Every finding on record at Monroe Manor

Based on observation, interview, and record review, the facility failed to follow current infection control standards for six residents (Residents #87, #4, #75, #1, #53, and #18), in a review of 20 sampled residents, when staff failed to follow enhanced barrier precautions (EBP, precautions for use during high-contact resident care activities for residents infected with a multi drug resistant organism (MDRO) or any resident who has a chronic wound and/or indwelling medical device) to prevent infection while providing personal care, failed to ensure urinary catheter (a flexible tube inserted into the bladder) tubing was not on the floor, failed to ensure oxygen tubing was properly stored when not in use, and failed to follow the facility's policy and procedure for handwashing, gloving, handling of linens and respiratory therapy. The facility census was 82. Review of the facility's undated policy, Handwashing/Hand Hygiene, showed the following:-This facility considers hand hygiene the primary means to prevent the spread of infections;-All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors;-Wash hands with soap and water when hands are visibly soiled, -Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively,soap and water before and after direct contact with residents, before performing any non-surgical invasive procedures, before and after handling an invasive device (e.g., urinary catheters), before handling clean or soiled dressings, gauze pads, etc., before moving from a contaminated body site to a clean body site during resident care, after contact with a resident's intact skin, after contact with blood or bodily fluids, after handling used dressings, contaminated equipment, etc., after contact with objects (e.g., medical equipment) in the immediate vicinity of the resident, after removing gloves, before and after entering isolation precaution settings, hand hygiene is the final step after removing and disposing of personal protective equipment; -The use of gloves does not replace hand washing/hand hygiene. Integration of glove use along with routine hand hygiene is recognized as the best practice for preventing healthcare-associated infections; Review of the facility's EBP Policy, last reviewed/revised 02/2026, showed the following:-Purpose: to decrease transmission of CDC-targeted and epidemiologically important multidrug resistant organisms when contact precautions do not apply;-EBP will be required on residents who have an indwelling catheter (suprapubic or inserted), have a wound requiring a dressing with the exception of skin tears requiring an adhesive bandage (Band-aid);-EBP will be required while performing the following high-contact resident care activities; dressing, bathing/showering, transferring, -Providing hygiene (peri-care); changing linens, changing briefs or assisting with toileting, device care or use, urinary catheter, wound care and/or any skin opening requiring a dressing, when anticipating close physical contact while assisting with transfers, mobility, etc., -EBP includes wearing gloves and gowns. Gloves will be stocked in the resident room in the glove holders, and gowns will be stocked in the resident's nightstand. Review of the Centers for Disease Control and Prevention (CDC), Definition and Scope of Enhanced Barrier Precautions, dated 6/28/24, showed standard precautions still apply while using Enhanced Barrier Precautions. If splashes and sprays are anticipated during the high-contact activity, face protection should be used in addition to gown and gloves. Review of the CDC's Best Practices for Environmental Cleaning in Global Healthcare Facilities with Limited Resources, Appendix D, Linen and laundry management, dated 3/19/24, showed the following:-Never carry soiled linen against the body. Always place it in the designated container;-Place soiled linen into a clearly labeled container (e.g., bag, bucket) in the resident care area. Do not transport soiled linen by hand outside the specific resident care area from where it was removed. Review of the facility policy, Respiratory Therapy, dated 11/2022, showed the following:-The facility will ensure each resident receives necessary respiratory care and services that is in accordance with professional standards of practice;-Oxygen tubing will be kept in Ziplock bags when not in use. Review of the facility's undated clean dressing change checkoff showed the following:-Remove dirty dressing and place in trash can;-Remove gloves and perform hand hygiene;-Clean wound with gauze and cleaning solution using a single outward strokes and separate gauze for each cleansing wipe;-Use dry gauze to pat the wound;-Apply clean dressing as ordered. 1. Review of Resident #87's undated face sheet showed the following:-Diagnoses of bacterial pneumonia (a serious lung infection caused by bacteria that infect the air sacs leading to inflammation and accumulation of fluid or pus), sepsis (infection of the blood) Influenza A with other respiratory symptoms, acute respiratory failure (a life-threatening, sudden-onset condition where the lungs cannot adequately transfer oxygen to the blood or remove carbon dioxide) with hypoxia (when the tissues in the body do not receive enough oxygen). Review of the resident's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 02/24/26, showed the resident had a urinary catheter. Review of the resident's care plan, updated 03/10/26, showed the following:-Impaired gas exchanged related to infection in the lungs;-Required a urinary catheter related to chronic kidney disease and urinary retention;-Do not allow tubing or any part of the drainage system to touch the floor;-Required EBP related to indwelling urinary catheter;-PPE will be readily available in the room;-Signs will be placed in the room to alert staff of EBP;-Staff will wear gown and gloves when providing personal cares, changing linens, and transferring resident when not in a public setting.-The care plan was not specific about the PPE requirement when emptying the catheter;-The care plan did not address respiratory equipment care. Review of the resident's April 2026 physician order sheet, showed the following:-May have urinary catheter for urinary retention;-Oxygen at 2 liters (L) per minute by nasal cannula as needed. Observation on 04/06/26 at 2:02 P.M. showed the following:-An EBP sign was posted on the resident's door, and PPE was available in the room; -An oxygen concentrator was at the resident's bedside and was running. The nasal cannula tubing and the nasal cannula, attached to the oxygen concentrator, lay directly on the floor. Observation on 04/07/26 at 9:26 A.M. and 1:29 P.M. showed the following:-The resident lay in bed;-An oxygen concentrator was at the resident's bedside and was running. The nasal cannula, attached to the oxygen concentrator, lay directly on the floor. Observation on 04/08/26 at 6:31 A.M. showed the following:-Certified Nurse Assistant (CNA) D put on gloves and emptied urine from the resident's catheter bag into the toilet. He/She did not wear a gown or face protection; -CNA D removed his/her gloves, did not perform hand hygiene, and put on new gloves. CNA D did not put on a gown; -CNA D assisted the resident to change his/her pants; -CNA D dropped the resident's urinary catheter bag on the floor multiple times while assisting the resident to change his/her pants; -CNA D removed the oxygen cannula from the resident's nose and placed it on the bed; he/she did not put the nasal cannula into a bag;-CNA D placed the resident's catheter bag directly on the floor and assisted the resident to stand while he/she pulled up the resident's pants;-The resident sat in the wheelchair;-CNA D hooked the resident's catheter bag under the resident's wheelchair. The catheter tubing touched the ground; -CNA D removed his/her gloves, did not perform hand hygiene, did not put on gloves, and assisted the resident to change his/her shirt;-CNA D put the foot pedals on the resident's wheelchair and handed the resident his/her glasses;-CNA D picked up the resident's dentures that sat directly on the bedside table without a barrier, rinsed the dentures in the sink, and handed them to the resident who put them in his/her mouth;-CNA D did not perform any hand hygiene;-CNA D shut off the oxygen concentrator and left the nasal cannula tubing lying directly on the resident's bed; -CNA D pushed the resident in his/her wheelchair to the dining room. The catheter tubing dragged on the floor down the hallway, approximately 300 feet. During an interview on 04/08/26 at 7:26 A.M., CNA D said the following:-The resident was on EBP due to having a urinary catheter;-He/She should have worn a gown when emptying the resident's catheter and when helping the resident get dressed; -He/She should wash his/her hands upon entering the room, between glove changes and upon finishing or exiting the room; -He/She should have performed hand hygiene upon entering the room, after emptying the catheter and when he/she changed his/her gloves; -He/She did not realize he/she placed the catheter bag directly on the ground during cares and did not realize the catheter tubing touched the ground after connecting it under the wheelchair;-He/She knew the catheter bag and tubing should never touch the ground due to infection control purposes;-He/She did not remember placing the resident's oxygen tubing on the bed. Usually, he/she wrapped the tubing and placed it on top of the oxygen concentrator, making sure to keep the nasal cannula off the ground;-There was not always a bag to store the oxygen tubing. If there was one, he/she put the tubing in it. Otherwise, he/she just hang the tubing, making sure to keep the nasal cannula off the ground. Observation on 04/08/25 at 6:49 A.M. showed the following:-Staff pushed the resident in the wheelchair down the hallway; -The resident's urinary catheter tubing dragged on the floor; -There was cloudy urine in the urinary catheter tubing. Observation on 04/08/25 at 6:56 A.M. showed the following:-The resident sat in a wheelchair in the dining room;-His/Her urinary catheter tubing sat directly on the floor under the wheelchair; -There was cloudy yellow urine in the urinary catheter tubing. Observation on 04/08/26 at 7:04 A.M. showed the resident's oxygen nasal cannula lay directly on the bed. Observation on 04/08/25 at 7:30 A.M. and 7:52 A.M., showed the following:-The resident sat in a wheelchair in the dining room;-His/Her urinary catheter tubing sat directly on the floor under the wheelchair; -There was cloudy yellow urine in the catheter tubing. Observation on 04/08/26 at 12:44 P.M. showed the resident was not in his/her room. The oxygen concentrator was turned on and the oxygen tubing lay across the bedside table. The oxygen tubing was not stored in a bag. Observation on 04/09/26 at 8:48 A.M. and 9:25 A.M. showed the resident was not in his/her room. The oxygen concentrator was turned on and the oxygen tubing lay on the floor. During an interview on 04/09/26 at 9:35 A.M., Licensed Practical Nurse (LPN) E said staff should store oxygen tubing in a bag when not in use. 2. Review of Resident #4's care plan, last reviewed/revised 02/17/26, showed the following:-The resident required a supra pubic urinary catheter (a sterile tube inserted into the bladder through the abdominal wall to drain urine) related to stroke;-Do not allow urinary catheter tubing or any part of the drainage system to touch the floor;-The resident required EBP during high contact resident care activities related to the presence of indwelling device(s), (urinary catheter);-The resident had a urinary catheter;-Ensure items for following enhanced barrier precautions are in place (gloves, gown, alcoholbased hand rub, face shield, signage, trash receptacle, soap and water);-Hand hygiene utilizing alcohol-based rub or soap and water before and after cares;-Place enhanced barrier precautions notification/signage near the resident's doorway to alert staff/visitors of precaution;-Utilize PPE (gowns, gloves, face shield) as indicated during high contact resident care activities (dressing, bathing/showering, transferring, performing hygiene, soiled linen changes, brief/pull-up changes, toileting assistance, device care, wound care). Review of the resident's comprehensive MDS, dated [DATE], showed the following:-He/She was severely cognitively impaired;-He/She had a urinary catheter;-He/She was dependent on staff for toileting hygiene, upper and lower body dressing, to roll left and right,sit to lying, lying to sitting on bedside and chair to bed to chair transfers. Review of the resident's April 2026 physician orders showed the resident had an order for a urinary catheter. Observation on 04/08/25 at 6:22 A.M., showed the following:-The resident lay in bed with the bed in the low position;-The resident's urinary catheter tubing lay directly on the fall mat next to the resident's bed; -The urine in the catheter tubing was dark yellow (normal urine color is clear, pale yellow to amber in color). During an interview on 04/08/26 at 6:28 A.M., CNA C said catheter tubing should never touch the floor. If catheter tubing sat on the floor, it could increase the resident's risk of infection. Observation on 04/08/26 at 6:55 A.M., showed LPN E entered the resident's room and performed a blood sugar finger stick on the resident and administered insulin. He/She stood on the right side of the resident's bed. The resident's catheter tubing lay directly on the fall mat beside the resident's bed. LPN E did not readjust the resident's catheter tubing. During an interview on 04/08/26 at 7:46 A.M. and 04/09/26 at 9:35 A.M., LPN E said the following:-Catheter tubing should not touch the floor;-When he/she entered the resident's room, he/she did not notice the catheter tubing lay directly on the fall mat;-Catheter bags and tubing should never touch or drag the ground, due to the increased risk of infection. Observation on 04/08/26 at 7:04 A.M. showed the resident's catheter tubing lay directly on the fall mat on the right side of the resident's bed. Observation on 04/08/26 at 7:09 A.M. showed the following:-CNA D entered the resident's room, did not perform hand hygiene, and put on gloves and gown;-The gowns were in a bag on the back of the resident's door, and the gloves were located by the sink. There were no face protection located near the resident's door or in his/her room;-CNA D emptied urine from the resident's catheter bag into the toilet. CNA D did not wear face protection;-CNA D removed his/her gloves, and without performing hand hygiene, put on new gloves; -CNA D cleaned the resident's peri area;-While wearing the same gloves he/she wore to provide incontinence care, CNA D opened the resident's bedside drawer, removed a tube of barrier cream, handed the barrier cream to CNA C, and CNA C applied a small amount from the tube onto CNA D's glove;-CNA D applied the barrier cream to the resident's peri area; -CNA D removed his/her gloves, did not perform hand hygiene, and put on new gloves;-CNA D performed additional peri care, did not remove his/her gloves, applied the Hoyer sling (device used for a mechanical lift) to the Hoyer lift (mechanical lift device), used the Hoyer lift control to lift the resident out of bed, and assisted the resident to put on a shirt; -CNA D removed his/her gloves, did not perform hand hygiene, and left the resident's room. During an interview on 04/08/26 at 7:35 A.M., CNA D said he/she should have washed his/her hands when he/she entered the resident's room and before he/she put on gloves. He/She should not touch any clean surfaces with dirty gloves. He/She did not change his/her gloves after performing peri care, and he/she touched the resident's clothes with dirty gloves. He/She did not wash his/her hands with soap and water or use hand sanitizer when he/she changed his/her gloves. He/She should have washed his/her hands with soap and water or used hand sanitizer during the resident's incontinence care. During an interview on 04/09/26 at 1:16 P.M., the Director of Nursing (DON) said catheter tubing should not lay on the floor. 3. Review of Resident #75's care plan, last reviewed/revised 01/16/26, showed the following:-He/She was incontinent of bowel and bladder; -Provide incontinence care after each incontinent episode. Review of the resident's quarterly MDS, dated [DATE], showed the following:-He/She was always incontinent of bowel and bladder;-He/She was dependent on staff for toileting hygiene. Observation on 04/06/26 at 11:37 A.M. showed the following:-Certified Nurse Assistant (CNA) G brought the sit-to-stand lift (a mechanical lift used to assist from a sitting to a standing position) into the resident's room;-CNA G washed his/her hands and put on gloves;-CNA G pulled down the resident's pants, removed the resident's urine soiled incontinence brief, and wiped feces from the resident's buttocks;-Without removing his/her gloves, CNA G applied a clean incontinence brief to the resident, pulled up the resident's pants, pulled down the resident's shirt, touched the controls of the sit-to-stand lift and lowered the resident into his/her wheelchair, and handed the resident his/her tablet and headphone while wearing the same gloves he/she wore to provide incontinence care;-CNA G removed his/her gloves, and without washing his/her hands, pushed the resident out of his/her room in his/her wheelchair. During an interview on 04/08/26 12:45 P.M., CNA G said the following:-He/She should remove his/her gloves when they were soiled and wash his/her hands with soap and water;-He/She did not take off his/her soiled gloves and wash his/her hands before touching clean surfaces;-He/She should not touch any clean surfaces with soiled gloves;-He/She forgot to remove his/her soiled gloves and wash his/her hands with soap and water before touching clean surfaces. During an interview on 04/09/26 at 10:01 A.M., the Director or Nursing said staff should not touch clean surfaces with contaminated gloves/hands. 4. Review of Resident #1's undated face sheet showed he/she had a diagnosis of pneumonia (infection and inflammation of the lung). Review of the resident's admission MDS, dated [DATE], showed continuous oxygen was used on admission and while a resident. Review of the resident's April 2026 physician order sheet showed an order for continuous oxygen at 3 liters (L)/minute via nasal cannula. Review of the resident's care plan, updated 02/18/26, showed no documentation regarding continuous oxygen use or care of respiratory equipment. Observation on 04/07/26 at 9:01 A.M. showed the following:-A portable oxygen tank on the resident's wheelchair. The oxygen tubing was coiled up and hung over the oxygen regulator. The nasal cannula was not in a bag;-The resident was not wearing oxygen. Observation on 04/07/26 at 12:07 P.M. showed the resident sat in his/her wheelchair in the dining room. He/She was not wearing oxygen. A portable tank was on the back of his/her wheelchair. The oxygen tubing hung freely from the tank and was not stored in a bag. Observation on 04/08/26 at 6:26 A.M. showed the resident sat in his/her wheelchair in his/her room. He/She was not wearing oxygen. The portable oxygen tank was on the back of the wheelchair and the tubing was not in a bag. Observation on 04/08/26 at 7:14 A.M. showed the resident sat in his/her wheelchair in the dining room. He/She was not wearing oxygen. A portable oxygen tank was on the back of his/her wheelchair and the oxygen tubing was not in a bag. Observation on 04/09/26 at 8:42 A.M. showed the resident sat in his/her wheelchair in his/her room. He/She was not wearing oxygen. A portable oxygen tank was on the back of his/her wheelchair. The oxygen tubing was coiled up and hung over the regulator and was not in a bag. Observation on 04/09/26 at 11:46 A.M. showed the resident sat in his/her wheelchair in the dining room. He/She was not wearing oxygen. The portable tank was on the back of the wheelchair and the oxygen tubing was not in a bag. During interviews on 04/07/26 at 9:01 A.M. and 04/09/26 at 8:42 A.M., the resident said the following:-He/She always used oxygen at night and as needed during the day;-He/She did not usually have a bag to store the oxygen tubing. 5. Review of Resident #53's physician orders, dated 03/24/26, showed the following:-Diagnoses included right knee infected arthroplasty (joint replacement);-Wet to dry dressing (a traditional, mechanical debridement method used to remove dead tissue from open wounds by applying saline-moistened gauze, letting it dry, and removing it) with 2x2 gauze, cover with ABD dressing (a highly absorbent, sterile, and non-stick medical dressing designed for large, heavily draining wounds or surgical sites), and secure with ace wrap once a day. Review of the resident's care plan, last reviewed/revised on 03/26/26, showed the following:-He/She had impaired skin related to an open wound on his/her knee;-Dressing changes as directed by physician; wet to dry dressing daily using aseptic technique (a procedure that healthcare providers use to prevent the spread of infection). Review of the resident's wound documentation, dated 04/03/26, showed the following:-He/She had a 2.7 centimeter (cm) (length) by 3 cm (width) stable lesion that was present upon admission to the right knee. During an interview on 04/08/26 at 3:30 P.M., the resident said the wound on his/her right leg was caused by an infection after he/she had knee surgery. He/She acquired the infection prior to his/her admission to the facility, and he/she had been on intravenous (IV; medication administered through an access to the vein) antibiotics which had been discontinued. He/She continued to require daily dressing changes to the right knee. Observation on 04/08/26 at 3:35 P.M., showed the following:-LPN A removed the ace bandage and ABD pad from the resident's right knee/leg;-LPN A removed his/her gloves and without washing/sanitizing his/her hands, put on new gloves;-LPN A cleaned the wound with wound cleanser, did not remove his/her gloves, and moistened a clean 2x2 dressing with wound cleanser and placed the dressing on the right knee wound, covered the 2x2 with an ABD pad, secured with gauze cling, and wrapped the leg with ace bandage. (LPN A did not change his/her gloves after he/she removed the old dressing and cleaned the wound and before he/she applied the new dressing.) During an interview on 04/08/26 at 4:45 P.M., LPN A said he/she does not sanitize his/her hands when he/she removes his/her gloves. He/She washed his/her hands before and after the dressing change, and thought that was sufficient. During an interview on 04/09/2026 at 10:01 A.M., the Director or Nursing said staff should remove their gloves and wash their hands and/or use sanitizer between glove changes. 6. Review of Resident #18's quarterly MDS, dated [DATE], showed the following:-He/She had two Stage II pressure ulcers (partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed without slough. May also present as an intact or open/ruptured blister);-He/She had one surgical wound and one skin tear. Review of the resident's care plan, last reviewed/revised 03/31/26, showed the following:-The resident required enhanced barrier precautions related to his/her wound;-Staff will wear a gown and gloves when providing personal cares, changing linens, and transferring the resident when not in a public setting. Review of the resident's physician order summary, dated April 2026, showed the following:-Right above the knee amputation (AKA) surgical incision. Cleanse wound with vashe cleanser (wound cleanser). Apply aquacel (wound care product used to manage moderate to high wound drainage) to wound bed. Cover with dry gauze and secure with medipore tape (cloth-like surgical tape). Change daily and as needed if soiled;-Coccyx pressure injury (PI) special instructions: Cleanse buttocks with wound cleaner, apply foam dressing every three days. Observation on 04/08/26 at 9:41 A.M., showed the following:-CNA F exited the resident's room;-He/She did not wear and gown and held the bed linens directly against to his/her body;-CNA F went back into the resident's room and placed the dirty linen directly on the floor;-CNA F put on gloves and placed the dirty linen into a black trash bag. During an interview on 04/08/26 at 9:41 A.M. and 04/09/26 at 1:03 P.M., CNA F said the following:-He/She had stripped the linens off the resident's bed;-There was EBP signage on the door, and he/she should have used a gown and gloves when he/she changed and handled the dirty linens from the resident's bed;-He/She went into the hallway, holding the dirty linens, to ask the housekeeper for a plastic bag;-He/She should not have placed the linens directly on the floor or up against his/her body. During an interview on 04/09/26 at 1:16 P.M., the Director of Nursing (DON) said the following:-Staff should wear gloves when handling dirty linens;-Staff should not hold dirty linens against their body, should not carry the linens outside of a resident's room without being in a trash bag, and should not place the linen directly on the floor;-Staff should wear a gown and gloves when changing bed linens for a resident on enhanced barrier precautions.

