for the resident as follows: -Assist to move in the bed at night; -Suggest and help the resident to reposition when in bed or in the wheel chair; -Apply lotion to skin on a regular basis; -Encourage to eat meals and provide alternates if needed; -Keep linens as wrinkle free as possible; -Check skin daily when providing care; -Report new reddened or open areas to the nurse; -Use any pressure relieving devices needed; -Put blue protector boots on his/her feet; -Keep heels of of the bed with pillows; -Use protective lotions to prevent skin breakdown; -Report skin redness or discoloration to the physician; Review of the resident's Skin Condition Report, dated 5/28/14, showed staff documented a new, facility acquired right heel pressure ulcer. The report also showed the wound measured 1.5 cm x 1 cm. Further review showed the staff assessed the wound base as 90% pink and 10% white, 80% granulation,10% eschar, and 10% slough. The staff did not document the stage of the pressure ulcer per the pressure ulcer staging definitions. Facility staff should have identified the wound as a Stage III pressure ulcer. Review of the resident's Skin Condition Report, dated 6/11/14, showed staff documented at 6:38 P.M. right heel pressure ulcer healed. Additional review of the resident's Skin Condition Report, dated 6/11/14, showed staff documented at 6:44 P.M. the right heel pressure ulcer continued. The report also showed the wound measured 1.3 cm x 1.6 cm. with the wound base as visible and 100% black eschar. Staff also documented the wound showed improvement. Staff did not document the stage of the pressure ulcer per the pressure ulcer staging definitions. Facility staff should have identified the wound as an unstageable pressure ulcer. Review of the resident's Skin Condition Report, dated 7/8/14, showed staff documented the right heel pressure ulcer as a Stage II. The report also showed the wound measured 0.2 cm x 0.2 cm x 0.1 cm. Further review showed the staff assessed the wound base as visible, 10% pink, and 90% black/brown, 90% eschar, and 10% slough per the pressure ulcer staging definitions. Facility staff should have identified the wound as an unstageable pressure ulcer. Review of the resident's Skin Condition Report, dated 7/15/14, showed staff documented the right heel pressure ulcer measured 0.4 cm x 1 cm. Further review showed the staff assessed the wound base as visible, 10% yellow, and 90% black. Staff also documented the area appeared dry and flaky, site improved, and no recent treatment changes made per the pressure ulcer staging definitions. Facility staff should have identified the wound as an unstageable pressure ulcer. Review of the resident's Skin Condition Report, dated 7/22/14, showed staff documented the right heel pressure ulcer wound base as visible and 100% black. Further review showed the staff documented the wound as improved and no treatment changes per the pressure ulcer staging definitions. Facility staff should have identified the wound as an unstageable pressure ulcer. Review of the resident's Skin Condition Report, dated 8/6/14, showed the staff did not document measurements of the right heel pressure ulcer. Review of the resident's Skin Condition Report, dated 9/1/14, showed the staff did not document the appearance of the wound base of the right heel pressure ulcer. Review of the resident's TAR, dated 5/2014, showed a new order, dated 5/23/14, for [MEDICATION NAME] (a medicated gauze wound treatment), cover with gauze, wrap with [MEDICATION NAME], and secure with tape to the right heel daily. Further review showed an order, dated 9/19/13, for Prevalon boots (pressure relieving devices) three times daily during the day, evening, and night to bilateral feet. Review also showed the staff did not document use of the boots 17 times during the month. Further review, showed no treatment or documentation of a Stage I pressure ulcer to the resident's right heel. Review of the resident's TAR, dated 6/2014, showed no treatment order changes and one un-documented treatment to the right heel pressure ulcer. Further review showed the staff did not document the use of the pressure relieving boots 15 times during the month. Review of the resident's TAR, dated 7/2014, showed no treatment order changes and two un-documented treatments to the right heel pressure ulcer. Further review showed the staff did not document the use of the pressure relieving boots 16 times during the month. Review of the resident's TAR, dated 8/2014, showed the staff did not document the application of the [MEDICATION NAME] treatment to the right heel pressure ulcer twice during the month. Further review showed a new treatment order for skin prep (a solution that provides a protective layer to the skin) to the right heel three times daily and let dry before touching socks/sheets etc. Review also showed the staff did not document the application of the skin prep 5 times during the month. Review also showed staff did not document the use of the pressure relieving boots four times during the month. Review of the resident's TAR, dated 9/2014, showed no changes to the treatment orders for the right heel pressure ulcer. Further review showed a new order, dated 8/28/14, for weekly skin/wound assessments. Review of the resident's nurse's note, dated 5/23/14, showed the staff notified the physician of a 1 cm x 1.5 cm round area, covered in eschar and slough to the resident's right heel. Further review showed treatment orders for [MEDICATION NAME], cover with gauze, wrap with [MEDICATION NAME], and secure received. Review of the registered dietician's note, dated 7/18/14, showed the dietician documented the pressure ulcer to the heel as healed. Further review showed the dietician did not recommend supplements. Review of the Dietary Manager's (DM) note, dated 9/5/14, showed the DM did not recommend interventions to address the resident's pressure ulcer. Review of the physician progress notes [REDACTED]. The note also showed an order for [REDACTED]. Review of the Physician's Progress Note, dated 6/18/14, showed the physician documented the resident complained of pain on 5/23/14 and he/she observed a 1 cm x 1.5 cm round area covered in eschar and slough. Further review showed the right heel to be elevated at rest, continue [MEDICATION NAME] dressings, and consider a follow-up appointment at the burn/wound clinic if worsening. Review of the Physician's Progress Note, dated 7/10/14 and 8/14/14, showed the physician documented a Stage II pressure ulcer to the right heel with pain at the wound site. Further review showed the right heel to be elevated at rest, continue [MEDICATION NAME] dressings, and consider a follow-up appointment at the burn/wound clinic if worsening. Observation on 9/11/14 at 11:27 A.M., showed the resident in his/her wheelchair without his/her feet elevated. Observation on 9/11/14 at 11:27 A.M., showed LPN F measured the right heel wound as length 1 cm and width 0.8 cm. Observation also showed the wound consisted of hard, dry, yellow and black tissue. Observation showed the wound as an unstageable pressure ulcer. Observation also showed the LPN assessed the wound as a scab. Facility staff should have identified the wound as an unstageable pressure ulcer per the pressure ulcer staging definitions. 4. During an interview on 9/11/14 at 11:33 P.M., LPN F said if wound deterioration or stalled progress for 2-3 weeks is noticed, the physician is notified for treatment order changes. The LPN said the physician must be notified for treatment orders and changes due to no standing orders, measurements are to be done every seven days, and a visual assessment should be done with every dressing change. He/She also said Resident #6 continues to be tracked and the wound is not worse and is not tunneling, but the facility has run out of options for treatment. The LPN also said the facility sometimes uses outside wound care, but not often and only if the wounds are so bad the facility cannot do anything more to treat. The LPN also said Resident #9's right heel pressure ulcer has gotten better. 5. During an interview on 9/12/14 at 4:40 P.M., the DON said pressure ulcers should have the appropriate descriptions documented in the medical record.