Based on interview, observation, and record review, the facility failed to follow professional standards and the facility's policy/procedure for failing to complete a dressing change per proper technique for one resident (Resident #53) who had surgical wound and history of infection in the surgical wound which had recently been treated with antibiotics, in a review of 20 sampled residents. The facility census was 82. Review of the facility's undated clean dressing change checkoff showed the following:-Verify and review physician's orders;-Remove dirty dressing and place in trash can;-Clean wound with gauze and cleaning solution using a single outward strokes and separate gauze for each cleansing wipe;-Use dry gauze to pat the wound;-Apply clean dressing as ordered. Review of the National Library of Medicine, MedlinePlus.gov, last reviewed on 01/21/25, showed the following steps should be followed when changing a wet to dry dressing:-Pour saline into a clean bowl. Place gauze pads and any gauze packing tape you will use in the bowl;-Squeeze the saline from the gauze pads or packing tape until it is no longer dripping;-Place the gauze pads or packing tape in your wound. Carefully fill in the wound and any spaces under the skin;-Cover the moistened gauze or packing tape with a large dry dressing pad. Use tape or rolled gauze to hold this dressing in place. 1. Review of Resident #53's admission Minimum Data Set (MDS), a federally mandated assessment to be completed by the facility, dated 01/26/26, showed the following:-His/Her cognition was intact;-He/She had a surgical wound. Review of the resident's physician's progress note, dated 03/12/26, showed the following:-The resident was status post right total knee arthroplasty (surgery to restore the function of a joint) that was complicated by a knee infection that required open debridement (the medical removal of dead, damaged, or infected tissue from a wound to promote healing and prevent infection) in September;-Cultures were positive for Staph epidermidis (common symbiont bacterium that can become infectious once inside the human host.);-He/She underwent surgery with replacement of the plastic in the joint on 12/02/25;-Examination showed an abscess of the right anterior aspect of his/her knee;-Diagnoses included an infection and inflammatory reaction due to an internal right knee prosthesis. Review of the resident's physician orders, dated 03/24/26, showed the following:-Right knee infected arthroplasty;-Wet to dry dressing (a dressing placed into a wound and allowed to dry before removing) with 2x2 gauze, cover with ABD dressing (a highly absorbent dressing designed for heavily draining wounds), and secure with ace wrap once a day. Review of the residents' care plan, last reviewed/revised on 03/26/26, showed the following:-He/She had impaired skin related to an open wound on his/her knee;-Dressing changes as directed by physician. Wet to dry dressing daily using aseptic technique (a procedure that healthcare providers use to prevent the spread of infection). Review of the resident's wound documentation, dated 04/03/26, showed he/she had a 2.7 cm (length) by 3 cm (width) stable lesion present upon admission to the right knee. During an interview on 04/08/26 at 3:30 P.M., the resident said the wound on his/her right leg was caused by an infection after he/she had knee surgery. He/She acquired the infection prior to his/her admission to the facility, and he/she had been on intravenous (IV; medication administered through an access to the vein) antibiotics which had been discontinued. He/She continued to require daily dressing changes to the right knee. Observation on 4/8/26 at 3:35 P.M. showed the following:-Licensed Practical Nurse (LPN) A removed the ace bandage and ABD pad from the resident's right knee/leg;-LPN A moistened a single 2x2 gauze with wound cleanser and cleaned the wound. LPN A wiped over the wound multiple times with the same 2x2 gauze;-LPN A moistened (not saturated) a clean 2x2 dressing with wound cleanser (not saline solution) and placed the dressing on the wound on the resident's right knee, covered the 2x2 with an ABD pad, secured with gauze cling, and wrapped the leg with ace bandage. During an interview on 04/08/26 at 4:45 P.M., LPN A said the dressing was supposed to be soaked in normal saline, but he/she did not have any normal saline. The order did not specify what to use, so he/she used the wound cleanser. He/She did not saturate the 2x2 gauze before he/she placed it on the wound. During an interview on 04/09/2026 at 10:01 A.M., the Director of Nursing said the following:-When completing a wet to dry dressing treatment, staff should place a 2x2 dressing in a cup of normal saline, wring out the 2x2 gauze but leave the dressing wet, and place the gauze over the wound. -LPN A should have used normal saline, not wound cleanser for the wet to dry dressing, per standard nursing protocol for wet to dry dressing changes.

Based on observation, interview, and record review, the facility failed to provide two residents (Resident #9 and #4), who relied on staff to assist with their activities of daily living (ADLs), in a review of 20 sampled residents, the necessary care to maintain good personal hygiene. The facility census was 82. Review of the facility policy, Perineal Care, dated March 2019, showed the following:-Purpose was to keep perineal clean and to prevent infection and odors in the perineal area;-Staff must clean all areas of the skin that are touched by soiled brief. Review of the facility policy, Indwelling Catheter Care, reviewed November 2025, showed when providing care to an uncircumcised male, retract the foreskin, cleanse the meatus as described, and return the foreskin to normal position. Review of Medline Plus Medical Encyclopedia, reviewed 07/01/25, showed the following:-Penis care (uncircumcised);-Gently retract the foreskin during bathing and clean the penis well. It is very important to reposition the foreskin back over the head of the penis after cleaning. Otherwise, the foreskin can slightly squeeze the head of the penis, causing swelling and pain. 1. Review of the Resident #9's quarterly Minimum Data Set (MDS), a federally mandated assessment to be completed by the facility, dated 03/06/26, showed the following:-He/She was occasionally incontinent of urine;-He/She was frequently incontinent of bowel;-He/She was dependent on staff for toileting and personal hygiene. Review of the resident's care plan, last reviewed/revised on 03/23/26, showed the following:-He/She had urinary and fecal incontinence related to decreased bladder/bowel control and cognitive/functional limitation as evidenced by episodes of wet/soiled briefs and need for assistance with toileting and hygiene;-Staff was to perform perineal care after each incontinence episode. Observation on 04/08/26 at 9:49 A.M. showed the following:-Certified Medication Technician (CMT) B and Licensed Practical Nurse (LPN) A assisted the resident to the toilet. The resident was incontinent of bladder and his/her incontinence brief and pants were soiled with urine. The resident had a bowel movement while on the toilet; -LPN A cleaned feces from the resident's rectal area; -Without cleaning the resident's front perineal area, LPN A and CMT B put a new incontinence brief on the resident, pulled up the resident's pants, and assisted the resident to the wheelchair. During an interview on 04/08/26 at 4:45 P.M., LPN A said he/she was not aware CMT B did not clean the resident's front perineal area. CMT B should have been cleaned the resident's frontal perineal area because the resident was incontinent of urine. During an interview 04/08/26 at 1:00 P.M., CMT B said LPN A was responsible to provide peri-care to the resident after the resident was incontinent of urine. He/She did not realize LPN A did not clean the resident's front perineal area. 2. Review of Resident #4's care plan, last reviewed/revised 02/17/26, showed the following:-The resident required a supra pubic catheter (a sterile tube inserted into the bladder through the abdominal wall to drain urine) related to stroke;-The resident was limited in ability to maintain his/her grooming/personal hygiene related to decreased mobility/stroke;-Provide assistance for washing/drying perineum as needed. Review of the resident's comprehensive MDS, dated [DATE], showed the following:-He/She had an indwelling urinary catheter;-He/She was dependent on staff for toileting hygiene. Observation on 04/08/26 at 7:09 A.M. showed the following:-CNA D and CNA C were in the resident's room to provide care for the resident;-CNA D pulled back the foreskin on the resident's genitalia to clean the area; -CNA D did not reposition the resident's foreskin back over the resident's genitalia once he/she provided perineal care. During an interview on 04/08/26 at 7:19 A.M., CNA D said he/she did not know he/she was supposed to reposition the foreskin to the normal position after providing care. During an interview on 04/08/26 at 7:26 A.M., CNA C said he/she was aware the resident's foreskin needed to be put back in place. He/She did not notice this when providing care. 3. During an interview on 04/09/26 at 1:16 P.M., the Director of Nursing (DON) said the following:-Staff should clean the front and back perineal areas when a resident was incontinent of urine; -After performing peri care for a male resident, staff should reposition the foreskin over the genitalia. If not, it could cut off circulation, cause a wound or cause an infection.

Based on observation, interview, and record review, the facility failed to ensure staff monitored and provided hand hygiene for one resident (Resident #6), in a review of ten sampled residents. Resident #6 had diagnosis of dementia and was incontinent of bowel and bladder. The resident wandered and continually placed his/her hands in his/her pants and fondled his/her genitalia. Resident #6 touched multiple items on the unit including a resident's meal tray, food items, drinking glasses, and a water pitcher on a medication cart without appropriate hand hygiene. The facility census was 80. Review of the undated facility policy, Hand Hygiene, showed the following: -When to use soap and water: -When hands are visibly dirty or visibly soiled with blood or other body fluids; -Before eating and after using the restroom; -After approximately 10 uses of Alcohol-based hand gel or hands feel tacky from use hand gel; -When to use alcohol-based hand gel: -Before and after resident contact; -After body fluid exposure or contact with other inanimate objects. 1. Review of Resident #6's undated face sheet showed the following: -He/She admitted to the facility on [DATE]; -He/She had diagnoses of Alzheimer's disease, unspecified, (progressive and debilitating disease that caused severe cognitive decline and affected ability to function in daily life) and Alzheimer's disease with early onset (diagnosed before the age of 65). Review of the resident's progress notes showed staff documented the following: -12/06/24 at 12:30 P.M., the resident was up ambulating in the unit, was incontinent of bowel and bladder, wandered in and out of other resident's rooms and grabbed other resident's belongings and carried them around; -12/07/24 at 2:08 A.M., the resident needed frequent continuous redirection, wandered in and out of other resident's rooms taking things and was incontinent of bowel and bladder functions; -12/07/24 at 11:29 A.M., the resident was up wandering in the dining room, was difficult to redirect from taking other resident's lunch items; -12/09/24 at 3:35 P.M., the resident was up wandering around the dining room, living room and hallway; had hands in his/her pants constantly touching genitals, removed food from other residents during meal time and resident must be observed closely. Review of the resident's Admission Minimum Data Set (MDS), a federally mandated assessment instrument, completed by facility staff, dated 12/11/2024, showed the following: -His/Her cognition was severely impaired; -The resident had daily behaviors not directed toward others (e.g. physical symptoms such as scratching self, pacing, rummaging, public sexual acts, or throwing or smearing food or bodily waste); -The resident wandered daily; -The resident was dependent on staff for hygiene; -The resident was frequently incontinent of bowel and bladder; -The resident was independent with mobility and walking. Review of the resident's progress notes showed staff documented the following: -On 12/17/24 at 10:13 A.M., the resident exhibited behaviors such as feces on hands and wandering into other residents' rooms; -On 12/18/24 at 6:13 P.M., the resident exhibited behaviors including wandering, attempting to go into open rooms and pick up items, constantly having his/her hand in his/her pants touching genitals, and required one on one supervision. Review of the resident's care plan, revised 12/20/2024, showed the following: -The resident wears a carpenter's apron at times for distraction from keeping his/her hands in his/her pants related to Alzheimer's; -He/She has socially inappropriate/disruptive behavior symptoms as evidenced by going into other resident's rooms, often puts his/her hands in pants touching genitals. Attempt to divert behavior by one on one conversation, walk with resident up and down halls, provide toileting, drinks, snacks, sensory items, magazine, book, TV, music; Dress in clothing that is difficult to remove; -Provide toileting assistance at least every two hours and as needed (PRN). -There were no interventions in the care plan to address the resident's hand hygiene related to the resident's behavior of continually touching his/her genitals. Review of the resident's progress notes showed staff documented the following: -On 12/23/24 at 6:11 P.M., the resident wandering into other residents' rooms and around noon, wandered into a resident's room and sat down and began eating that resident's lunch. Apron, belt, and jeans have not been successful in keeping the resident's hand out of his/her pants and fondling genitals; -On 12/24/20 at 5:46 P.M., the resident continued to wander into other residents' rooms (opened and closed doors), picking up items that do not belong to him/her; wearing the jeans, belt, and apron do not prevent the resident from keeping the resident's hand out of his/her pants and fondling genitals; incontinent of bowel and bladder; difficult to toilet; -On 12/30/24 at 2:55 P.M., he resident continued to wander into other residents' rooms; continues to have his/her hand down his/her pants fondling genitals; took food from other resident's trays at mealtime and staff must observe closely; -On 12/31/24 at 6:49 P.M., the resident continued to wander, go into other residents' rooms and take items, continues to have his/her hands in his/her pants fondling genitals; -On 01/06/25 at 6:39 P.M., the resident continued to wander into other residents' rooms and pick up items; continues to put hands in pants and fondles genitals despite any attempts to prevent; -On 01/07/25 at 6:50 P.M., the resident wandered with feces on his/her hand, the resident threw feces across the floor. Continued to wander with hand down his/her pants fondling genitals and into other residents' rooms picking up random objects. Observation of the resident on 01/13/25 showed the following: -At 2:30 P.M., the resident wandered around the unit, wearing jeans and a carpenter belt with his/her hand down his/her pants fondling his/her genitals. No staff redirected the resident or intervened to provide hand hygiene; -At 2:39 P.M., the resident grabbed Resident #4's stuffed animal and put it in his/her mouth; -At 2:40 P.M., staff handed Resident #4 his/her stuffed animal back without cleaning it first and did not assist Resident #6 with hand hygiene; -At 3:00 P.M., the resident walked on the unit with his/her hands in his/her pants, walking up behind Resident #10 and touched Resident #10's shoulders. Housekeeper C observed this and consoled Resident #10 as he/she appeared afraid, but did not wash Resident #6's hands or alert care staff that Resident #6's hands needed to be washed. Resident #6 continued to walk with his/her hands in his/her pants, removed his hand, touched bread in a sack on a dining room table and then touched a bag of bread near the coffee pot. No staff redirected the resident or intervened to provide hand hygiene. Observation of the resident on 01/14/25 at 10:20 A.M., showed he/she wandered up and down the hall with his/her hand down his/her pants. He/She walked up to the medication cart near the nurse's station, and picked up a pitcher of water. Certified Medication Technician (CMT) E removed the pitcher from the resident's hand and placed it back on the medication cart without cleaning or replacing the water pitcher. CMT E did not assist the resident to provide hand hygiene and CMT E did not perform hand hygiene after touching the same water pitcher. 2. During an interview on 01/13/2025 at 4:10 P.M., Resident #1 said the following: -Due to Resident #6's behaviors, including having his/her hands in his/her pants and then putting his/her hands all over the glasses and silverware on the tables at meal times, he just tried to stay in his/her room and has meals delivered to his/her room; -Resident #6 came into his/her room, sat down in his/her chair and stuck his/her fingers into his/her food while he/she was eating; he/she did not like that because he/she knew where Resident #6's hands had been; -Resident #6 always has his/her hands down the front of his/her pants. 3. During an interview on 01/13/2025 at 6:15 P.M., CMT D said it was very difficult keeping things sanitized after Resident #6 had his/her hands down his/her pants and then touched things. During an interview on 01/14/2025 at 10:05 A.M., CMT E said the following: -He/She could not always watch Resident #6; -Resident #6 touched himself/herself inappropriately; -If he/she was not constantly watching Resident #6, he/she went into other resident's rooms, picked things up and carried them away. During an interview on 01/14/2025 at 10:20 A.M., CMT F said Resident #6 kept his/her hands down his/her pants and constantly touched things. It was hard to keep things sanitized. During an interview on 1/13/2025 at 2:15 P.M. and 6:15 P.M., Licensed Practical Nurse (LPN) B said he/she had difficulty with meal prep and service due to Resident #6 picking up drinks (glasses for all of the residents), from the tables or going in other resident rooms and eating their food. Resident #6's hands may be dirty from having his/her hands in his/her pants and staff do not always catch what he/she has touched. Other residents see it and this upsets them. During an interview on 01/13/25 at 5:55 P.M., 01/13/25 at 6:30 P.M. and 01/14/25 at 7:00 P.M., the Director of Nurse (DON) said they tried to educate staff about hand sanitizing and keeping the resident's hands clean after having touched his/her genitals. During an email communication on 01/30/2025 at 5:21 P.M., the DON said the following: -Staff should be cleaning up the area and the resident after the resident urinates or defecates; -Staff should be sanitizing high touch areas frequently throughout the day; -There should be no time when the resident urinates or defecates that the staff are not immediately taking him/her to the bathroom to clean him/her up and wash his/her hands. MO246694

Based on observation, interview, and record review, the facility failed to ensure three residents (Residents #2, #1, and #3), in a review of four sampled residents, received care and/or services per physician's orders and professional standards of care. Staff failed to ensure Resident #2, who had a significant wound/skin history, had weekly skin assessments completed and/or documented as ordered, and failed to obtain a follow up urinalysis (urine test used to detect an infection) ordered on 08/01/24. The facility failed to obtain labs as ordered and failed to follow up timely on lab results to monitor Resident #1's potassium level, who had a diagnoses of hypokalemia (low blood potassium level) and an ileus (a temporary condition where your intestine can't push food and waste out of your body which can be caused by chemical, electrolyte, or mineral imbalances such as decreased blood potassium level). The facility failed to follow discharge orders for Resident #3 by failing to complete dressing changes as ordered. The facility census was 68. 1. Review of an email received from the Director of Nursing (DON) on 11/13/24 showed the facility did not have a policy for following physician orders. 2. Review of Resident #2's Care Plan, last reviewed/revised on 05/16/24, showed the following: -He/She had pressure ulcers related to incontinence/decreased mobility; -Assess and record the condition of the skin surrounding the pressure ulcer weekly; -Assess the pressure ulcer for location, stage, size (length, width, and depth), presence/absence of granulation tissue, and epithelization weekly; -Conduct a systematic skin inspection weekly and report any signs of further skin breakdown; -He/She had history of cellulitis (bacterial infection of your skin and the tissues beneath your skin); -Monitor bilateral lower extremities (BLE) for signs/symptoms of cellulitis i.e. redness, swelling, etc. -He/She had history of ulcers to bilateral lower extremities. Review of the resident's Physician's Orders, dated June 2024, showed an order to complete a skin assessment observation weekly on Friday day shift (6:30 A.M. to 6:30 P.M.). Review of the resident's weekly skin assessment documentation, dated June 2024, showed no documentation staff completed a skin assessment from 6/21/24-6/30/24. Review of the resident's Physician's Orders, dated July 2024, showed an order to complete skin assessment observation weekly on Friday day shift (6:30 A.M. to 6:30 P.M.). Review of the resident's wound management detail report, dated 07/08/24, showed the facility's wound care nurse, Registered Nurse (RN) A, documented the following: -A declining 4.5 centimeter (cm) by 1 cm by 0.1 cm (length x width x depth) venous ulcer (a wound on the leg or ankle caused by abnormal or damaged veins) located on the right shin (lower leg); -A stable 2.4 cm by 2.4 cm by 0.1 cm venous ulcer located on the right ankle; -A declining 5 cm by 4.6 cm venous ulcer located on the left proximal (situated near the center of the body or center of attachment) shin; -A declining 0.6 cm by 0.5 cm venous ulcer located on the left distal (situated away from the center of the body or point of attachment) shin. Review of the resident's weekly skin assessment documentation, dated 07/13/24, showed the resident had abnormal skin with no new areas. (The assessment did not include any additional information regarding the resident's venous ulcers.) Review of the resident's weekly skin assessment documentation, dated July 2024, showed no documentation facility staff completed a skin assessment from 07/13/24 through 7/31/24. Review of the resident's July 2024 Physician's Orders, showed an order dated 7/24/24 for Rocephin (antibiotic) 1 gram intramuscularly (IM) with lidocaine (anesthetic) 2.1 milliliters (ml) every day for five days to treat UTI (discontinue date 7/28/24). Review of the resident's wound care clinic orders, dated 07/26/24, showed to complete the following dressing changes to bilateral lower extremities every third day and as needed: -Cleanse the legs/feet and dry well; -Paint all wounds and skin with Betadine (antiseptic solution) and allow to dry; -Once Betadine is dry, apply Cavilon Advance Wand (barrier to protect skin) around all wound beds and between toes, and allow to dry to protect from drainage; -Cover all wound beds with Mepilex (absorbent foam dressing to treat chronic and acute wounds); -Follow with double layer of Medigrip size E from toes to knees and keep legs elevated; -Cut a one inch strip of Interdry(used to prevent moisture) and weave in/out toes to help wick moisture every A.M./P.M. Review of the resident's Progress Note, dated 08/01/24 at 7:06 A.M., showed the resident's physician assessed the resident and ordered for a repeat UA specimen to be obtained. Review of resident's Progress Notes, dated 08/01/24 to 08/03/24, showed no documentation staff attempted to obtain the UA, no documentation the resident refused for staff to collect urine, and no documentation staff notified the physician when unable to collect a urine specimen for the UA. Review of the resident's weekly skin assessment documentation, dated August 2024, showed no documentation facility staff completed a skin assessment on 8/1/24 (the facility's last documented skin assessment was completed on 7/13/24). During an interview on 10/30/24 at 9:50 A.M., Licensed Practical Nurse (LPN) B said the following: -A licensed nurse was to complete weekly skin assessments on shower days and to document the assessment in the resident's electronic medical record; -He/She was not sure why the UA was not obtained for the resident; -The resident often refused care. Staff were to document in the resident's electronic record when a resident refused care and multiple attempts to provide care; -The physician should have been made aware when the resident refused, and staff should have documented this in the electronic medical record. During an interview on 10/31/24 at 8:49 A.M., Registered Nurse (RN) A, the facility's wound care nurse, said the following: -He/She or the charge nurses completed the weekly skin assessments. -He/She was responsible for completing the wound assessments, but the charge nurses could complete them in his/her absence. -Staff should document when a resident refused care, including dressing changes, tests, and assessments, in the resident's electronic medical record; -If a resident refused care, staff should make multiple attempts to provide the care and should document the attempts and interventions in the resident's electronic medical record. During an interview on 11/12/24 at 11:10 A.M., the DON said the following: -She expected staff to complete skin assessments weekly as ordered and to document the assessment in the resident's electronic health record ; -The charge nurses were responsible to complete weekly skin assessments and to document the assessments in electronic medical record when they were due; -The Care Plan Coordinator looked at residents' skin after each shower; -Staff notified the resident's physician of the resident's increased behaviors on 8/1/24 and obtained an order for a UA but staff could not straight cath (insert tube into the bladder to drain/collect urine specimen) the resident who thought staff were trying to hurt him/her. During an interview on 11/12/24 at 11:10 A.M., the Care Plan Coordinator said the shower aides completed the shower sheets. She monitored the shower sheets to see if there were any skin issues that needed to be addressed. The shower aides came to her if they saw anything concerning and she assessed the resident, but she did not physically assess every resident's skin after each shower. If she assessed the skin, she would have documented it in the resident's medical record. During an interview on 11/06/24 at 10:00 A.M., the resident's physician said the following: -He expected staff to complete weekly skin assessments as ordered and to document the assessments in the medical record; -He expected staff to complete all orders as written; -He expected staff to make multiple attempts to fulfill the orders and to document the attempts in resident's medical record; -He expected staff to notify him/her when a resident refused the care; -He did not recall staff notifying him/her that they were unable to obtain the repeat UA (ordered on 8/1/24). 3. Review of Resident #1's hospital records, dated 07/23/24, showed the resident had a blood potassium (mineral the body needs to work properly) value of 3.0 (normal potassium level is 3.5 to 5.2) and was started on intravenous (IV) potassium as the resident had been reported to have an ileus. Review of the resident's hospital discharge instructions, dated 07/26/24, showed the following: -Basic Metabolic Panel (BMP; bloodwork to measure electrolyte levels including potassium) for hypokalemia to be completed on 07/28/24; -Potassium chloride (potassium supplement) 20 milliequivalents (mEq) tablet, extended release; three tablets twice a day (BID) until 07/28/24, then draw BMP and magnesium level and notify physician to adjust medication; -Potassium chloride 20 mEq, extended release; one tablet once a day at bedtime until 07/28/24, then draw BMP and magnesium level and notify physician to adjust medication. Review of the resident's undated Face Sheet showed the following: -He/She was admitted to the facility on [DATE]; -Diagnoses included an ileus. Review of the resident's Physician's Orders, dated 07/26/24, showed the following: -Potassium chloride 20 mEq tablet, extended release; three tablets BID for hypokalemia (end date 07/28/24); -Potassium chloride 20 mEq, extended release; one tablet once a day at bedtime for hypokalemia (end date 07/28/24). (Review showed no documentation of an order to obtain a BMP on 7/28/24.) Review of the resident's Medication Administration Record (MAR), dated July 2024, showed staff did not administer the potassium chloride 20 mEq, extended release at bedtime on 07/28/24 due to the medication was unavailable. Review of the resident's medical record showed no documentation staff obtained the ordered labs for potassium and magnesium on 7/28/24 through 7/31/24. Review of the resident's Family Nurse Practitioner's progress note, dated 07/30/24, showed an order for a comprehensive metabolic panel. (The progress note did not identify the resident had a diagnosis of hypokalemia and history of an ileus, and did not provide instructions to discontinue or continue the potassium supplement.) Review of the resident's progress note, dated 08/01/24 at 4:01 P.M., showed staff had increased concerns with the resident's confusion and abdominal distension. Labs were drawn with results pending. (The lab for potassium level was originally ordered for 7/28/24 and was not drawn until 08/01/24). Review of the resident's lab report, obtained 08/01/24, showed the following: -The resident's potassium level was obtained on 08/01/24; -No documentation when the facility received report of the results. Review of the resident's medical record for 08/01/24 through 08/03/24 showed no documentation the facility received the results of the resident's ordered lab for potassium level that was obtained on 8/1/24. Review of the resident's Progress Note, dated 08/04/24 at 5:07 P.M., showed lab reported (potassium was 3.0) to the resident's physician and orders obtained for potassium chloride 40 mEq by mouth three times a day (TID) and repeat BMP on 08/08/24. (The facility received the results of the ordered lab on 08/04/24. The original order directed staff to obtain the lab for potassium level on 7/28/24. The resident did not receive potassium supplement from 7/30/24-8/4/24. Once lab results were received on 08/04/24 (seven days after the labs were originally ordered), the physician ordered to restart the potassium.) During an interview on 10/28/24 at 1:35 P.M., the DON said the following: -The resident was admitted to the facility from the hospital on 07/26/24 with a history of an ileus; -The resident's hospital discharge orders included potassium chloride twice a day (BID) and at bedtime, and to recheck potassium level on 07/28/24; -The facility had issues with the lab company not coming to the facility to obtain labs; this was the reason for the delay in obtaining the resident's ordered labs. The facility also had issues with the lab company not sending the results of ordered labs; -The lab company collected the resident's blood specimen on 08/01/24; -She contacted the lab on 08/02/24 for the results. There were no results and she was unsure why; -She did not work on 08/03/24, and no one contacted the lab for results; -She contacted the lab on 08/04/24 and obtained the results; -Charge nurses have the capability to call the lab company for lab results and should follow up if the labs were not received. During an interview on 10/31/24 at 8:49 A.M., RN A said the following: -The facility had problems with the lab company not completing the ordered labs and with turn around times for results; -Generally, there was a 24-hour turn around time for lab results; -If the facility did not receive the lab results within a 24-hour timeframe, staff should call and inquire about the results; -He/She recalled the facility having to contact the lab for the results of the resident's lab work, but did not recall the date. During an interview on 11/06/24 at 10:00 A.M., the resident's physician said he/she expected staff to follow orders as written. 4. Review of Resident #3's Face Sheet showed he/she admitted to the facility on [DATE] with diagnoses of biliary acute pancreatitis ( gallstones get stuck in the ducts that lead from your gallbladder to your small intestines through your pancreas), cholecystitis (inflammation of gallbladder), cholangitis (inflammation in your bile ducts). Review of the resident's hospital discharge orders, dated 10/10/24, showed the following: -Cleanse around biliary drain tube (catheter through the skin and into the bile ducts) with normal saline, pat dry, and apply dry sponge dressing daily and as needed (PRN); -Cleanse around the gastrostomy tube (g-tube; a tube inserted through the belly that brings nutrition directly to the stomach) with normal saline, pat dry, and apply drain sponge daily and PRN. Review of the resident's Physician Orders, dated 10/10/24 to 10/28/24, showed the following: -No documentation of an order to cleanse around biliary drain tube with normal saline, pat dry, and apply dry sponge dressing daily and PRN; -No orders to cleanse around the g-tube with normal saline, pat dry, and apply drain sponge daily and PRN. Review of the resident's Treatment Administration Record (TAR), dated 10/10/24 to 10/27/24, showed the following: -No documentation of an order to cleanse around biliary drain tube with normal saline, pat dry, and apply dry sponge dressing daily and PRN; -No orders to cleanse around the g-tube with normal saline, pat dry, and apply drain sponge daily and PRN. Review of the resident's admission Minimum Data Set (MDS), a federally mandated assessment instrument, dated 10/17/24, showed the resident's cognition was intact. Review of the resident's Care Plan, dated 10/28/24, showed the following: -He/She required a feeding tube (g-tube); -There was no documentation to show the resident had a biliary drain tube. Observation on 10/28/24 at 11:30 A.M. showed the resident had a g-tube and biliary drain tube. During an interview on 10/28/24 at 11:30 A.M., the resident said he/she had two drains (a biliary drain tube and a g-tube). Earlier that morning, staff told him/her the dressings should have been changed daily. He/She was not sure when the last time they were changed and/or how often they were supposed to be changed. When staff removed the dressings on 10/28/24, the old dressings looked like there was some drainage on them and the g-tube dressing had an odor. During an interview on 10/28/24 at 4:55 P.M., Licensed Practical Nurse (LPN) D said the following: -The resident had a g-tube and biliary drain tube; -Staff should change the dressings daily; -He/She was not sure why staff had not changed the dressings prior to today. -The DON and/or management staff enter all of the orders for all new residents. During an interview on 10/28/24 at 5:00 P.M., the DON said the resident did not have orders for dressing changes to the g-tube and biliary drain tube. After she reviewed the discharge orders, she noted the order was overlooked when transcribed and the resident should have daily dressing changes to both the g-tube and biliary drain tube. She and/or nursing management staff review and transcribe all new admission orders. She was unsure why the order was missed. MO240027 MO240225 MO241299

Based on interview and record review, the facility failed to notify the physician when two residents (Residents #1 and #2), in a review of four sampled residents, had a change in condition. The facility's census was 68. 1. Review of an email received from the facility's Director of Nursing (DON) on 11/13/24 showed the facility did not have a policy for when to notify physician. 2. Review of the Resident #1's face sheet showed the following: -He/She admitted to the facility on [DATE]; -Diagnoses included an ileus. Review of the resident's Nursing Progress Note, dated 08/01/24 at 7:04 A.M., showed the resident's physician examined the resident and reviewed medications with no new orders. Review of the resident's Physician's Progress Note, dated 08/01/24, showed the following: -The resident was admitted for rehabilitation on 07/26/24; -The resident had a history of dementia and congestive heart failure (the heart cannot pump blood well enough to give the body a normal supply) with recent hospitalization ; -The resident's abdomen was soft and nontender; -The resident had no edema; -The resident's respiratory effort was normal; -Continue to monitor and assess for health status changes and contact physician with any changes. Review of the resident's Progress Notes, dated 08/01/24 at 4:01 P.M., showed staff had increased concerns with the resident's confusion and abdominal distension. (Review showed no documentation staff notified the resident's physician of the resident's increased confusion and/or abdominal distention.) Review of the resident's Progress Note, dated 08/01/24 at 4:38 P.M., showed staff notified the resident's family of the resident's decline in condition from previous note with increased labored breathing, abdominal distension, and edema. (Review showed no documentation staff notified the resident's physician of the resident's change in condition.) Review of the resident's Skilled Nursing Assessment, dated 08/02/24 at 1:45 A.M., showed the following: -The resident had difficulty concentrating and was anxious; -His/Her abdomen was swollen and distended. Review of the resident's Progress Note, dated 08/02/24 at 1:52 A.M., showed the resident continued to have confusion. Review of the resident's medical record showed no documentation staff notified the resident's physician of the resident's increased confusion and abdominal distention on 08/02/24. Review of the resident's Skilled Nursing Assessment, dated 08/03/24 at 3:43 P.M., showed the resident had edema in his/her abdomen. Review of the resident's Progress Note, dated 08/03/24 at 3:43 P.M., showed the resident had edema in his/her abdomen. (Review showed no documentation staff notified the resident's physician of the resident's abdominal edema on 08/03/24.) Review of the resident's Skilled Nursing Assessment, dated 08/04/24 at 6:36 A.M., showed the resident had edema in his/her abdomen. Review of the resident's Progress Note, dated 08/04/24 at 5:07 P.M., showed the following: -Lab (Potassium level 3.0 milliequivalents per liter (mEq/L)) (the normal range for potassium is between 3.5 and 5.2 mEq/L) reported to the resident's physician and orders obtained for potassium chloride 40 mEq by mouth three times a day and repeat BMP on 08/08/24; -The resident's family was not pleased with the orders and came to transport the resident to the hospital for further treatment. During an interview on 10/28/24 at 1:35 P.M., the Director of Nursing (DON) said she expected staff to notify the resident's physician with any changes in the resident's condition and document the notification in the resident's medical record. During an interview on 10/31/24, Registered Nurse (RN) A said the following: -He/She thought the physician was aware of the resident's change in condition; -If he/she notified the physician, he/she should document the physician notification in the resident's electronic medical record. During an interview on 11/06/24 at 10:00 A.M., the resident's physician said the following: -He saw the resident on 08/01/24 and didn't note any significant changes that warranted further evaluation; -He did not recall staff notifying him/her of the resident's change in condition; -He expected staff to notify him of any changes in the resident's condition. 3. Review of Resident' #2's care plan, last revised on 05/13/24, showed the resident exhibited behavioral symptoms (tells everyone that someone stole his/her stuff) regarding misplaced wallet, personal items, and family pictures. Review of the resident's Progress Note, dated 08/01/24 at 7:06 A.M., showed the resident's physician assessed the resident and ordered a repeat UA specimen to be obtained. Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment to be completed by the facility, dated 08/02/24, showed the following: -His/Her cognition was severely impaired; -He/She had delusional behaviors; -He/She was physically and verbally aggressive towards others daily; -He/She had other behaviors that were not directed towards others four to six days of the previous seven-day look back period. Review of the resident's Progress Note for Behavioral Monitoring, dated 08/02/24 at 4:37 P.M., showed the resident exhibited verbal outbursts, wandering, agitation, and restlessness. Review of the resident's medical record showed no documentation staff notified the resident's physician of the resident's behaviors on 08/02/24. Review of the resident's progress note, dated 08/03/24 at 3:37 P.M., showed the resident's behaviors included restlessness, pacing, rummaging, and wandering. Review of the resident's Progress Note, dated 08/04/24 at 11:57 A.M., showed the resident displayed verbal outbursts, exit seeking, and increased paranoia. Review of the resident's Progress Note, dated 08/04/24 at 12:47 P.M., showed the resident experienced hallucinations, increased agitation, and paranoia due to previous diagnosis of UTI and was sent to the hospital for evaluation. Review of the resident's medical record showed no documentation staff obtained the UA as ordered on 08/01/24, and no documentation to show staff notified the resident's physician that the UA was not obtained. Review of the resident's progress note, dated 08/04/24 at 4:12 P.M., showed the resident was admitted to the hospital for confusion and urine issues. During an interview on 10/30/24 at 9:50 A.M., Licensed Practical Nurse (LPN) B said the following: -The resident's cognition declined, and the resident showed increased confusion, anxiety, agitation, and hallucinations; -The resident refused cares which should have been documented in the resident's electronic medical record; -Staff should have notified the resident's physician of the resident's increased behaviors and refusal of care/treatment; -He/She thought the resident's physician was aware, but was not 100% sure; -Staff should document when they notify the physician in the resident's electronic medical record. During an interview on 10/31/24 at 8:49 A.M., RN A said the following: -Staff should notify the resident's physician when a resident refused care and treatments; -Staff should document the physician notification in the resident's electronic medical record. During an interview on 11/12/24 at 11:10 A.M., the DON said the following: -Staff notified the resident's physician of increased behaviors on 8/1/24 and obtained an order for a UA; -Staff were unable to obtain the urine specimen for the UA due to resident's incontinence, and staff were not able to straight cath the resident because the resident was delusional and thought staff were trying to harm him/her. (Review of the resident's medical record showed no documentation staff attempted to obtain a urine sample.) -She expected staff to notify the physician of the resident's refusal and inability to obtain the urine specimen, and document in the resident's electronic medical record. During an interview on 11/06/24 at 10:00 A.M., the resident's physician said the following: -He expected staff to notify him/her when the resident refused care/treatment; -He did not recall staff notifying him/her about the inability to obtain the repeat UA. MO240027 MO240225 MO 241299

Based on observation, interview, record review, and review of facility policy, the facility failed to ensure a physician's order was obtained to continue an indwelling urinary catheter for one resident of two residents (Resident (R) 19) reviewed for catheters. Findings include: Review of R19's undated Face Sheet from the Face Sheet section of the Resident tab of the electronic medical record (EMR) revealed R19's relevant diagnoses included urinary tract infection; chronic kidney disease, stage 3, and retention of urine. Review of the Census section of the Resident tab in the EMR revealed R19 was initially admitted to the facility on [DATE]. R19 most recently discharged from the facility to the hospital on 02/29/24 and readmitted to the facility on [DATE]. Review of R19's Progress Notes section of the Resident tab in the EMR revealed on 03/01/24 at 2:24 AM, R19 returned from the emergency room with an indwelling foley catheter placed and instructions to retain catheter until treating physician decides on removal. Review of R19's Care Plan located in the EMR under the Care Plan section of the RAI [Resident Assessment Instrument] revealed, a Care Plan started on 03/01/24 for the problem [R19] requires an indwelling urinary catheter [related to] [urinary tract infections]/inability to urinate on own. Approaches included change catheter per [physician] order. During an observation on 03/11/24 at 10:26 AM, R19 was seated in his/her recliner in his room. R19's catheter was observed to be draining clear urine and secured to his/her leg, with the collection bag in a dignity pouch. During an interview on 03/12/24 at 2:00 PM, Certified Medication Technician (CMT) 1 stated R19 had the catheter placed during his/her most recent hospitalization . CMT1 stated R19 had problems with urinary retention and quickly developed urinary tract infection without his/her catheter. During an interview on 03/13/24 at 10:03 AM, the Assistant Director of Nursing (ADON) stated R19 had a catheter because he/she had issues with urinary retention. The ADON stated R19 did not like having a catheter and believed staff where waiting on the in-house practitioner for approval to remove the catheter. During an interview on 03/13/24 at 2:30 PM, the Director of Nursing (DON) stated R19's catheter was placed during his/her most recent hospitalization . The DON stated the hospital discharge instruction stated it was up to the primary care physician to continue the catheter. The DON stated R19 gets tired of the catheter and does void without it, however he/she does not fully empty his bladder and he/she does not recognize that. The DON stated the plan was for the Physician to review the catheter tomorrow with R19, with the goal of R19 keeping the catheter. The DON reviewed R19's current physician orders in the EMR and confirmed there were no current orders for R19's catheter. Review of the facility policy, Indwelling Catheter Justification and Removal, dated November 2019, revealed the procedure stated The admitting nurse will obtain the following from the physician. a. An order to change the catheter as needed for blockage b. Supporting diagnosis for catheter use c. Orders to perform catheter care each shift d. Orders to irrigate the catheter as needed for occlusion or blockage e. Order to change catheter to obtain urinalysis when catheter has been in place greater than 14 days.

Based on interview, record review, and facility policy review, the facility failed to ensure the Attending Physician for one of five residents (Resident (R) 41) reviewed for unnecessary medications provided a rationale for not following the Consultant Pharmacist's recommendation related to an anti-anxiety medication that was ordered as needed (PRN) without a stop date. This had the potential for the resident being administered medication unnecessarily. Findings include: Review of the undated facility policy titled Drug Regimen Review Policy stated .5. Each resident's primary care physician must respond to consult reports within 10 business days. If this is not followed, the medical director will be consulted for further intervention.7. If PCP (primary care provider) does not wish to make change as recommended on a pharmacist consult report, they will be required to document their rationale as to why, on the report. Review of R41's medications located in the electronic medical record (EMR) under the Resident Documents tab revealed an order dated 02/06/24 for lorazepam 0.5 milligrams (mg) every four hours PRN for anxiety. Review of the Consultant Pharmacist Recommendation located in the EMR under the Resident Documents tab dated 02/06/24 revealed the pharmacist advised the Attending Physician that PRN psychotropic medications were limited to 14 days, and the doctor should reassess the need for the medication even in a hospice resident. The Attending Physician signed the recommendation and indicated he disagreed with the recommendation but did not write a rationale explaining why he disagreed. During an interview with the Director of Nursing (DON) on 03/13/24 at 12:20 PM she stated the Attending Physician almost never wrote a rationale when he disagrees with the consultant pharmacist's recommendations. She stated she had spoken to him numerous times with no luck. She had also requested the Medical Director speak to him. During a telephone interview with the Attending Physician on 03/14/24 at 10:50 AM he stated he gets these [pharmacy recommendations] all day long and doesn't have time to write a rationale.

Based on observation, interview, and record review, the facility failed to use appropriate infection control procedures to prevent or reduce the risk of spreading the virus [CONDITION(S)]-CoV-2, (a coronavirus discovered in 2019), which causes COVID-19 infection (an infectious disease caused by severe acute respiratory syndrome), when the facility failed to separate five residents (Residents #2, #9, #11, #14, and #16), who tested negative for COVID-19, from their roommates (Residents #1, #8, #12, #13, and #15), who tested positive for COVID-19 infection. The facility also failed to ensure two residents (Residents #4 and #16), did not share a bathroom with two residents (Resident #2 and #5) who had tested positive for COVID-19, and failed to social distance or separate two COVID-19 positive residents (Residents #8 and #28) from two COVID-19 negative residents (Resident #20 and #29) from each other when the facility allowed residents to eat meals together in the community dining room, unmasked and at tables together. Further interview showed staff donned (put on) personal protective equipment (PPE) such as gowns, upon coming to work, and did not doff (take off) them between cares with COVID-19 positive and negative residents, doffing and reapplying only when going on break or leaving the facility. Additionally, the facility failed to monitor/assess seven residents (Resident #1, #2, #9, #11, #12, #15, and #16) for COVID-19 signs and symptoms. During the on-site visit, the facility said they had been in an outbreak testing since 6/24/22 and the facility currently identified eleven residents who tested positive for COVID-19. The facility census was 75. The administrator was notified on 8/10/22 of the Immediate Jeopardy (IJ), which began on 7/25/22. The IJ was removed on 8/10/22, as confirmed by surveyor onsite verification. Review of the Centers for Disease Control and Prevention's (CDC) Interim Infection Prevention and Control Recommendations to Prevent [CONDITION(S)]-CoV-2 Spread in Nursing Homes, updated 02/02/22, showed the following: -Older adults living in congregate settings are at high risk of being affected by respiratory and other pathogens, such as [CONDITION(S)]-CoV-2 (the pathogen that causes COVID-19 infection); -Even as nursing homes resume normal practices, they must sustain core infection prevention and control (IPC) practices and remain vigilant for [CONDITION(S)]-CoV-2 infection among residents and health care personnel (HCP) in order to prevent spread and protect residents and HCP from severe infections, hospitalization s, and death; -Actively monitor all residents at least daily for fever (temperature greater to or equal to 100 degrees Fahrenheit) and symptoms consistent with COVID-19. Ideally, include an assessment of oxygen saturations via pulse oximetry (a test to monitor the level of oxygen in the blood); -In response to a newly identified [CONDITION(S)]-CoV-2 infected health care provider or resident (an outbreak), consider increasing the monitoring for all residents from daily to every shift to more rapidly detect those with new symptoms. Increase monitoring of residents with suspected or confirmed [CONDITION(S)]-CoV-2 infection, including assessment of symptoms, vital signs, oxygen saturation via pulse oximetry, and respiratory exam, to identify and quickly manage serious infection. -Identify space in the facility that could be dedicated to monitor and care for residents with confirmed [CONDITION(S)]-CoV-2 infection; -The location of the COVID-19 care unit should ideally be physically separated from other rooms or units housing residents without confirmed [CONDITION(S)]-CoV-2 infection. This could be a dedicated floor, unit, or wing in the facility or a group of rooms at the end of the unit that will be used to cohort residents with [CONDITION(S)]-CoV-2 infection; -Ideally, a resident with suspected [CONDITION(S)]-CoV-2 infection should be moved to a single-person room with a private bathroom while test results are pending; -If limited single rooms are available, or if numerous residents are simultaneously identified to have known [CONDITION(S)]-CoV-2 exposures or symptoms concerning for COVID-19, residents should remain in their current location pending return of test results; -Residents should only be placed in a COVID-19 care unit if they have confirmed [CONDITION(S)]-CoV-2 infection. -Roommates of residents with [CONDITION(S)]-CoV-2 infection should be managed as described in Section: Manage Residents who have had Close Contact with Someone with [CONDITION(S)]-CoV-2 Infection; -Manage Residents who had Close Contact with Someone with [CONDITION(S)]-CoV-2 Infection: -Residents who are not up to date with all recommended COVID-19 vaccine doses and who have had close contact with someone with [CONDITION(S)]-CoV-2 infection should be placed in quarantine after their exposure, even if [CONDITION(S)] testing is negative. HCP caring for them should use full PPE (gowns, gloves, eye protection, and N95 or higher-level respirator). -Residents who are up to date with all recommended COVID-19 vaccine doses and residents who have recovered from [CONDITION(S)]-CoV-2 infection in the prior 90 days who have had close contact with someone with [CONDITION(S)]-CoV-2 infection should wear source control and be tested as described in the testing section. In general, these residents do not need to be quarantined, restricted to their room, or cared for by HCP using the full PPE recommended for the care of a resident with [CONDITION(S)]-CoV-2 infection unless they develop symptoms of COVID-19, are diagnosed with [CONDITION(S)]-CoV-2 infection, or the facility is directed to do so by the jurisdiction's public health authority. Quarantine might also be considered if the resident is moderately to severely immunocompromised. Review of the CDC Infection Control for Nursing Homes, Recommended Infection Prevention and Control (IPC) practices when caring for a patient with suspected or confirmed [CONDITION(S)]-CoV-2 infection, updated 02/02/22, showed the following: -The IPC recommendations described below also apply to patients with symptoms of COVID-19 (even before results of diagnostic testing) and asymptomatic patients who have met the criteria for empiric Transmission-Based Precautions (quarantine) based on close contact with someone with [CONDITION(S)]-CoV-2 infection. However, these patients should NOT be cohorted with patients with confirmed [CONDITION(S)]-CoV-2 infection unless they are confirmed to have [CONDITION(S)]-CoV-2 infection through testing; -Place a patient with suspected or confirmed [CONDITION(S)]-CoV-2 infection in a single-person room. The door should be kept closed (if safe to do so). The patient should have a dedicated bathroom; -Only patients with the same respiratory pathogen should be housed in the same room; -In general, it is recommended that the door to the room remain closed to reduce transmission of [CONDITION(S)]-CoV-2. This is especially important for residents with suspected or confirmed [CONDITION(S)]-CoV-2 infection being cared for outside of the COVID-19 care unit. However, in some circumstances (e.g., memory care units), keeping the door closed may pose resident safety risks and the door might need to remain open. If doors must remain open, work with facility engineers to implement strategies to minimize airflow into the hallway. Review of a facility policy titled, ISOLATION AND QUARANTINE RESIDENTS, dated 2/4/22, showed the following: 1. CLOSE CONTACT (day of contact is day O); a. VACCINATED AND BOOSTER; i. No quarantine; ii. Wear surgical mask when out of room; iii. Test accordingly; iv. Place in quarantine and retest if symptoms appear b. UNVACCINATED OR VACCINATED BUT NO BOOSTER i. Place in quarantine immediately ii. Follow testing procedures iii. May be removed from quarantine after seven days with a negative test iv. May be removed from quarantine after ten days if no symptoms appear 2. POSITIVE COVID TEST (day of test is day 0) a. Vaccination status does not matter b. Can remove from isolation with: i. Fever free x 24 hours without fever reducing medications ii. Two consecutive negative tests at least 24 hours apart 3. NEW ADMISSIONS a. WITH COVID-19 i. Place in isolation until ten days have passed from positive test with day of testing being day 0 b. WITHOUT COVID-19 i. UNVACCINATED OR VACCINATED WITH NO BOOSTER A. Place in quarantine x 14 days with admitted being day O B. Monitor for symptoms x 14 days C. Offer vaccination ii. VACCINATED AND HAVE BOOSTER A. No quarantine necessary B. Monitor for symptoms x 14 days 4. RESIDENTS WHO LEAVE THE FACILITY FOR> 24 HOURS a. VACCINATED AND BOOSTER i. Encourage to wear mask and social distance while out ii. Educate families to wear mask and social distance iii. Do not need tested b. UNVACCINATED OR VACCINATED AND NO BOOSTER i. Encourage to wear mask and social distance while out ii. Educate families to wear mask and social distance iii. Test upon entrance into the facility iv. Test again day 5-7 (with day of return being day 0) Review of the facility policy, titled Personal Protective Equipment Policy and procedure, dated March 2022, showed PPE to be worn per CDC recommendations. Review of the Centers for Disease Control and Prevention's (CDC) Interim Infection Prevention and Control Recommendations to Prevent [CONDITION(S)]-CoV-2 Spread in Nursing Homes, updated 02/02/22, showed the following: -Manage Residents with Suspected or Confirmed [CONDITION(S)]-CoV-2 Infection --Healthcare Personnel (HCP) caring for residents with suspected or confirmed [CONDITION(S)]-CoV-2 infection should use full PPE (gowns, gloves, eye protection, and a NIOSH-approved N95 or equivalent or higher-level respirator). Review of the Centers for Disease Control and Prevention's Strategies for Optimizing the Supply of Isolation Gowns, updated Jan. 21, 2021 showed the following: Crisis Capacity Strategies- --Extended use of isolation gowns. Consideration can be made to extend the use of isolation gowns (disposable or reusable) such that the same gown is worn by the same HCP when interacting with more than one patient housed in the same location and known to be infected with the same infectious disease (i.e., COVID-19 patients residing in an isolation cohort). However, this can be considered only if there are no additional co-infectious diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . If the gown becomes visibly soiled, it must be removed and discarded or changed as per usual practices. --Re-use of isolation gowns. The risks to HCP and patient safety must be carefully considered before implementing a gown reuse strategy. Disposable gowns generally should NOT be re-used, and reusable gowns should NOT be reused before laundering, because reuse poses risks for possible transmission among HCP and patients that likely outweigh any potential benefits. Similar to extended gown use, gown reuse has the potential to facilitate transmission of organisms (e.g., C. auris) among patients. However, unlike extended use, repeatedly donning and doffing a contaminated gown may increase risk for HCP self-contamination. If reuse is considered, gowns should be dedicated to care of individual patients. 1. Observation of the facility's East Wing on 8/10/22 at 4:30 P.M. showed it was not closed off from the rest of the facility. There was no signage that indicated the area was a COVID unit. 2. Review of Resident #8's undated face sheet showed his/her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the resident's COVID-19 test, dated 8/9/22, showed the resident tested positive for COVID-19. 3. Review of Resident #9's undated face sheet showed his/her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of resident's immunization history showed he/she refused COVID-19 vaccination series. Observation on 8/10/22 at 4:30 P.M. showed the resident's bed was by the window. Resident #8's (COVID-19 positive resident) bed was by the door. The curtain was pulled between the two beds. There were no bedside commodes located in the room. The door to the room was open. There was no sign on the door to indicate Resident #8 was positive for COVID-19. There was no personal protective equipment (PPE) located outside of the resident's room. Review of resident's preventative health documentation showed the resident tested negative for COVID-19 on 7/28/22, 7/31/22, 8/3/22, and 8/6/22. There was no documentation to show the facility tested the resident on 8/9/22. (The resident's roommate, Resident #8, tested positive for COVID-19 on 8/9/22.) Review of the resident's care plan dated 4/25/22 showed no documentation to include increased monitoring or additional precautions to protect the resident from COVID-19 infection, after staff left the resident in room with a COVID-19 positive resident on 8/9/22. 4. Review of Resident #4's face sheet showed his/her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] -Acute respiratory failure; -Pneumonia due to [CONDITION(S)] associated coronavirus; -[CONDITION(S)]; -Diabetes. Review of the resident's immunization history showed he/she refused COVID-19 vaccination series on 3/9/21. Review of the resident's quarterly MDS, dated [DATE], showed the following: -He/She was independent with toilet use; -He/She was always continent of bowel and bladder; -He/She was steady at all times on and off the toilet. Review of the resident's COVID-19 testing for 8/3/22 and 8/6/22 showed the resident's test result was negative. Review of the facility resident room roster on 8/10/22 showed the resident resided in room [ROOM NUMBER]. Observation on 8/10/22 at 5:00 P.M. showed room [ROOM NUMBER] shared a bathroom with room [ROOM NUMBER] (a room where a COVID-19 positive resident resided). There were no bedside commode located in the room. This COVID-19 negative resident shared a bathroom with a COVID-19 positive resident. 5. Review of Resident #5's face sheet showed his/her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] -Diabetes; -[CONDITION(S)]. Review of the resident's admission MDS, dated [DATE], showed the following: -He/She required extensive assistance with toileting; -He/She was frequently incontinent of bowel and bladder; -He/She was not steady moving on and off the toilet and required staff assistance for stabilization. Review of the resident's COVID-19 testing for 8/3/22 and 8/6/22 showed the resident's test results were positive. Review of the facility resident room roster on 8/10/22 showed the resident resided in room [ROOM NUMBER]. Observation on 8/10/22 at 5:00 P.M. showed room [ROOM NUMBER] shared a bathroom with room [ROOM NUMBER]. There was no bedside commode located in the room. The door to the room was open. There was no personal protective equipment (PPE) located outside of resident's room. This COVID-19 positive resident shared a bathroom with a COVID-19 negative resident (#4) and his/her room had no available PPE outside the room or containers for dirty disposal. 6. Review of Resident #13's face sheet showed his/her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] -Dementia; -Acute respiratory disease. Review of the resident's preventative health documentation showed the resident tested positive for COVID-19 on 7/30/22. 7. Review of Resident #14's face sheet showed his/her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] -Heart failure; -Diabetes. Review of the facility resident room roster showed the resident resided in a room with Resident #13 (who tested COVID-19 positive on 7/30/22 and was not moved out of the shared room). Review of the resident's preventative health documentation showed the resident (Resident #14) tested negative for COVID-19 on 7/31/22. Review of the resident's facility progress notes showed staff documented on 8/10/22 at 8:30 A.M., the resident (Resident #14) tested positive for COVID-19 on 8/9/22. Observation on 8/10/22 at 5:02 P.M. showed the door to the room was open. There was no sign on the door to indicate a resident was on isolation. There was no PPE located outside of resident's room. 8. Review of Resident #20's face sheet showed his/her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] -Alzheimer's dementia; -Heart failure; -Anxiety disorder. Review of resident's preventative health documentation showed the resident tested negative for COVID-19 on 7/28/22, 7/31/22, 8/3/22 and 8/6/22. Observation on 8/10/22 at 5:00 P.M. showed Resident #20 (a COVID-19 negative resident) sat at the dining room table in the community dining room for the evening meal with Resident #8 (a COVID-19 positive resident). There was no social distancing and residents were not wearing masks. 9. Review of Resident #28's significant change MDS, dated [DATE], showed his/her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] -Anemia; -Diabetes; -High blood pressure. Review of resident's preventative health documentation showed resident tested positive for COVID-19 on 8/5/22. 10. Review of Resident #29's face sheet showed his/her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] -Anxiety; -High blood pressure. Review of resident's preventative health documentation showed resident tested negative for COVID-19 on 8/3/22 and 8/6/22. Observation on 8/10/22 at 5:00 P.M. showed Resident #29 (a COVID-19 negative resident) sat at the dining room table in the community dining room for the evening meal with Resident #28 (a COVID-19 positive resident). There was no social distancing and residents were not wearing masks. 11. Review of Resident #1's face sheet showed his/her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the resident's COVID-19 testing log, dated 7/28/22, showed the resident tested positive for COVID-19. Review of the resident's progress notes, dated 7/29/22, showed the resident with intermittent productive cough, denied pain or shortness of air. The resident continued on COVID-19 monitoring. Remained in isolation and stayed in room for all activities and meals. Review of the resident's progress notes, dated 7/30/22, showed the resident remained in isolation with full personal protective equipment due to active COVID-19 infection. All activities, meals, and therapies completed in the resident's room. Review of the resident's COVID-19 testing log, dated 7/31/22, showed the resident tested negative for COVID-19. Review of the resident's COVID-19 testing log, dated 8/3/22, showed the resident tested positive for COVID-19. Review of the resident's medical record showed no documented assessment for signs and symptoms of COVID-19. 12. Review of Resident #2's face sheet showed the resident's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the resident's preventative health documentation showed on 7/28/22, the resident tested negative for COVID-19. Review of Resident #1's (Resident #2's roommate) COVID-19 testing log, dated 7/28/22, showed the resident tested positive for COVID-19. Review of the resident's care plan showed no updated documentation to include increased monitoring or additional precautions to protect the resident from COVID-19 infection, after staff left the resident in the room with a COVID-19 positive resident on 7/28/22. Review of the resident's preventative health documentation showed on 7/31/22, the resident tested negative for COVID-19. Review of the resident's preventative health documentation showed on 8/3/22, the resident tested positive for COVID-19. Review of the resident's progress notes showed no documentation the resident was separated from his/her roommate who tested positive for COVID-19 on 7/28/22. There was no documentation to show staff monitored the resident for signs and symptoms of COVID-19. During interview on 8/10/22 at 7:15 P.M., the resident's family member said he/she was notified when the resident tested positive. He/She knew the resident's roommate and the resident who shared the bathroom with Resident #2 (Resident #15) tested positive, because the resident called and told him/her. The family member said Resident #2 wasn't moved after his/her roommate, Resident #1 tested positive for COVID-19. Observation on 8/10/22 at 4:16 P.M., showed a sign posted outside the resident's room noting contact and droplet precautions, however, there was no PPE present outside the room. The resident and his/her roommate, Resident #1, were in the room. The door to the room was open. Further observation showed Resident #2 shared a bathroom with Resident #16 (a negative resident). 13. Review of Resident #15's face sheet showed his/her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the resident's annual MDS, dated [DATE], showed the following: -He/She was independent with ADLs, including toileting; -He/She was always continent of bladder and bowel. Review of the resident's progress notes, dated 7/25/22, showed the resident tested positive for COVID-19 that morning during outbreak testing. Review of the resident's progress notes, dated 7/30/22, showed the resident remained in isolation with full personal protective equipment due to active COVID-19 infection. No respiratory distress. All activities, meals, and therapies completed in resident's room. Review of the resident's medical record showed no documentation of assessment for signs and symptoms of COVID-19. 14. Review of Resident #16's face sheet showed the resident had a responsible party and diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the resident's vaccine record showed the following: -He/She received the COVID-19 vaccine on 1/9/21; -He/She received the COVID-19 vaccine on 2/6/21; -He/She received the COVID-19 booster on 3/30/22. Review of the resident's progress notes, dated 7/25/22, showed the facility placed the resident on isolation in the morning due to his/her roommate tested positive for COVID-19 during outbreak testing. Review of the Resident #15's (Resident #16's roommate) resident's progress notes, dated 7/25/22, showed the resident tested positive for COVID-19 that morning during outbreak testing. Review of the resident's progressive health care document showed the resident was tested for COVID-19 on 7/28/22, 7/31/22, 8/3/22 and 8/6/22. The resident tested negative on all the listed test dates. Review of the resident's progress notes showed no documentation the resident was separated from his/her roommate who tested positive for COVID-19 on 7/25/22. There was no documentation to show staff monitored the resident for signs and symptoms of COVID-19. 15. Review of Resident #11's face sheet showed his/her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the resident's vaccine record showed the following: -He/She received the COVID-19 vaccine on 7/27/21; -He/She received the COVID-19 vaccine on 8/31/21. Review of the resident's preventative health documentation showed the resident tested negative for COVID-19 on 7/28/22. Review of the Resident #12's (Resident #11's roommate) COVID-19 testing log, dated 7/30/22, showed the resident tested positive for COVID-19. Review of the resident's preventative health documentation showed the resident tested negative for COVID-19 on 7/31/22. Review of the resident's preventative health documentation showed the resident tested positive for COVID-19 on 8/3/22. Review of the resident's progress notes showed no documentation the resident was separated from his/her roommate who tested positive for COVID-19 on 7/30/22. There was no documentation to show staff monitored the resident for signs and symptoms of COVID-19. Review of the resident's care plan showed no updated documentation to include increased monitoring or additional precautions to protect the resident from COVID-19 infection, after staff left the resident in a room with a COVID-19 positive resident on 7/30/22. 16. Review of Resident #12's face sheet showed his/her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . (The resident's roommate (Resident #11) tested negative for COVID-19 on 7/28/22). Review of the resident's COVID-19 testing log, dated 7/30/22, showed the resident tested positive for COVID-19. Review of the resident's progress notes, dated 7/31/22 at 6:06 A.M., showed the resident tested positive for COVID-19 on rapid test. He/She was asymptomatic and placed on contact/droplet isolation per facility policy. Review of the resident's COVID-19 testing log, dated 8/3/22, showed the resident tested positive for COVID-19. Review of the resident's medical record showed no documented assessment for signs and symptoms of COVID-19. 17. During an interview on 8/10/22 at 3:45 P.M., Certified Nurse Assistant (CNA) B said residents who tested positive for COVID-19 had been left in rooms with residents who tested negative for COVID-19 due to exposure. He/She was unsure which residents were positive for COVID-19. There was usually a sign outside the resident's door that alerted staff of the resident testing positive for COVID-19, but right now the entire hall was quarantined and PPE (gowns, N95 respirator masks, and face shields) was used on all residents residing on the hall whether they were positive or negative. He/She wore the same gown when assisting all residents. He/She only changed his/her gown when he/she left the area (area where all of the residents who tested positive, had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . All residents whether they were positive or negative for COVID-19 were dining in the main dining room. During an interview on 8/10/22 at 4:25 P.M., Licensed Practical Nurse (LPN) C said residents who had tested positive for COVID-19 were not quarantined to their rooms. There had been residents who tested positive for COVID-19 in the same room with residents who had tested negative for COVID-19, but he/she didn't think there were any at the current time. Residents who tested positive for COVID-19 could eat in the dining room with residents who tested negative for COVID-19. During an interview on 8/1/22 at 2:45 P.M. the director of nursing (DON) said facility was in a COVID-19 outbreak. There were no residents that tested positive until 7/11/22 and they were all in the same area. There were a lot more residents who tested positive on 7/30/22, and three more on 8/9/22. Staff tried to quarantine residents to their room, but could not keep them in their rooms. When there were so many positive COVID-19 residents, the east wing was made a COVID unit because all of the residents in this area were either currently positive for COVID, previously tested positive for COVID, or had been exposed to someone who had tested positive for COVID. The facility did not have enough staff to feed 30 residents in their rooms and ensure they were clean and dry, so all residents were coming out of their rooms for meals whether they were positive or negative for COVID-19. She would like for all residents to wear masks if they would, but staff could not make them. All of the residents on the East hall were either positive for COVID-19/or were exposed to COVID-19. Those residents who tested negative for COVID-19 sat with residents who were positive for COVID-19 because they had been exposed to the virus. She understood residents could not be moved because of state guidance. COVID-19 positive residents were in the same rooms with COVID-19 negative residents and shared bathrooms. Staff were expected to use a N95 respirator mask, face shield, and gown when caring for residents on the East hall. Staff were only required to change their gowns when they were soiled and if staff left the unit. Staff could potentially provide care for COVID-19 negative residents while wearing the same gowns they wore when providing care to COVID-19 positive residents. During an interview on 8/10/22 at 6:30 P.M., the administrator said the outbreak of residents that tested positive for COVID-19 was too large for the facility to be able to put them all on one unit. They had viewed all of the residents either positive or exposed, so having them all together was the best they could do. During an interview on 8/26/22 at 3:24 P.M., the administrator said the following: -In the beginning of COVID-19, the facility had a designated area that could be used as a COVID-19 positive only wing and they had used the unit (a unit for residents with dementia) and the East wing in the past, with the fire doors shut, because there had been lesser numbers of COVID-19 positive residents; -With the larger number of COVID-19 positive residents, there was just no way to move all the residents, keeping them all together and away from those residents that tested negative for COVID-19; -At that time, the residents on the unit (a unit for residents with dementia) had all tested negative, so COVID-19 positive residents could not be moved to the unit; -Residents on the unit (a unit for residents with dementia) could not be moved off the unit to be able to place all of the COVID-19 positive residents on the unit because the residents on the unit had dementia and were on a secure unit, so moving them off of the unit would not be safe; -The West wing of the facility was empty and had been closed for over a year; COVID-19 positive residents could not be moved to this wing because the call light system only functioned at the West wing nursing station and she did not have staff to designated to just the West wing. NOTE: At the time of the abbreviated survey, the violation was determined to be at the immediate jeopardy level K. Based on observation, interview and record review completed during the onsite visit, it was determined the facility had implemented corrective action to remove the IJ violation at the time. A final revisit will be conducted to determine if the facility is in substantial compliance with participation requirements. At the time of exit, the severity of the deficiency was lowered to the E level. This statement does not denote that the facility has complied with State law (Section 198.026.1 RSMo.) MO 310

Based on observation, interview and record review the facility failed to develop a comprehensive care plan for four residents (Residents #6, #13, #42 and #173). The facility did not address or include interventions for the following: Resident #6 was a smoker, resident #13 utilized oxygen therapy, resident #42's pain or resident #172's pressure ulcers and presence of a wound vac. The facility census was 70. 1. During interview on 4/28/22 at 2:08 P.M., the Director of Nurses (DON) said the facility did not have a policy for updating care plans. Review of the Centers for Medicare and Medicaid Services (CMS), Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual, Version 1.17.1, Chapter 4, revised October 2019, showed the following: -The care plan is driven not only by identified resident issues and/or conditions but also by a resident's unique characteristics, strengths, and needs; -A care plan that is based on a thorough assessment, effective clinical decision making, and is compatible with current standards of clinical practice can provide a strong basis for optimal approaches to quality of care and quality of life needs of individual residents; -A well developed and executed assessment and care plan: 1. Looks at each resident as a whole human being with unique characteristics and strengths; 2. Views the resident in distinct functional areas for the purpose of gaining knowledge about the resident's functional status (MDS); 3. Gives the IDT a common understanding of the resident; 4. Re-groups the information gathered to identify possible issues and/or conditions that the resident may have (i.e., triggers); 5. Provides additional clarity of potential issues and/or conditions by looking at possible causes and risks (CAA process); 6. Develops and implements an interdisciplinary care plan based on the assessment information gathered throughout the RAI process, with necessary monitoring and follow- up; 7. Reflects the resident's/resident representative's input, goals, and desired outcomes; 8. Provides information regarding how the causes and risks associated with issues and/or conditions can be addressed to provide for a resident's highest practicable level of well- being (care planning); 9. Re-evaluates the resident's status at prescribed intervals (i.e., quarterly, annually, or if a significant change in status occurs) using the RAI and then modifies the individualized care plan as appropriate and necessary; 10. Reviews and revises the current care plan. 2. Review of Resident #173's face sheet showed he/she was admitted to the facility on [DATE] with a readmitted [DATE]. Review of Resident #173's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] -diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling) pressure ulcer to the sacral region; -Prosource 30 milliliters (ml) by mouth two times daily for wound healing; -Cleanse genitalia with wipes, pat dry and apply Triple Antibiotic Ointment (TAO) to lesion every shift. Review of the resident's admission Minimum Data Set (MDS), a federally mandated assessment instrument to be completed by the facility and dated 9/20/21 showed the following: -At risk for pressure ulcers; -One stage I (Intact skin with non-blanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have a visible blanching; in dark skin tones only it may appear with persistent blue or purple hues) pressure ulcer; -One stage IV pressure ulcer present on admission or re-entry; -One unstageable pressure ulcer. -Diabetic foot ulcer; -Ulcer care; -Non-surgical dressing other than feet; -Dressings to feet. Review of the resident's Treatment Administration Record (TAR) dated 10/1/21 showed the following: -Wound vac(vacuum-assisted closure of a wound)-change dressing three times weekly on Monday, Wednesday and Friday. Vac suction at 125 millimeters of mercury (mm)/Hg. Xerfoam (occlusive dressing which keeps air out) to exposed bone. (9/22/21-11/11/21) -Santyl ointment 250 unit/gram nickel thick daily to right plantar foot, cleanse area with cleaner, pat dry, apply nickel thick Sanytl to black/yellow tissue, cover with calcium alginate and wrap with [MEDICATION(S)]. Change daily and as needed (PRN) for soiling/dislodgement until healed. (10/27/21-11/11/21) Review of the resident's quarterly MDS, dated [DATE] showed the following: -Presence of one stage IV pressure ulcer; -Presence of one unstageable pressure ulcer; -Diabetic foot ulcer; -Ulcer care; -Non-surgical dressing other than feet; -Dressings to feet. Review of the resident's wound management report dated 12/27/21 showed the following: -Pressure ulcer to sacrum (triangular bone just below the lumbar spine) identified on 9/13/21; -Length one centimeter (cm) x width 0.8 cm x depth 3 cm. During interview on 4/28/22 at 11:30 A.M. the Assistant Director of Nursing (ADON) said the following: -He/She was the wound nurse when the resident was in the facility; -The resident was admitted with a wound vac but it was discontinued due to pain and they had tried wet to dry dressings. Review of the resident's care plan dated 9/13/21 and last reviewed/revised 10/26/21 showed it did not address the presence or treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] 3. Review of Resident #13's POS dated 4/22 showed the following: -diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] -Oxygen (02) at 2 liters per minute (LPM) per nasal cannula PRN. Observation on 4/25/22 at 8:40 A.M. showed the resident sat in a recliner in his/her room reading. The resident wore an oxygen nasal cannula attached to a concentrator. Observation on 4/25/22 at 12:10 P.M. showed the resident sat in a wheelchair at the dining table with 02 on per tank (back of chair) at 2 LPM per nasal cannula. Observation on 4/26/22 at 9:35 A.M. showed the resident sat in a recliner wearing an 02 cannula which was attached to an oxygen concentrator with humidification attached. The concentrator was set on 2 LPM. A portable 02 tank also sat close to the resident. During interview on 4/26/22 at 9:35 A.M. the resident said the following: -He/She had to wear 02 at all times; -When he/she went out or to the dining room, staff switched from the concentrator to the tank. Review of the resident's quarterly MDS dated [DATE] showed the resident used 02 while a resident. Review of the resident's current care plan, initially dated 2/15/22 showed it did not address the resident's use of oxygen. 4. Review of Resident #42's the resident's POS dated 4/22 showed the following: -diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] -Tylenol 325 milligrams (mg) give two by mouth every six hours; -[MEDICATION(S)] ophthalmic drops (used to treat eye inflammation and infections) 0.3-0.1% administer one drop to left eye four times daily times 14 days for eye pain; -Weight bear as tolerated to left lower extremity with boot in place. Review of the resident's significant change MDS dated [DATE] showed the resident received PRN pain medication. Review of the resident's care plan dated 3/27/22 showed it did not address pain for the resident. Interview on 4/26/22 at 2:00 P.M. showed the resident showed he/she had pain in his/her left eye and lower back at times. 5. Review of Resident #6's annual Minimum Data Set (MDS) dated [DATE] showed the following: -Extensive assist of two for transfers; -Used a wheelchair; -Limited assist of one for locomotion. Review of the resident's smoking assessment dated [DATE] showed the resident was safe with smoking but required staff supervision. During interview on 4/25/22 at 10:08 A.M. Licensed Practical Nurse (LPN) B said the resident was a smoker and staff supervised him/her outside (in the front) when he/she smoked. Review of Resident #6's current care plan, initially dated 2/4/20, showed it did not address that the resident was a smoker or provide any instruction for staff or the resident regarding safety. During interview on 4/28/22 at 1:10 P.M., the Director of Nurses (DON) said the following: -If a resident is a known smoker, it should be addressed on the care plan; -She would expect a care plan for a resident with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] -Wounds should be updated on the care plan including where it is, what it is, any treatments including a wound vac and direction for the CNAs as what to report to the nurse; -The care plan should include if a resident is on oxygen therapy.

Based on interview and record review, the facility failed to update interventions in the resident's care plan to reflect current care needs for four residents (Resident #25, #36, #43 and #67), in a review of 21 sampled residents. The facility census was 70. During interview on 4/28/22 at 2:08 P.M., the Director of Nurses (DON) said the facility did not have a policy for updating care plans. Review of the Centers for Medicare and Medicaid Services (CMS), Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual, Version 1.17.1, Chapter 4, revised October 2019, showed the following: -The care plan is driven not only by identified resident issues and/or conditions but also by a resident's unique characteristics, strengths, and needs; -A care plan that is based on a thorough assessment, effective clinical decision making, and is compatible with current standards of clinical practice can provide a strong basis for optimal approaches to quality of care and quality of life needs of individual residents; -A well developed and executed assessment and care plan: 1. Looks at each resident as a whole human being with unique characteristics and strengths; 2. Views the resident in distinct functional areas for the purpose of gaining knowledge about the resident's functional status (MDS); 3. Gives the IDT a common understanding of the resident; 4. Re-groups the information gathered to identify possible issues and/or conditions that the resident may have (i.e., triggers); 5. Provides additional clarity of potential issues and/or conditions by looking at possible causes and risks (CAA process); 6. Develops and implements an interdisciplinary care plan based on the assessment information gathered throughout the RAI process, with necessary monitoring and follow- up; 7. Reflects the resident's/resident representative's input, goals, and desired outcomes; 8. Provides information regarding how the causes and risks associated with issues and/or conditions can be addressed to provide for a resident's highest practicable level of well- being (care planning); 9. Re-evaluates the resident's status at prescribed intervals (i.e., quarterly, annually, or if a significant change in status occurs) using the RAI and then modifies the individualized care plan as appropriate and necessary; 10. Reviews and revises the current care plan. 1. Review of Resident #36's face sheet showed the resident's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the resident's nurses' notes showed on 12/30/21 he/she was readmitted to the facility and received an antibiotic for a urinary tract infection ([CONDITION(S)]). Review of the resident's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the resident's nurses' notes showed on 1/7/22, the resident was shaking and had a temperature of 101.4 (Fahrenheit not specified) - normal is 98.6 ,B/P 160/100 (normal 120/80). The resident was sent to hospital. Review of the resident's hospital discharge note, dated 1/7/22, showed the resident's urine culture positive for ESBL (enzyme found in some strains of bacteria) (normal is negative) producing E.coli (bacteria found in the intestinal tract) and proteus mirabilis (bacterium that is a frequent cause of catheter-associated urinary tract infections (CAUTIs)). Review of the resident's POS dated January 2022, showed an order on 1/10/22 for [MEDICATION(S)] (antibiotic used to treat UTIs) 250 milligrams (mg) three tablets by mouth daily for seven days for [CONDITION(S)]. Review of the resident's nurses' notes showed the following: -On 1/10/22, the resident was readmitted with an order for [MEDICAL RECORD OR PHYSICIAN ORDER] -On 1/13/22, new order to obtain straight catheter urinalysis this evening; Review of the resident's urinalysis, dated 1/14/22, showed few bacteria. Review of the resident's nurses' notes showed the following: -On 2/5/22, the resident fell and was sent to hospital; -On 02/10/22 at 1:17 P.M., the resident returned from the hospital and he/she was pleasantly confused. His/Her right leg was in a Velcro splint and he/she was bed bound for the time being. He/She had an indwelling catheter. He/she had a fractured femur. Review of the resident's POS, dated February 2022, showed the following: -Functional Capacity: Non-Weight Bearing to Right Lower Extremity. DO NOT USE HOYER LIFT Due to FEMUR FRACTURE. Bed bound until Physical Therapy determines otherwise. Review of the resident's care plan, dated 2/6/20 and last reviewed on 2/9/22, showed the following: -diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] -Provide incontinence care after each incontinent episode; -On 2/5/22 (date of resident's fall) with an intervention to frequently check on the resident while in bed; -Limited ability to transfer self related to balance; -Resident will transfer self with one to two person assistance; -No documentation of the resident's fall with a femur fracture on 2/5/22, the presence of an indwelling catheter or Velcro splint, recurrent UTIs, or how to transfer the resident. Review of the resident's POS, dated March 2022, showed on 3/4/22 the resident was admitted to hospice for [CONDITION(S)] stage four. Review of the resident's nurses notes, dated 3/04/22 showed the resident was admitted to hospice services. Review of the resident's Significant Change Minimum Data Set (MDS), a federally mandated assessment instrument required to be completed by facility staff, dated 3/8/22, showed the following: -Severely impaired cognition; -Required extensive assistance of two staff for toileting and personal hygiene; -Required extensive assistance of two staff for transfers; -Range of motion limitations on one side of the lower body; -Required an indwelling catheter; -Frequently incontinent of bowel; -No falls in the look back period; -Received hospice services. Observation on 4/26/22 at 1:44 P.M., showed two staff transferred the resident from his/her wheelchair into bed using a gait belt and a slide board. During interview on 4/27/22 at 1:22 P.M., CNA F said the resident transfers with two assist and a slide board. Review of the resident's care plan showed no documentation the resident had range of motion limitations to one side of the lower body, how to transfer the resident or that he/she received hospice services. 2. Review of Resident #67's face sheet showed diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the resident's Quarterly MDS, dated [DATE], showed the following: -Cognitively intact; -Required an indwelling urinary catheter; -diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the resident's nurses' notes showed the following: -On 03/20/22 at 11:09 P.M., staff observed the resident was not acting right. He/She had difficulty making sentences, had a blank stare at times, and drifted in and out of sleep. He/She was also shaking and said he/she was cold. Temp 100.2, heart rate 111 (normal 60-100), respiratory rate 24 (normal), BP 136/79. His/Her lungs were clear and skin was hot and pale. The urine in the catheter bag was dark red with small clots in tubing. The Director of Nurses (DON), the resident's spouse and physician were notified. The resident's spouse said he/she would like the resident sent to the hospital for evaluation as he/she has had [CONDITION(S)]'s in the past that quickly progressed into [CONDITION(S)]; -On 03/21/2022 at 01:32 A.M., facility staff received an update from the hospital and the resident was admitted ; -On 03/28/2022 at 6:54 P.M., the resident returned from the hospital with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the resident's POS, dated March 2022, showed the following: -Implanted port (A device used to draw blood and give treatments, including intravenous fluids, blood [CONDITION(S)], or drugs such as [CONDITION(S)] and antibiotics), change Huber needle (special curved needle used to access an implanted port) and central line dressing every week; -Flush port with 10 cubic centimeters (cc) of normal saline before and after each intravenous (IV) (given in the vein) infusion; -On 3/28/22, [MEDICATION(S)] (antibiotic) two gram (gm) IV daily; -On 3/28/22, [MEDICATION(S)] (antifungal often given with antibiotics) 500 mg IV every eight hours. Review of the resident's care plan, dated 11/7/19 and last reviewed 4/13/22, showed no documentation the resident had an implanted port or directed staff on how to care for or flush the port. 3. Review of Resident #25's face sheet showed the following: -admitted [DATE]; -diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] -Generalized anxiety disorder; -Benign neoplasms of cerebral meninges-[CONDITION(S)]. Review of resident's admission MDS dated [DATE], showed the following: -Cognition severely impaired; -No psychosis; -No physical or verbal behaviors; -No rejection of care; -Wandering occurred one to three days of seven. Review of resident's care plan, revised on 3/14/22 showed no Wander Guard placement. Review of the resident's POS dated 4/28/22, showed an order on 4/7/22 for Wander Guard placement and functioning check every shift. Observation on 4/27/22 at 1:00 P.M. showed that resident had Wanderguard on his/her wrist. Review of the resident's care plan showed there was no update the resident wore a Wanderguard or expectation for checking the device. 4. Review of Resident #43's face sheet showed the following: -admitted on [DATE]; -diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] -Cognitive communication deficit. Review of resident's PPS five day scheduled assessment dated [DATE] showed the following: -Cognition severely impaired; -No psychosis; -No physical behaviors; -Verbal behaviors directed towards others; -No rejection of care; -No wandering occurred. Review of resident's care plan, revised 4/26/22 showed no Wanderguard placement. Review of the resident's POS dated 4/28/22 showed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Observation on 4/27/22 at 1:00 P.M. showed that resident had Wanderguard on his/her wrist. During interview on 4/27/22 at 2:16 P.M. and 4/28/22 at 1:10 P.M. showed the Director of Nurses (DON) said the following: -She gives the staff up to seven days to update the care plan; -A Wanderguard should be part of a resident's care plan; -Any discussion of changes for residents from the morning Interdisciplinary team (IDT) meetings should be updated on the care plan; -If a resident had an implanted port, it should already be on the care plan and the care plan should have been updated with IV antibiotics; -If a resident fell and sustained a fracture and the resident's mode of transfer had changed it should be updated on the care plan; -If a resident is receiving hospice services then that should be included on the care plan; -Wounds should be updated on the care plan including the location, type and any treatments wand direction for the CNAs as what to report to the nurse; -If a resident now has a catheter then it should be on the care plan.

Based on observation, interview and record review, the facility failed to provide appropriate treatment and services consistent with acceptable standards of practice to prevent and treat urinary tract infections (UTIs) for four residents (Resident #6, #36, #57, and #67), of 21 sampled residents, who had an indwelling urinary catheter (a sterile tube inserted into the bladder to drain urine). The facility reported twelve residents with indwelling catheters. The facility census was 70. 1. Review of the facility policy Indwelling Catheter Care dated 11/19 showed the intent of the facility policy was to ensure that the residents receive care and services to prevent urinary tract infections in those residents with indwelling catheters, in accordance with standards of practice. Procedure: 1. Perform hand hygiene before beginning the procedure and assemble all supplies; 2. Knock before entering the room, introduce self, and explain procedure to the resident; 3. Place supplies on the bedside table or over bed table and arrange supplies so they can be easily reached. Pull the privacy curtain. 4. Perform hand hygiene and put gloves on; 5. Position resident for comfort; 6. Using disposable wipes: a. Female- cleanse labia with single downward cleansing stroke using a different wipe for each cleansing stroke on each side of the labia and urethral meatus.; b. Male-Cleanse male glans with circular strokes from the meatus outward, using a different wipe for each cleansing circular stroke; c. Uncircumcised males-Retract the foreskin, cleanse the meatus as described, and return foreskin to normal position 7. Secure catheter tubing with non-dominant hand and with a single downward, cleansing stroke, cleanse catheter tubing from meatus towards collection bag; 8. Turn resident on side to perform backside cleaning again using single cleansing strokes from front to back and reposition resident for comfort; 9. Discard supplies, remove gloves and perform hand hygiene. 2. Review of the CNA Pericare Check Off Sheet (undated), showed the procedure as follows: 1. Collect all necessary equipment; 2. Provide privacy to the resident and explain procedure to the resident; 3. Wash hands and put gloves on; 4. Expose the perineal areas and remove the brief. Remove soiled clothing as necessary and place in bag; 5. Clean soiled area of skin; 6. Wash pubic area to perineal area using front to back technique. Dispose of cloth after single, downward cleaning motion; 7. Remove gloves, wash hands, and put on clean gloves; 8. Reposition resident if required, wash buttock and anal area; 9. Dispose of soiled brief in bag; 10. Remove gloves and wash hands. Put on new pair of gloves; 11. Apply brief and/or clothing; 12. Remove and discard gloves and wash hands; 13. Make resident comfortable and place call light within reach if applicable; 14. Report any changes to the charge nurse. 1. Review of Resident #36's nurses notes showed the following: -On 12/28/21, he/she was sent to hospital for shaking and blood pressure (BP) 158/110 (normal 120/80) and kept for observation; -On 12/30/21 he/she was readmitted to the facility and received an antibiotic for a [CONDITION(S)]. Review of the resident's Physician Order Sheet, dated December 2021, showed an order on 12/31/21 for [MEDICATION(S)] (antibiotic used to treat UTIs) three grams by mouth every 72 hours for two doses. Review of the resident's nurses' notes showed on 1/7/22, the resident was shaking and had a temperature of 101.4 (normal is 98.6), BP 160/100. The resident was sent to hospital. Review of the resident's hospital discharge note, dated 1/7/22, showed the resident's urine culture positive for ESBL (enzyme found in some strains of bacteria - normal is negative), producing E.coli (bacteria found in the intestinal tract) and proteus mirabilis (bacterium that is a frequent cause of catheter-associated urinary tract infections (CAUTIs)). Review of the resident's Physician Order Sheet, dated January 2022, showed an order on 1/10/22 for [MEDICATION(S)] (antibiotic used to treat UTIs) 250 milligrams (mg) three tablets by mouth daily for seven days for [CONDITION(S)]. Review of the resident's nurses' notes showed the following: -On 1/10/22, the resident was readmitted with an order for [MEDICAL RECORD OR PHYSICIAN ORDER] -On 1/13/22, new order to obtain straight catheter urinalysis this evening; Review of the resident's urinalysis, dated 1/14/22, showed few bacteria. Review of the resident's nurses' notes showed the following: -On 1/21/22, new orders for [MEDICATION(S)] cream ([MEDICATION(S)] cream used to treat urinary tract infections) to the front genitalia every other day for chronic [CONDITION(S)]; -On 2/5/22, the resident fell and was sent to hospital; -On 2/10/22 the resident was readmitted with a fractured femur and an indwelling catheter. Review of the resident's care plan, dated 2/6/20 and last reviewed on 2/9/22, showed the following: -diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] -Provide incontinence care after each incontinent episode. Review of the resident's Significant Change Minimum Data Set (MDS), a federally mandated assessment instrument required to be completed by facility staff, dated 3/8/22, showed the following: -Severely impaired cognition; -Required extensive assistance of two staff for toileting and personal hygiene; -Required total assistance of one staff for bathing; -Required an indwelling catheter; -Frequently incontinent of bowel. Review of the resident's care plan showed no documentation the resident required an indwelling urinary catheter and no staff direction regarding care of the catheter. Review of the resident's Physician Order Sheet (POS), dated February 2022, showed no order for an indwelling catheter. Observation on 4/26/22 at 1:44 P.M., showed Licensed Practical Nurse (LPN) D and Certified Nurse Assistant (CNA) C transferred the resident from his/her wheelchair to his/her bed with a gait belt (canvas belt placed around the resident's waist to assist with ambulation and transfers) and slide board. CNA C picked up the resident's catheter bag which contained urine in the bag and tubing, and hooked it on his/her pant leg above the resident's bladder during the transfer. Observations on 4/25/22 at 2:01 P.M. and 3:28 P.M. showed the resident lay in his/her low bed and his/her urinary catheter bag, covered with a dignity bag, touched floor. Observations on 4/26/22 showed the following: -At 10:13 A.M. the resident sat in his/her wheelchair with his/her urinary catheter bag hooked under his/her wheelchair. As staff wheeled the resident to the nurses' station, the catheter bag and tubing drug the floor; -At 11:07 A.M., the resident sat in his/her wheelchair at nurses' station. The catheter bag and tubing rested on the floor; -At 12:11 P.M., the resident sat in his/her wheelchair in the dining room. He/she fed him/herself lunch. The catheter bag and tubing sat on the floor. The urine was amber in color with white sediment noted in the tubing; -At 12:44 P.M., the resident propelled him/herself in the main dining room and the catheter bag and tubing drug the floor; -At 1:06 P.M., the resident propelled him/herself in the main dining room and the catheter bag and tubing drug the floor. Observations on 4/27/22 showed the following: -At 5:43 A.M. the resident's catheter bag was hooked to the bed frame and sat on the floor; -At 6:20 A.M., the resident's catheter bag was hooked to the bed frame and sat on the floor; -At 6:30 A.M., the resident's catheter bag was hooked to the bed frame and sat on the floor; -At 7:13 A.M., the resident's catheter bag was hooked to the bed frame and sat on the floor; -At 7:27 A.M., the resident's catheter bag was hooked to the bed frame and sat on the floor; -At 7:49 A.M., the resident's catheter bag was hooked to the bed frame and sat on the floor; -At 8:01 A.M., the resident's catheter bag was hooked to the bed frame and sat on the floor; -At 8:20 A.M., the resident's catheter bag was hooked to the bed frame and sat on the floor; -From 9:00 A.M. to 10:20 A.M., continuous observation showed the resident's catheter bag was hooked to the bed frame and sat on the floor; -At 10:36 A.M., LPN D administered pain medication to the resident. The resident's catheter bag remained on the floor; -At 10:50 A.M.,the resident's catheter bag was hooked to the bed frame and sat on the floor. Observation on 4/27/22 at 12:12 P.M., showed the following: -The resident lay in bed. The resident's catheter bag sat on the floor; -CNA E and CNA F entered the resident's room, washed their hands and put on gloves; -CNA E hung an empty urinal on the end of the resident's bed, picked the catheter bag up to his/her waist height (above the resident's bladder), cleaned the catheter bag opening with an alcohol pad and emptied the urine into the urinal (while holding the bag at waist height above the resident's bladder). Urine was noted in the tubing and flowed back toward the resident's bladder. Observation on 4/28/22 at 8:24 A.M., showed the resident lay in his/her bed and his/her catheter bag sat on the floor. During interview on 4/28/22 at 8:39 A.M., CNA C said if the resident has a catheter, he/she hooks it on his/her pants during the transfers to prevent pulling or tugging on the catheter. The catheter bag should not be higher than the bladder to prevent infections. Staff should keep the catheter bags off the floor to prevent infections. During interview on 4/28/22 at 10:02 A.M., CNA E said a resident's catheter should be below the level of the bladder and off the floor because the floor was dirty. Urine could run back towards the bladder when emptying the catheter bag into a urinal hooked on the end of the bed. 2. Review of Resident #67's face sheet showed diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the resident's Quarterly MDS, dated [DATE], showed the following: -Cognitively intact; -Required total assistance of two staff for toileting; -Required total assistance of one staff for bathing; -Required extensive assistance of two staff for hygiene; -Required an indwelling urinary catheter; -Always incontinent of bowel; -diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the resident's nurses' notes showed the following: -On 03/20/22 at 11:09 P.M., staff observed the resident was not acting right. He/She had difficulty making sentences, had a blank stare at times, and drifted in and out of sleep. He/She was also shaking and said he/she was cold. Temp 100.2, heart rate 111 (normal 60-100), respiratory rate 24 (normal), BP 136/79. Skin was hot and pale. The urine in catheter bag was dark red with small clots in tubing. The Director of Nurses (DON), the resident's spouse and physician were notified. The resident's spouse said he/she would like the resident sent to the hospital for evaluation as he/she has had [CONDITION(S)]'s in the past that quickly progressed into [CONDITION(S)]; -On 03/21/2022 at 01:32 A.M., facility staff received an update from the hospital and the resident was admitted ; ; -On 03/28/2022 at 6:54 P.M., the resident returned from the hospital with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the resident's POS, dated March 2022, showed the following: -On 3/28/22, [MEDICATION(S)] (antibiotic) two gram (gm) intravenously (IV) (given in the vein) daily; -On 3/28/22, [MEDICATION(S)] (antifungal often given with antibiotics) 500 mg IV every eight hours; -Change suprapubic catheter every month and change drainage bag weekly (previous order); -Flush suprapubic catheter with 0.25% acetic acid solution (used to cleanse the bladder and prevent infection) 30 cubic centimeters (cc) daily for sediment (previous order). Review of the resident's care plan, last reviewed 4/13/22, showed the following: -Resident requires a suprapubic catheter related to [CONDITION(S)] bladder; -Do not allow tubing or any part of the drainage system to touch the floor; -Keep the catheter system a closed system as much as possible; -Manipulate the tubing as little as possible during care and provide catheter care as ordered and as needed; -Position bag below the level of the bladder; -Flush the suprapubic catheter per the physician orders. Observation on 4/27/22 at 12:11 P.M., showed the following: -The resident lay on his/her back/left side in bed; -CNA E and CNA entered the resident's room, washed their hands and put on gloves; -CNA E asked the resident to raise his/her bed because it was too low and the catheter bag was on the floor; -CNA F opened an alcohol wipe package and cleaned the catheter insertion site with an alcohol pad wiping towards the insertion site multiple times with the same surface; -CNA F did not clean the catheter tubing from the insertion site towards the catheter bag; -CNA E cleaned the opening of the catheter bag with an alcohol wipe and hung the empty urinal on the foot of the resident's bed; -CNA E picked up the catheter bag to his/her waist height (above the level of the resident's bladder) and emptied the urine into the urinal; -The urine in the tubing flowed back towards the resident and was amber colored with sediment; -CNA E emptied over 1000 cc (cubic centimeters) of urine. During interview on 4/27/22 at 13:22 P.M., CNA F said he/she usually uses both the alcohol wipes and disposable wipes to provide catheter care. He/She didn't use wipes on the resident because he/she thought these irritated the resident's skin. Staff should clean from the insertion site outwards. Staff should keep the catheter bag on the bed frame and at least two inches off the floor because the floor was dirty and keep the catheter bag below the bladder to prevent infections. 3. Review of Resident #6's urinalysis report dated 3/26/22 showed the following: -Clarity: cloudy (clear); -Blood: large (negative); -Leukocytes: large (negative); -White Blood Cell (WBC): 10-20 Hpf (High power field) (0-5); -Red Blood Cell (RBC): 5-10 (Hpf) (0-5); -Bacteria: full field (rare); -Mucous: present (none); -Handwritten order on lab showed [MEDICATION(S)] (antibiotic) one gram daily intramuscular, times three days and increase Acidophilus (probiotic) to two times daily (BID) times seven days. Review of the resident's POS dated 4/22 showed the following: -diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] -Size 16 French urinary catheter, change PRN (as needed) (3/25/22). Review of the resident's quarterly MDS, dated [DATE] showed; -Extensive assist of one staff for bed mobility, dressing and personal hygiene; -Presence of an indwelling urinary catheter. Review of the resident's care plan, last revised 4/25/22 showed the resident had an indwelling urinary catheter. Observation on 4/27/22 at 7:00 A.M. showed the following: -The resident lay in his/her bed on his/her back; -LPN B entered and prepared to perform catheter care on the resident; -He/She performed catheter care with gloved hands, using perineal wipes but did not cleanse the entire genitalia surrounding the insertion site of the catheter; -He/She finished perineal care and continued with morning cares. Record review of the resident urine culture report dated 4/16/21 showed the following: -Organism: Proteus Vulgaris/ Penneri -Colony count: 50,000-60,000 CFU(Colony Forming Unit)/ml (milliliter) swarming. During interview on 4/27/22 at 1:04 P.M. LPN B said that all areas of the genitalia should be cleansed when performing perineal care. 4. Review of Resident #57's significant change MDS dated [DATE] showed the following: -Presence of a urinary catheter; -Total dependence of one staff for personal hygiene and toileting; -Occasionally incontinent of bowel. Review of the resident's POS dated 4/22 showed diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the resident's care plan dated 4/3/22 showed the following; -Resident required an indwelling urinary catheter; -Resident will have catheter care managed appropriately; -Provide catheter care every shift as needed. Observation on 4/26/22 at 10:05 A.M. showed the resident lay in his/her bed and the urinary catheter tubing lay on the floor. Observation on 4/27/22 at 8:15 A.M. showed the following: -The resident lay in his/her bed; -LPN B entered and with gloved hands prepared the resident for catheter/perineal care; -He/She cleansed the urinary catheter with a wipe moving from dirty to clean (towards the insertion site). During interview on 4/27/22 at 1:05 P.M. LPN B said the following: -Catheter tubing should never touch the floor; -When performing catheter care, staff should cleanse the tubing by wiping away from the resident. During interview on 4/28/22 at 1:10 P.M., the Director of Nurses (DON) said staff should use disposable wipes or soap and water for catheter care and should clean from the insertion site away from the body. Staff should not use alcohol pads to complete catheter care. No part of the catheter bag or tubing should touch the floor nor the dignity bag. Staff should never hook the catheter bag on their pants during a transfer and should hold the catheter bag in their hand down low. She said it was not appropriate to empty a catheter bag in a urinal on the end of the bed as it was an infection control issue and could cause urine to flow back towards the bladder. Staff should put a urinal on a towel or paper towels on the floor and empty the catheter bag. Staff should hook the catheter bag on the crossbars under the resident's wheelchair making sure the bag and tubing do not touch the floor. She would not expect the catheter bag and tubing to drag on the floor.

Based on observation, interview and record review the facility failed to adequately provide ordered treatments, and failed to prevent further tissue damage for one resident (Resident #6) who had one Stage II pressure ulcer, (A partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed without slough. May also present as an intact or open/ruptured blister) and one Stage III (Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining or tunneling) pressure ulcer which were not present upon admission. Facility staff failed to complete ordered treatments timely and did not properly reposition the resident while in the bed. The facility census was 70. Review of the facility policy Clean Dressing Change, dated November 2019 showed the intent was to ensure dressings are changed in accordance with the State and Federal guidelines. #19. Apply clean dressings as ordered and ensure dressings are initialed and dated. .During interview on 5/12/22 at 10:50 A.M. the Director of Nurses (DON) said they did not have a policy on repositioning residents but that he/she would expect staff to follow the CNA guidelines for repositioning a resident in bed. Review of the Nurse Assistant In A Long Term Care Facility, dated 2001, showed the following: Principles to remember when lifting and moving a resident: E. Always use a lift sheet to move the resident. Never slide his/her skin over the sheets. A lift sheet can be used to help lift the resident, which helps prevent friction on the skin; F. Sliding causes the resident's skin to rub against the sheets, which can scratch and injure the skin. Steps of procedure for moving resident to head of bed (two-person assist): -Moving resident to head of bed (two-person assist): Position a lift sheet/folded regular sheet under shoulders and hip area. Each nurse assistant should roll edges of sheet toward resident's body and grasp rolled sheet with resident's shoulders and at the mid-hip area. On the count of three, each nurse assistant lifts the resident up off the surface of the bed and toward the head of the bed while shifting weight from back foot to front foot. 1. Review of Resident #6's annual Minimum Data Set (MDS), a federally mandated assessment instrument to be completed by the facility and dated 1/18/22 showed the following: -Extensive assist of one staff for bed mobility, dressing and personal hygiene; -At risk for pressure ulcers; -No unhealed pressure ulcers. Review of the resident's Physician Order Sheet, dated April 2022 showed the following: -Cleanse bilateral buttocks with warm water and soap, pat dry, apply collagen (protein used for tissue repair) and normal saline paste to open areas. Cover with hydrogel absorbent sheet wound dressing. Change daily and as needed (PRN) (4/25/22); -Pro-source (liquid protein) 30 milliliters by mouth daily for wound healing; -L-emental (supplement for wound healing) one packet mixed with beverage of choice daily for wound healing. Review of the resident's quarterly MDS, dated [DATE] showed; -Extensive assist of one staff for bed mobility, dressing and personal hygiene; -At risk for pressure ulcers; -Presence of one Stage II pressure ulcer (not present on admission or re-entry into the facility); -Presence of one Stage III pressure ulcer (not present on admission or re-entry into the facility); -Nutrition and hydration to manage pressure ulcers; -Pressure ulcer care; -Applications of ointment/medications other than to feet. Review of the resident's care plan, last revised 4/25/22 showed the following: -Pressure ulcer related to incontinence/pressure; -Ulcer will heal without complications; -Indwelling urinary catheter to promote wound healing, remain on I-emental to prevent skin breakdown; -Keep linens clean, dry and wrinkle free. Observation on 4/25/22 at 11:45 A.M. showed the following: -The resident lay on his/her right side in the bed while Licensed Practical Nurse (LPN) B cleaned feces from the resident's backside; -There was no dressing noted to the resident's buttock wounds which comprised of two open areas with smears of blood noted; -LPN B finished perineal care, dressed the resident and he/she and Certified Nurse Assistant (CNA) G assisted the resident to the side of the bed and transferred him/her to his/her wheelchair; -Staff placed no dressing on the resident's wounds. Observation on 4/25/22 at 2:30 P.M. showed Registered Nurse (RN) A (wound nurse) performed the treatment and placed a dressing on the resident. Observation on 4/27/22 at 7:00 A.M. showed the following: -The resident lay on his/her back in the bed; -LPN B entered and prepared to perform morning cares on the resident; -He/She performed front perineal care and then used the cloth pad the resident lay on and pulled him/her across the bed to the left side and then rolled him/her to his/her right side; -He/She cleansed the resident's buttocks (no dressing noted), tucked the soiled brief and pad and assisted the resident to his/her back. He/She walked to the right side of the bed, grabbed the pad and pulled the resident across the bed to the right and rolled him/her to his/her left side. -LPN B finished cares and then used the bottom sheet to pull the resident across the bed to the left. During interviews on 4/27/22 LPN B said the following: -At 11:08 A.M. RN A had not yet applied the resident's dressing; -At 1:04 P.M. RN A had not applied the resident's dressing, but he/she was calling him/her now. The wound nurse was responsible for the treatment and he/she could not do it because he/she did not have the supplies needed. During interview on 4/28/22 at 11:27 A.M. RN A said the following: -He/She was the wound nurse and responsible for wound care; -If staff find a dressing missing they should reapply a new one immediately; -He/She would not expect a dressing to be off for several hours; -Supplies should be available to all nursing so dressings can be replaced PRN; -Staff in the cottage did not have access to the dressing supplies needed to replace the resident's dressing. Review of the resident's wound management report, dated 4/28/22 showed the following: -Location-right buttock; -Type-pressure ulcer; -Length 0.4 centimeters (cm) x Width 0.1 cm x Depth 0.1 cm; -Exudate: light, bloody (bright red, thin); -Tissue type: granulation; -No odor, tunneling or undermining. During interview on 4/28/22 at 1:10 P.M., the DON said the following: -Dressings should be re-applied as soon as they are discovered to be missing; -She would not expect wounds to go without dressings for several hours; -Supplies should be available to all nursing staff in the event they would need to replace one; -Any licensed nurse could perform a treatment and apply a dressing; -When positioning a resident in bed, two staff should perform the task by lifting the resident; -She would not expect staff to drag a resident across a bed/mattress with a pad or a sheet as it could cause shearing.

Based on observation, interview and record review, the facility failed to administer medications with an error rate of less than 5% when staff failed to administer medications separately via peg tube (tube inserted through the abdominal wall into the stomach to provide medications and nutrition) for one resident (Resident #7), in a review of 21 sampled residents. There were 31 opportunities with three errors, which resulted in an error rate of 9.68 %. The facility census was 70. Review of the facility's policy, Enteral Feeding Medication Administration, dated 11/2019, showed the following: -It is the policy of the facility to provide appropriate medication administration to residents who receive their medications via an enteral feeding tube to ensure that residents attain or maintain the highest practicable physical, mental and psychosocial well-being in accordance to State and Federal regulation; -Prior to medication administration, flush the tube with 30 milliliters (ml) of water, mix each crushed medication with five to ten ml of water and flush with ten ml of water between each medication and flush with 30 ml of water after the last medication. Review of The Journal of [MEDICATION(S)] and Enteral Nutrition, dated March/April 2009, showed the following: -In the same way nurses or pharmacists would not routinely mix different medications in the same intra-venous bag or syringe without assuring drug stability and compatibility, the same should be said about the preparation of medication for administration through enteral feeding tubes. -Practice Recommendations: 1. Do not add medication directly to an enteral feeding formula. 2. Avoid mixing together medications intended for administration through an enteral feeding tube given the risks for physical and chemical incompatibilities, tube obstruction, and altered therapeutic drug responses (i.e., do not mix medications together, but do dilute them appropriately prior to administration). 3. Each medication should be administered separately through an appropriate access. Liquid dos-age forms should be used when available and if appropriate. Only immediate-release solid dosage forms may be substituted. Grind simple compressed tablets to a fine powder and mix with sterile water. Open hard gelatin capsules and mix powder with sterile water. 1. Review of Resident #7's care plan, dated 11/21/19 and last reviewed 1/14/22, showed the following: -Requires a feeding tube related to dementia; -Assess for complications; -Assess for dehydration; -Monitor and record weight. Notify physician and family of significant weight change; -Care plan did not direct staff on how to prepare and administer medications through the peg tube. Review of the resident's Quarterly Minimum Data Set (MDS), a federally mandated assessment instrument required to be completed by facility staff, dated 1/30/22, showed the following: -Severely impaired cognition; -Required total assistance of one staff for eating; -Received nutrition via peg tube (feeding/gastrostomy tube); -Received scheduled pain medication. Review of Resident #7's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] -[MEDICATION(S)] (used to treat Alzheimer's disease) five milligrams (mg) by mouth (this is the way the order reads but they give it per tube) daily; -[MEDICATION(S)] (for arthritic pain) 200 mg per g-tube daily; -[MEDICATION(S)] (for anxiety) 0.5 mg per g-tube once a day on Tuesdays and Fridays one hour prior to showers; -Check tube placement per measurement; -Elevate the head of the bed 30 degrees for peg tube feedings; -Give 60 cubic centimeters (cc) water before and after bolus feedings; -diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] Observation on 4/26/22 at 9:30 A.M., showed the following: -Licensed Practical Nurse (LPN) D exited the medication room with a medication cup of white powder; -LPN D reported the resident's [MEDICATION(S)], [MEDICATION(S)] and [MEDICATION(S)] were all together in the medication cup; -LPN D dissolved the medications in the cup with water; -LPN D checked the resident's g-tube for placement by measuring the length of the tube from the abdominal wall to the port end as ordered; -LPN D flushed the g-tube with water, administered the dissolved medications and flushed the g-tube again with water. During interview on 4/27/22 at 1:56 P.M., LPN D said he/she was aware medications should be dissolved in water and given separately but he/she puts them all together and did not give a rationale for why. During interview on 4/28/22 at 1:10 P.M., the Director of Nurses (DON) said she expected staff to prepare each medication individually in a medication cup unless otherwise care planned and this would require a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] .

Based on interview and record review, the facility failed to follow professional standards of practice for one resident (Resident #1) of five sampled residents when staff failed to monitor the resident for [MEDICATION(S)] (blood thinner used to treat and prevent blood clots) precautions, and report abnormal bruising in a timely manner to the physician. The census was 74. Record review of Nursing 2020 drug handbook, copyright 2020 showed the following: -Wafarin sodium ([MEDICATION(S)]) (anticoagulant) (blood thinner); -PT (prothrombin time, a blood test to evaluate blood clotting) and INR (international normalized ratio, a blood test used to monitor how well the blood-thinning medication, [MEDICATION(S)] is working) determinations are essential for proper control; -Adverse reactions include: hemorrhage (bleeding); -Nursing considerations: [MEDICATION(S)] can cause major or fatal bleeding, which is more likely to occur during the starting period and with a higher dose; -Regularly monitor INR in all patients; -Regularly inspect patient for bleeding gums, bruises on arms or legs, petechiae (pin point spots on skin due to bleeding), nosebleeds, melena (dark stools), tarry stools, hematuria (blood in the urine), and hematemesis (blood in vomit); -Monitor for purple-toes syndrome, characterized by a dark purple or mottled color of the toes. During interview on 8/13/21 at 3:30 P.M. the Assistant Director of Nursing (ADON) said the facility did not have a policy regarding [MEDICATION(S)] or bleeding precautions until after the resident was admitted to the hospital on 7/28/21. 1. Review of Resident #1's hospital discharge summary date 6/18/21 showed the following: -Lower extremity (LE) [CONDITION(S)] (or a DVT, which is a blood clot in a deep vein, usually in the legs) was likely chronic; -A pulmonary embolism (a condition in which one or more arteries in the lungs become blocked by a blood clot) can't be ruled out, will treat with an anticoagulant (blood thinner) for at least three months; -[MEDICATION(S)] level was noted to be therapeutic for two consecutive days, and [MEDICATION(S)] (anticoagulant or a blood thinner) drip was discontinued; -The resident was discharged to a skilled facility. Record review of the hospital's discharge medication list dated 6/18/21 showed the following: -New medications for this admission: [MEDICATION(S)] for a DVT; -[MEDICATION(S)] 2 milligrams (mg) tablet, take 4 mg daily; -The resident was refusing lab draws, no INR for two days, would recommend INR draw tomorrow if the resident was agreeable to ensure that the resident was not supratherapuetic (above established reference ranges), Target INR 2 to 3. Record review of the resident's physician order [MEDICAL RECORD OR PHYSICIAN ORDER] -admitted : 6/18/21; -diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] -[MEDICATION(S)] ([MEDICATION(S)] generic for [MEDICATION(S)]) 4 mg daily for a DVT. Record review of the resident's nursing note dated 6/18/21 at 11:25 P.M. showed admission assessment completed no skin issues noted at this time. Record review of the resident's nursing note dated 6/20/21 at 10:40 P.M. showed no skin issues at this time. Record review of the resident's [MEDICATION(S)] and INR results dated 6/21/21 showed the following: -PT: 26.9 second (s), normal reference range (9.2-11.7); -INR: 2.70 Normal reference (standard hospital protocol is 2.0 - 3.5). Record review of the resident's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the resident's admission Minimum Data Set (MDS), a federally mandated assessment completed by facility staff, dated 6/23/21, showed the following -Cognition intact; -Extensive assistance of two staff members with bed mobility, transfers, dressing, toilet use and personal hygiene; -Dependent on one staff member for bathing; -Impairment of on one side for upper and lower body; -Anticoagulant medication use for the past seven of seven days. Review of the resident's care plan dated 6/25/21 showed the following: -The resident was limited in an ability to transfer self, related to weakness and scoliosis (curvature of the spine); -Assist of one or two staff members for transfers, uses gait belt and Hoyer (mechanical lift) lift as needed; -The resident was limited in the ability to dress and undress self. Record review showed no documentation the resident's care plan addressed [MEDICATION(S)] therapy or bleeding precautions. Record review of the resident's skin monitoring: comprehensive shower review (completed by the shower aide) dated 7/1/21 showed the following: -Visual assessment: Bruising; - Bruising indicated (by circling the area) to the inner upper arm and forearm; -Sheet was signed by the charge nurse. Record review showed no documentation the physician was notified of the resident's bruising. Record review of the resident's nursing note dated 7/28/21 at 9:48 A.M. showed the following: -The ADON was called to the bathroom due to bruising noted to the resident's torso (chest, abdominal and genital/rectal area) posterior (back) and anterior (front); -Noted resident sitting on toilet with bruising, dark purple in color to torso anterior and posterior covering 75% of area; -Resident with [MEDICATION(S)] and [MEDICATION(S)] (nonsteroidal therapy used to treat arthritis therapy); -Will notify representative and the physician. Record review of the resident's nursing note dated 7/28/21 at 10:04 A.M. showed staff spoke with the physician's office who gave orders per the nurse practitioner to hold the resident's [MEDICATION(S)] and obtain STAT (urgent order) PT/INR. Review of the resident's nursing note dated 7/28/21 at 5:15 P.M. showed the following: -Received notification from lab of critical PT/INR. PT: 94.3, INR 11.56 (INR levels above 4.9 are considered critical and increase the risk of bleeding); -Notified the nurse practitioner and received new order to send to the emergency room (ER for) evaluation due to possible bleed; -Emergency medical services (EMS) notified via call to 911. Record review of the resident's hospital admission record dated 7/28/21 at 7:18 P.M. showed the following: -admitted from the facility with INR of 11 and extensive bruising, no obvious bleeding; -The facility reported they held [MEDICATION(S)] for one day; -Extensive flat bruising over torso that stops at waist; -Stop [MEDICATION(S)]; -Hold aspirin and [MEDICATION(S)]; -Give vitamin K (used for [MEDICATION(S)] overdose and helps the blood clot) 5 mg by mouth; -Admission diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] -Hemoglobin level (normal hemoglobin levels is 11 to 18 grams per deciliter, (gl/dL) was 7.0 gl/dL (prior discharge it was 9.7 gl/dL). Record review of the resident's hospital history and physical dated 7/29/21 at 12:54 A.M. showed the following: -Physical exam purple/bluish ecchymosis over the thorax (the part of the body between the neck and the abdomen) (define) extending to right upper extremity, right arm bruising in medical aspect extending to the elbow; -Right foot ecchymosis; -The 24 hour plan was to discontinue [MEDICATION(S)], call nursing home for inquiries about INR monitoring; -Stop transfusion as hemoglobin is 7.4. During an interview on 8/12/21 at 3:00 P.M., CNA (Certified Nurse Aide) B said the following: -He/She provided routine showers to all the residents; -He/She documented on the shower sheet if anything abnormal to the resident's skin was observed during the shower; -He/She gave the shower sheet to the nurse to sign off on, the charge nurse did not assess the resident's skin during the shower; -He/She completed only a couple showers on the resident as the resident did not like to shower and had refused; -The resident had two palm size bruises on his right arm otherwise he/she did not recall any issues with the resident's skin; -He/She did not know what a blood thinner was or specific things to know when a resident was on a blood thinner; -He/She was not aware the resident was on a blood thinner. During an interview on 8/12/21 at 2:48 P.M., CNA C said the following: -Two or three days before the resident was readmitted the hospital he/she observed bruising from the resident's nipple line down to his/her navel; -The bruising was pretty extensive, it was dark purple and solid across the resident's rib cage; -He/She thought the charge nurse already knew about the bruising so he/she did not report it; -He/She did not know the resident was on a blood thinner, if he/she would have known, he/she would have been more adamant to report the extensive bruising. During an interview on 8/13/21 at 2:50 P.M., CNA D said the following: -He/She had worked with the resident on different occasions; -The resident didn't like to take a shower and didn't change his/her clothes routinely; he/she often slept in the same clothes; -He/She wouldn't know if a resident was on a blood thinner, because he/she did not pass medications; -He/She assisted the resident to the bathroom the day the resident went to the hospital; -He/She lifted the resident's shirt and saw bruising across his/her chest; -He/She notified the ADON of the bruising. During an interview on 8/12/21 a 3:10 P.M., wound nurse/Licensed Practical Nurse (LPN) A said the following: -The shower aide would report if there was any changes in the skin; -She did not complete a weekly skin assessment on each of the residents; -If there was any changes with a resident's skin the aides would report it to him/her. During interview on 8/12/21 at 11:50 A.M. and 2:05 P.M. and 8/13/21 at 1:30 P.M. and 2:30 P.M., the ADON said the following: -She had been assisting with updating care plans; -[MEDICATION(S)] and any special precautions had not been addressed on the resident's care plan; -She would expect the care plan to include [MEDICATION(S)] precautions; -The CNAs would not know the resident was on a blood thinner and what to watch for if it was not addressed on the care plan; -She reviewed the resident's discharge orders from the hospital; -She did not realize [MEDICATION(S)] was a new medication for the resident, she would have asked the physician for lab work to be completed more frequently to assure the [MEDICATION(S)] level was normal; -She obtained a PT/INR on 6/21/21 and it was within normal limits; -She received an order to redraw the PT/INR in a month but forgot to write the order; -The CNAs should report any bruising to the charge nurse as soon as it was observed so the charge nurse could look into the cause; The bruising covered 75 % of the resident's torso; -She notified the physician and obtained an order to check a PT/INR; -The wound nurse was to be completing weekly skin assessments and documenting the assessments on the shower sheet; -A skin assessment was to be completed on each resident weekly during the resident's shower by a licensed nurse; -The licensed nurse signed off on the shower sheet which was to indicate the nurse had assessed the resident's skin; -If there was any skin issues identified, the nurse was to document it on the shower sheet in the comment section; -The shower aide was not qualified to complete weekly skin assessments on each resident; -Skin issues such as pressure ulcers as well as other skin issues could be missed if a weekly skin assessment was not being completed; -On 7/28/21 staff reported to him/her abnormal bruising to the resident's torso; -The resident had bruising from his/her arm pits going down to the resident's waist. During an interview on 8/20/21 at 9:45 A.M., the administrator said the following: -Staff should report bruising to the charge nurse when it was observed; -She would expect [MEDICATION(S)] to be care planned; -She was not aware the [MEDICATION(S)] was a new medication for the resident. During an interview on 8/19/21 at 4:27 P.M. the resident's physician said the following: -If the medication ([MEDICATION(S)]) was new it should be drawn (labs) weekly to assure it was therapeutic; -Any abnormal bruising should be reported to the nurse; -Routine education on [MEDICATION(S)] use and precautions should be completed with facility education. MO 2

Based on observation, interview, and record review, the facility failed to maintain an infection control program during a Coronavirus Disease 2019 (COVID-19, an infectious disease caused by severe acute respiratory syndrome Coronavirus 2 ([DIAGNOSES REDACTED]-CoV-2) pandemic, to provide a safe and sanitary environment for all residents. Facility staff failed to utilize appropriate personal protective equipment (PPE) which included eye protection when working with COVID-19 positive residents, failed to consistently identify which precautions to follow and what PPE was required outside of COVID-19 positive resident rooms, and failed to encourage or remind residents to wear facemasks when outside of their rooms throughout the facility. A sample of nine residents was selected for review. The facility census was 66. Review of the CDC guidance, How to Prevent Spread of Novel or Targeted [MEDICAL CONDITION], updated 7/26/19, showed when implementing contact precautions, it is critical to ensure staff have awareness of the facility's expectations about hand hygiene and PPE use and access to appropriate supplies. To accomplish this, post clear signage on the door or wall outside of the resident's room indicating the type of precautions and required PPE (e.g., gown and gloves). Review of the Centers for Disease Control (CDC) guidance, titled Preparing for COVID-19 in Nursing Homes, updated on 6/25/20, showed the following: -Residents with known or suspected COVID-19 should be cared for using all recommended PPE, which includes use of an N95 mask or higher level respirator (or a facemask if a respirator is not available), eye protection ( goggles or a face shield that covers the front and sides of the face), gloves, and gown; -Residents should wear a cloth face covering or facemask (if tolerated) whenever they leave their room. Review of the facility's COVID-19 Policy and Procedure, dated November 2020, showed the following: -PPE will be worn per CDC recommendations; -Identified COVID Cases in the Facility: Staff will wear PPE of gowns, gloves, and N95 respirator; -If the resident needs to leave the room for any reason, a facemask will be placed on the resident and movement inside the facility will be limited. 1. Review of the spreadsheet provided by the facility on 11/4/20, showed 18 residents were actively quarantined due to being positive for COVID-19, including sampled Residents #1, #2, #3, #4, #5, #6, #7, #10, #11 and #12. 2. Observation on 11/4/20 at 9:55 A.M., showed the following: -Resident #10 lived in a cottage with ten other residents and was the only COVID-19 positive resident in the cottage; -Housekeeper A stood in the hallway outside the resident's room; -There was a picture of a red ball with spikes (indicating the [MEDICAL CONDITION]) on the door of the room; -There was no signage on the door indicating which precautions were in place or what PPE staff should utilize when entering the room; -Housekeeper A wore a N95 mask and put on gloves and a disposable gown; he/she did not put on eye protection; -Housekeeper A entered the resident's room and changed the bed linen while the resident sat in a chair in the room. The housekeeper was within six feet of the resident; -Housekeeper A cleaned the resident's room and bathroom. During an interview on 11/4/20 at 10:00 A.M., Housekeeper A said the resident was COVID-19 positive. He/she wore a N95 mask, disposable gown, and gloves when in COVID-19 positive residents' rooms. Housekeeper A said he/she did not use any eye protection such as a face shield or goggles when he/she was in COVID-19 positive residents' rooms. 3. Observation on 11/4/20 at 10:00 A.M., showed Resident #6 was in his/her room on the dementia unit. The resident had oxygen on per nasal cannula as he/she sat in the recliner watching television. During interview on 11/4/20 at 10:32 A.M., the Assistant Director of Nursing (ADON) said he/she was going to start an intravenous solution (IV) on the resident since the resident was not bouncing back from COVID-19 diagnosis. Observation on 11/4/20 at 10:32 A.M., showed the ADON entered the resident's room with equipment to start the IV. The ADON wore a N95 mask, gown, and gloves, but did not wear a face shield or goggles to perform the procedure. 4. During an interview on 11/4/20 at 11:26 A.M., Certified Medication Technician (CMT) C said he/she wore a N95, gown, and gloves when working with COVID-19 positive residents. Staff were not required to wear a face shield or goggles. CMT C said he/she was administering medications on the COVID-19 unit. Observation on 11/4/20 at 11:35 A.M., showed Resident #3 sat at a table in the common area of the COVID-19 unit, located on the 100 hall. The resident did not wear a mask and coughed intermittently. Another resident propelled himself/herself in a wheelchair into the common area and sat at the table next to Resident #3. A third resident walked in the common area and was not wearing a mask. He/She sat down at the table next to Resident #3 and began talking with him/her. CMT C stood in the common area of the COVID-19 unit at a medication cart and did not encourage the residents to wear masks. Observation on 11/4/20 at 11:38 A.M., showed the following: -CMT C stood at the medication cart on the COVID-19 unit, located on the 100 hall; -CMT C wore a N95 mask and disposable gown; -CMT C washed his/her hands, applied gloves and entered Resident #12's room on the COVID-19 unit; -CMT C did not wear a face shield or goggles; -CMT C administered medications to the resident. Observation on 11/4/20 at 12:06 P.M., showed Certified Nurse Aide (CNA) D was in the common area of the COVID-19 unit, located on the 100 hall. CNA D wore a N95 mask, gown, and gloves. CNA D passed out meal trays to COVID-19 positive residents who were seated in the common area. None of the seven residents wore a mask. CNA D did not encourage any of the residents in the common area to wear a mask. CNA D did not wear a face shield or goggles. Observation on 11/4/20 at 12:23 P.M., showed CNA D sat at a table on the COVID-19 unit, located on the 100 hall, next to Resident #4 and assisted the resident to eat. CNA D wore a N95 mask, gown, and gloves. CNA D did not wear a face shield or goggles. Resident #4 coughed intermittently as CNA D assisted him/her to eat. Observation on 11/4/20 at 12:30 P.M.,. showed CNA D entered Resident #11's room, located on the COVID-19 unit on the 100 hall, with a meal tray and assisted the resident to eat as the resident lay in bed. CNA D wore a N95 mask, gown, and gloves. CNA D did not wear a face shield or goggles. 5. Observation on 11/4/2020 at 12:20 P.M., showed several residents in the dining room on the dementia care unit (a designated COVID-19 unit). Four to five residents sat at each table. Staff assisted the residents to eat. The staff wore N95 masks, gowns, and gloves, however, no staff wore eye protection when assisting the COVID-19 positive residents to eat. 6. Observation on 11/4/20 at 11:22 A.M., showed six residents sat at tables in the main dining room of the facility (not a designated COVID-19 area). Staff continued to bring more residents into the dining room, preparing for lunch. None of the residents wore masks. Staff members did not encourage the residents in the dining room to wear a mask. Residents passed within six feet of one another as staff propelled residents into the dining room past residents who were already seated at tables. Observation on 11/4/20 at 12:45 P.M., showed several residents seated next to one another in wheelchairs near the nurse's station on the east side of the facility. This area was not a designated COVID-10 unit in the facility. Staff assisted residents from the main dining room back to their rooms on the east hall. Resident #8 stood in the hallway. None of the residents wore masks. Staff members did not encourage residents in the hallway and near the nurse's station to wear a mask. During an interview on 11/4/20 at 12:48 P.M., Resident #8 said he/she lived at the end of the east hall. He/She said residents only had to wear masks when they went outside. Residents did not have to wear masks when they were inside the facility. 7. Observation on 11/4/20 at 9:42 A.M., showed Resident #1 resided on the 200 hallway which was not a designated COVID-19 unit. Six residents resided on this hall, with two of these residents on isolation for COVID-19. Resident #1 had a container with two drawers outside his/her room. The drawers contained disposable gowns, gloves, hand sanitizer, and trash bags. There were no face shields or goggles in the container. There was no signage posted on the resident's door or outside the room indicating the resident was on any precautions or what PPE staff should utilize when entering the room. Observation on 11/4/20 at 9:45 A.M., showed Resident #2 resided on the 200 hallway, which was not a designated COVID-19 unit. He/She had a container with two drawers outside his/her room. The drawers contained disposable gowns, gloves, hand sanitizer, and trash bags. There were no face shields or goggles in the container. There was no signage posted on the resident's door or outside the room indicating the resident was on any precautions or what PPE staff should utilize when entering the room. During an interview on 11/4/20 at 12:40 P.M., CMT F said Resident #1 and Resident #2 did not have any signs on their doors showing they were on precautions. CMT F knew these two residents were COVID-19 positive because they had the containers of PPE outside their rooms. CMT F wore a disposable gown, N95 mask, and gloves when he/she worked with Resident #1 and Resident #2. CMT F did not wear a face shield or goggles when working with COVID-19 positive residents unless he/she had to administer a breathing treatment. CMT F said staff members used to wear face shields, but quit about two months ago when the facility switched all staff to wearing the N95 masks. 8. During an interview on 11/4/20 at 8:45 A.M., the Assistant Director of Nursing (ADON) said staff were expected to wear a gown, gloves, and a N95 mask when providing care for COVID-19 positive residents. Staff were not utilizing face shields or goggles except when administering a breathing treatment. During an interview on 11/4/20 at 10:08 A.M., CMT B said staff wore the N95 mask at all times in the facility. When going into a COVID-19 positive resident's room, staff wore the N95 mask, gown, and gloves. Staff did not wear face shields or goggles. During an interview on 11/4/20 at 12:14 P.M., laundry staff E said he/she wore a N95 mask, gown, and gloves when in COVID-19 positive residents' rooms. He/She never wore a face shield or goggles. During an interview on 11/4/20 at 1:00 P.M., Licensed Practical Nurse (LPN) G said he/she wore a N95 mask, gown, and gloves when working with COVID-19 positive residents. LPN G only used a face shield when he/she administered a breathing treatment to a resident due to the aerosol the nebulizer created. Residents did not have to wear masks when they were out of their rooms unless they were visiting with a family member outside or if a quarantined or isolated resident had to leave their room for some reason, During an interview on 11/4/20 at 1:30 P.M., the Director of Nursing (DON) said the following: -Residents were given masks to wear when they went outside or when they went to an appointment. Residents who were negative for COVID-19 did not have to wear masks when they were out of their rooms, inside the facility. -Staff wore a N95 mask, gown, and gloves in COVID-19 positive residents' rooms. -Staff only wore a face shield if they administered a breathing treatment to a resident. -Resident #1 did not have signage on his/her door indicating the resident was on isolation precautions and he/she should have. -Resident #2 also did not have signage on his/her door indicating the resident was on isolation precautions. Resident #2 just returned from the hospital the day before but should have a sign in place. During interviews on 11/4/20 at 3:30 P.M. and 11/5/20 at 9:30 A.M., the ADON said he/she read the CDC guidance incorrectly and thought face shields or goggles were only required when N95 masks were not available and staff were wearing the surgical masks. The facility switched from wearing the surgical masks to the N95 masks on 10/17/20. COVID-19 positive residents who lived on the designated COVID-19 units were not required to wear a mask when they left their rooms because all of the residents on those units were already positive for [MEDICAL CONDITION]. The COVID-19 positive residents, not on designated COVID-19 units, should wear a mask when they leave their rooms. Residents who were negative for COVID-19 only wore masks when they went outside, but did not have to wear masks while out of their rooms, inside the facility. During a telephone interview on 11/18/20 at 9:50 A.M., the administrator said she expected staff to follow CDC guidelines regarding PPE when working with COVID-19 positive residents, which included eye protection. She expected signage to be posted outside of COVID-19 positive residents' rooms or units regarding the type of precautions to follow and what PPE was required.

Based on observation, interview, and record review, the facility failed to monitor the effectiveness of current fall interventions, failed to modify the interventions as necessary to prevent further falls, and failed to consistently implement fall interventions for two residents (Resident #19 and Resident #55), in a review of 18 sampled residents, and one additional resident (Resident #22), who had a history of [REDACTED]. Resident #22 fell and fractured his/her right hip. Resident #19 fell and sustained lacerations to the forehead and lip and a right temporal mild traumatic subarachnoid hemorrhage (bleeding in the space between the brain and the tissue covering the brain). Resident #55 fell and sustained a laceration to the forehead. The facility census was 75. 1. Review of the facility policy, Resident Accident/Incident, revised (MONTH) 2005, showed the following: -The Accident/Incident report is completed for all accidents/incidents where there is injury or the potential to result in injury to the resident or others; -This includes bruises, skin tears, falls, or other incidents/accidents not elsewhere classified; -The Fall Scene Investigation Report will be completed for all falls; -Procedure: The licensed nurse shall: 1. After a fall, the following will be assessed before a resident is moved: vital signs, pain (location, type, and intensity), orientation, level of consciousness, skin integrity, body alignment (range of motion and rotation of limbs;) 2. Provide emergency care if indicated; 3. Obtain all information surrounding the accident/incident; 4. Notify the physician and the designated contact person by phone of any accident/incident resulting in an injury that may have the potential need for medical attention; 5. Following an accident that results in a head injury, take vital signs and do neuro checks every 15 minutes x 4, every 30 minutes x 2, and then every four hours x 2; 6. Document in the medical record all action taken and any injuries found; 7. Fill out accident/incident report form or fall scene investigation report completely depending on the incident; 8. Turn in the completed form to Director of Nursing (DON) for review; 9. The DON and Administrator shall review, track, and follow up with accidents/incidents as necessary; The policy did not include the review and/or implementation of interventions after a resident falls. 2. Review of Resident #22's falls scale observation, dated 12/10/18, showed the following: -The resident had a fall in the last three months; -The resident used crutches, cane, or walker; -The resident's gait/transfer status was impaired; -The resident was oriented to his/her own ability; -The resident was at high risk for falls. Review of the resident's significant change Minimum Data Set (MDS), a federally mandated assessment completed by facility staff, dated 12/13/18, showed the following: -His/her cognition was moderately impaired for making daily decisions; -He/she had a [DIAGNOSES REDACTED].>-He/she did not reject care; -He/she required extensive assistance from two staff with bed mobility, transfers, toilet use, and walking in his/her room; -He/she was not steady and only able to stabilize with human assistance with transferring from a seated to standing position, on and off toilet, and surface to surface transfers; -Care areas triggered included falls. -He/she had one non-injury fall since previous assessment. Review of the resident's physician's order sheet (POS), dated 1/1/19 to 1/31/19, showed the following: -His/her [DIAGNOSES REDACTED]. -Functional capacity: two staff assist with transfers, up in wheelchair as needed, and use of stand-up or Hoyer lift as needed; -Encourage resident to lay down in bed and elevate legs; -Special instructions: if resident refused to lay down, notify resident's family every shift; day shift, evening shift, and night shift (ordered 1/11/19). Review of the resident's progress notes, dated 1/11/19 to 1/31/19, showed no evidence the resident's family was notified of the resident's non-compliance with lying down. Review of the resident's event report, dated 1/22/19, showed the following: -Event date: 1/22/19 at 7:10 A.M.; -Location of fall: resident's room; -Resident was noted sitting on side of his/her bed prior to the fall; -Fall was unwitnessed; -There were no injuries; -Immediate interventions taken: none -Outcome of interventions: there were no interventions used. Review of the resident's care plan, last updated on 1/25/19, showed the following: -Problem: He/she was forgetful and had poor safety awareness; -He/she required one or two staff to assist with transfers; -Encourage him/her to lay down in bed or sit in the recliner to elevate his/her legs and decrease risk of falling out of his/her wheelchair. He/she usually refused, but please keep trying; -Remind him/her to adjust his/her position or encourage him/her to sit in the recliner if he/she appeared to be too close to the edge of his/her bed; -Handwritten note dated 1/25/19. The resident fell on [DATE] and 1/22/19. His/her refrigerator was moved so he/she could access it safer. Staff was directed to change his/her gripper socks when they were wet to prevent falls. He/she would often sit on the side of the bed and fall asleep. Staff was to encourage him/her to either lay down in bed or offer to transfer him/her to a recliner or wheelchair. He/she often refused to lay down and could be hateful or yell at you. Staff was to give words of encouragement and try again. If he/she still refused, have someone else try and report to the charge nurse. Review of the facility's Fall Scene Investigation Report, dated 2/11/19, showed the following: -The resident fell on [DATE] at 7:10 A.M.; -Factors observed at the time of the fall included the resident slid off the side of the bed; -The fall was unwitnessed and he/she was found on the floor; -Prior to the event, the resident was noted rolling/sliding out of the bed; -The resident was alone and unattended at the time of the fall; -The resident said he/she was sitting too close to the edge of the bed and slid out; -The resident was bare footed at the time of the fall; -Re-creation of the previous three hours prior to the fall showed the resident had been in bed sleeping; -Root cause of this fall included the resident's mood and/or mental status, and the resident was sitting too close to the edge of the bed; -There were no initial interventions documented to prevent further falls; -On 2/11/19 (20 days after the fall occurred), additional care plan/nurse aide assignment updates included to encourage the resident to lay down and not sit on the edge of the bed due to falling asleep and safety. Review of the resident's progress notes, dated 2/11/19 at 12:32 P.M., showed the following: -Performance Improvement Plan (PIP) meeting was held regarding the resident's fall that occurred on 1/22/19; -The resident sits on the edge of his/her bed, falls asleep, and slides off the bed; -Staff was to encourage the resident to either lay down in bed or get in a chair for safety. Review of the resident's POS, dated 3/1/19 to 3/31/19, showed the following: -His/her [DIAGNOSES REDACTED]. -Functional capacity: two staff assist with transfers, up in wheelchair as needed, and use of stand up or Hoyer lift as needed; -Resident was to elevate his/her bilateral lower extremities when not at meals or activities; -Special instructions: if resident refused to lay down, notify resident's family every shift; day shift, evening shift, and night shift (ordered 1/11/19). Review of the resident's progress notes, dated 3/1/19 to 3/31/19, showed there was no documentation to show the resident's family was notified of the resident's non-compliance with lying down. Review of the resident's event report, dated 3/2/19, showed the following: -Event date: 3/2/19 at 4:00 A.M.; -Location of fall: resident's room; -Resident was noted sitting on side of his/her bed prior to the fall; -Fall was unwitnessed; -The resident complained of excruciating/worse possible pain in his/her right hip; -Immediate interventions taken: none -Outcome of interventions: there were no interventions used. Review of the resident's nursing progress note, dated 3/2/19 at 4:00 A.M., showed the following: -He/she was summoned to the resident's room where the resident was noted to be on the floor lying on his/her left side; -The resident complained of severe right hip pain; -The resident was sent to the emergency room . Review of the resident's hospital medical records, dated 3/2/19, showed the following: -The resident was transferred from another hospital for a new onset of peri-prosthetic (previous artificial implant) [MEDICAL CONDITION]; -The resident reportedly had a ground-level accidental fall and landed on his/her right hip; -Imaging showed an acute [MEDICAL CONDITION] femoral shaft (thigh bone, situated nearer to the center of the body or point of attachment); -The resident's past medical history included dementia and right hip arthroplasty (reforming of hip joint) [AGE] years ago; -He/she stated he/she normally mobilizes in a wheelchair, but did occasionally walk with use of a walker; -treatment of [REDACTED]. Review of the resident's hospital discharge summary, dated 3/5/19, showed the resident was discharged back to the facility for a non-op (no surgical repair) trial. The resident was at high risk from a cardiac (heart) standpoint in a perioperative (time period for surgical procedure) setting. Review of the facility's Fall Scene Investigation Report, dated 3/8/19, showed the following: -The resident fell on [DATE] at 4:00 A.M.; -Factors observed at the time of the fall included the resident slipped and slid off the side of the bed; -The fall was unwitnessed and he/she was found on the floor; -Prior to the event, the resident was noted rolling/sliding out of the bed; -The resident was alone and unattended at the time of the fall; -The resident said he/she just slid off the bed; -The resident was barefoot at time of the fall; -Re-creation of the previous three hours prior to the fall showed the resident was asleep in his/her bed while sitting on side of bed. Nursing assistant asked the resident to lay down in bed, but resident would not comply; -Root cause of this fall included footwear and the resident's mood and/or mental status, and the resident was sitting too close to the edge of the bed; -Resident would not lay down in bed properly and would only sit on the edge of the bed. All staff requested him/her to lay down, but he/she refused to comply; -There were no initial interventions documented to prevent further falls; -On 3/8/19, additional care plan/nurse aide assignments updates included staff education on the importance to encourage the resident to lay down. Staff was instructed to call the resident's family if he/she refused to lay down. Staff was to offer to transfer the resident to the recliner or wheelchair (resident returned from the hospital on [DATE] and interventions were not added until three days after his/her return). During an interview on 3/8/19 at 2:55 P.M., Certified Nursing Assistant (CNA) I said the following: -The resident required staff encouragement to lay down; -The resident now required the use of a Hoyer lift for all transfers because he/she was unable to sit up after his/her fall on 3/2/19. During an interview on 3/12/19 at 1:05 P.M., Licensed Practical Nurse (LPN) J said the following: -He/she was the charge nurse on 3/2/19 when the resident fell ; -The resident was on hourly checks and everyone working went by his/her room and instructed him/her to scoot back if he/she was too close to the edge of the bed; -He/she was in the resident's room approximately 10 minutes prior to the fall and encouraged him/her to lay down, but the resident was rude and non-compliant with his/her encouragement; -The resident had wraps on both feet that were slick; -He/she was pretty sure the resident had grippy socks on and was not sure why it was documented on the event report that he/she did not; -He/she was at the nurse's desk when he/she heard the resident holler for help; -He/she went to the resident's room and noted the resident was on the floor complaining of right hip pain; -The resident's family was not made aware of the resident's non-compliance with lying down because he/she had spoken to the family prior to the incident on 3/2/19, and they requested to be notified during waking hours only unless for emergencies; -There is a place on the fall paperwork for the charge nurse to complete what interventions they felt would be appropriate for the resident, but essentially it was the fall review board that made the final decision and placed the interventions on the resident's care plan; -The resident had slid out of bed several times, but never had sustained an injury; -There were no other interventions in place to prevent him/her from falling from the bed other than frequent monitoring every hour and encouraging him/her to lay down, but he/she was non-compliant; -The administrator, DON, assistant director of nursing (ADON), and department heads met every morning. He/she was not included in the morning meetings. After the meetings, they provided a typed document that instructed staff if residents needed any special cares such as every 30 minute checks, if they were non-compliant, or other specifics with regards to resident's care needs. During an interview on 3/20/19 at 10:20 A.M., the resident's family member said the following: -The resident would generally listen to family and they could possibly persuade the resident to be compliant with lying down; -Staff was instructed to notify the resident's family day or night when the resident was being non-compliant to staff's requests such as laying down; -There were no parameters on what time of day staff could not call; -The facility staff never called the family to make them aware of the resident's non-compliance with lying down. During an interview on 3/8/19 at 5:57 P.M., the DON said the following: -The resident had a couple of incidents of sliding out of the bed and maybe another out of his/her wheelchair prior to the fall on 3/2/19; -He/she expected staff to review/revise interventions on the resident's care plan after the resident fell on [DATE] before 2/11/19. It was not an appropriate time frame to update the care plan 20 days after the fall; -Staff was expected to offer the resident to sit in the recliner and to frequently encourage/educate the resident not to sit on the side of the bed; -The resident's status had declined since the fall on 3/2/19; he/she was unable to throw his/her legs out of bed now and he/she required the use of a Hoyer lift for transfers; -He/she did not consider the resident was at risk for falling now because he/she was in bed and unable to move due to the [MEDICAL CONDITION]. 3. Review of Resident #19's admission nursing assessment, dated 9/13/18, showed the resident's [DIAGNOSES REDACTED]. Review of the resident's fall scale observation, dated 9/14/18, showed the resident was at high risk for falls. Review of the resident's admission MDS, dated [DATE], showed the following: -Short and long-term memory problems; -Moderately impaired daily decision making; -Inattention present, fluctuates; -Disorganized thinking present, fluctuates; -The resident had a fall in the last month prior to admission; -The resident had a fall in the last two to six months prior to admission; -The resident had a fracture related to a fall in the six months prior to admission; -Required extensive assist of two or more staff for transfers; -Required limited assist of one staff member to walk in room and corridor. Review of the resident's admission care plan, dated 9/16/18, showed the following: -I need help with my cares; -I am alert to person and family; -I need one to two people to help transfer me in/out of chairs or bed; -I have a walker for transfers and to ambulate to/from meals with one to two people and a gait belt; -I am a HIGH FALL RISK so please monitor me closely and frequently; -I have a wheelchair for long distances but I need to be in a regular chair at meals to help prevent me from falling; -Please sit me at an assisted table in the special needs unit (SNU) dining room for closer supervision; -If I am in my wheelchair, I can propel myself or you can push me but DO NOT leave me in the wheelchair because I will unlock the brakes, get up on my own and have a risk of falling; -I have dementia and am hard of hearing; -Please use slow short simple phrases and yes or no questions when talking to me so I may understand better; -I will often try to get up on my own and have the risk of falling; -I have had several falls because of my memory; -I am not as steady as I used to be but in my mind I still think I can do what I used to; -If I am restless at night, please place me in the recliner at the nurses' station for closer supervision; -If I am in my bed, please check on me every hour to make sure I am not restless and try to get up because I do not want to fall. Review of the resident's progress notes, dated 9/20/18 at 8:42 P.M., showed the following: -The resident had a fall in the dining room area at 4:00 P.M.; -He/she had been taken to the bathroom and then in wheelchair to his/her table with wheels locked; -This fall was not witnessed but he/she had managed to unlock the wheelchair and stood by himself/herself and obviously was not able to bear his/her own weight and went to the floor; -The resident was assisted into a straight back chair; -Observed resident push table away from him/her several times with attempt to stand; -He/she followed verbal redirection. (Staff did not follow the interventions in the resident's care plan at the time of this fall and left the resident in his/her wheelchair.) Review of the resident's medical record showed no fall scene investigation report for the 9/20/18 fall. Review of the resident's fall event report, dated 9/20/18, showed the following: -Possible contributing factors: multiple falls prior to coming to this facility with aged bruising to face, upper and lower extremities and perineal area; -Interventions-Immediate measures taken: none. Review of the resident's progress notes, dated 9/21/18 at 12:19 P.M., showed the following: -PIP meeting for fall on 9/20/18; -Resident is receiving therapy; -Walk to dine initiated to help keep wheelchair out of dining room and prevent falls. Review of the resident's care plan showed no evidence staff modified current interventions or developed new interventions to prevent further falls after the resident fell on [DATE]. Review of the resident's fall scene investigation report, dated 9/27/18 at 12:00 A.M., showed the following: -Fall summary: found on the floor (unwitnessed); -Describe initial interventions to prevent future falls: blank. Review of the resident's progress notes, dated 9/27/18 at 6:38 A.M., showed the following: -Resident was found on the floor in front of his/her bathroom; -He/she was transferring himself/herself to the bathroom using his/her wheelchair as a walker. Review of the resident's progress notes, dated 9/27/18 at 11:40 A.M., showed the following: -PIP meeting for fall on 9/27/18; -Staff to check the resident every hour if in bed in room. If restless, then place at the nurses station in recliner for closer supervision; -Education to staff. Review of the resident's fall event detail report, dated 9/27/18, showed no evidence staff identified interventions/immediate measures taken following the fall. Review of the resident's care plan showed no evidence staff modified current interventions or developed new interventions to prevent further falls after the resident fell on [DATE]. Review of the resident's fall event detail report, dated 9/28/18, showed the following: -Event date: 9/28/18 at 4:10 P.M.; -The resident sat on the edge of recliner and slid out; -Interventions-Immediate measures taken: none. Review of the resident's fall scene investigation report, dated 9/28/18 at 11:25 P.M., showed the initial intervention to prevent future falls was to toilet the resident more frequently and hopefully have him/her negative for [MEDICAL CONDITION] (a bacterium which infects humans, and other animals. Symptoms can range from diarrhea to a serious and potentially fatal inflammation of the colon) so staff don't have to take resident to his/her room to toilet. Review of the resident's care plan showed no evidence staff modified current interventions or implemented new interventions to prevent further falls after the resident fell on [DATE]. Review of the resident's progress notes, dated 10/3/18 at 12:30 P.M., showed the following: -Resident in dining room; -Staff was in room and the resident got up on his/her own; -When staff saw the resident, the resident was falling to his/her left. The resident went down on his/her buttocks, then laid down. Review of the resident's fall scene investigation report, dated 10/3/18 at 12:30 P.M., showed initial interventions to prevent future falls included the resident will be moved to a table with feeders to be closely supervised. Review of the resident's medical record showed no fall event detail report dated 10/3/18. Review of the resident's care plan, revised 10/4/18, showed the following: -I had falls on 9/20/18, 9/27/18, 9/28/18 and 10/3/18; -Please provide closer supervision at all times to help decrease my falls; -If I am restless, you can walk me with my walker. Review of the resident's progress notes, dated 10/5/18 at 12:21 P.M., showed the following: -PIP meeting today for falls on 9/28/18 and 10/3/18; -Resident continues to have decreased safety awareness due to dementia and tries to get up on his/her own; -Staff educated for closer supervision, walking with walker when restless and sitting at the assisted feeding table in the SNU dining room for closer supervision. Review of the resident's progress notes, dated 10/21/18 at 6:23 A.M., showed the following: -Resident stated he/she was going to the bathroom and fell ; -Resident has a four centimeter (cm) laceration above left eyebrow, abrasion on left cheek and has a busted upper lip; -No other injuries noted; -Physician called at 4:15 A.M.; -ER called at 4:23 A.M.; -Ambulance picked up at 4:35 A.M. Review of the Emergency Department disposition summary, dated 10/21/18, showed the following: -Examination of the cranium, the face, the neck does not reveal any obvious foreign bodies other than the laceration that is somewhat arrowhead shaped above the left eyebrow; -A small abrasion to his/her left check with a slight skin tear that is not repairable; -He/she also has a small superficial laceration to the upper lip at the philtrum (a vertical indentation in the middle area of the upper lip) approximately 7 millimeters (mm) in length and maybe 1 mm in depth and width; -He/she also has a laceration to the right lower lip which is S shaped in nature approximately 1 cm in total length superficial minimally through the first layer of skin and does cross the vermillon border (also called margin or zone, is the normally sharp demarcation between the lip and the adjacent normal skin); -He/she is given Keflex (antibiotic) seven day supply [MEDICATION NAME] for his/her deep wound to the left supraorbital rim. Review of the resident's fall scene investigation report, dated 10/21/18 at 4:00 A.M., showed initial interventions to prevent future falls included to keep the resident's call light in reach, instruct the resident to call for help, and constant checking. Review of the resident's progress notes, dated 10/21/18 at 11:15 A.M., showed the following: -Resident returned to facility; -Has bandage on forehead, scrape on left cheek and lacerations to mouth. Review of the resident's progress notes, dated 10/21/18 at 2:00 P.M., showed the following: -Called to resident's room by family member; -Resident found sitting on floor by bed; -Resident noted to have bruising and some swelling around left eye, looked like glasses had been smashed into this area; -Areas cleaned and new bandage applied. Review of the resident's fall scene investigation report, dated 10/21/18, showed no evidence initial interventions to prevent future falls were identified. Review of the resident's fall event detail report, dated 10/21/18 at 6:04 P.M., showed no evidence interventions/immediate measures were taken following the fall. Review of the resident's progress notes, dated 10/26/18 at 11:40 A.M., showed the following: -PIP meeting today for falls on 10/21/18; -Resident continues to get up on his/her own; -Will try non-skid gripper socks at bedtime, remove mat on the floor and move resident closer to west nurses' station. Review of the resident census report showed the resident moved from room [ROOM NUMBER] to room [ROOM NUMBER] (closer proximity to the nurses' station) on 10/30/18. Review of the resident's care plan, revised 11/2/18, showed the following: -The resident had several falls recently with one requiring sutures above the left eyebrow; -Non-skid gripper socks will be put on at bedtime, mat on the floor will be removed and move me closer to the nurses' station for my safety. Review of the resident's progress notes, dated 11/8/18 at 5:15 P.M., showed the following: -The resident was found on the floor in the dining room sitting in an upright position on the floor next to his/her table; -The resident denies any injuries or discomfort. Review of the resident's fall event detail report, dated 11/8/18 at 6:57 P.M., showed interventions/immediate measures taken was one-on-one attention. Review of the resident's fall scene investigation report, dated 11/8/18, showed initial interventions to prevent future falls was one-on-one. Review of the resident's care plan showed no evidence the resident fell on [DATE], and no evidence staff modified current interventions or developed new interventions to prevent further falls after the resident fell on [DATE]. Review of the resident's progress notes, dated 11/18/18 at 11:15 P.M., showed the following: -Resident was found sitting on the floor in his/her room scooting toward the bathroom; -He/she appeared to have slid out of bed and was scooting across the floor; -No new injuries were noted. Review of the resident's fall scene investigation report, dated 11/18/18, showed initial interventions to prevent future falls was one-on-one. Review of the resident's fall event detail report, dated 11/19/18 at 1:00 A.M., showed interventions-immediate measures taken: toileted and returned to bed. Review of the resident's care plan showed no evidence the resident fell on [DATE], and no evidence staff evaluated current interventions or modified/developed new interventions to prevent further falls after the resident fell on [DATE]. Review of the resident's progress notes, dated 11/19/18 at 11:40 P.M., showed the following: -At 10:45 P.M., the resident got up from bed without assistance (bed in low position and call light in reach). Heard a loud thump. The resident had walked to the doorway of his/her room falling face first. The resident had a large amount of blood coming from his/her face. At that time noted he/she had split his/her upper and lower lip open. Small opening to the left upper eye. Applied pressure to upper left eye and to lip; -At 10:55 P.M., licensed practical nurse (LPN) placed call to 911 and spoke to the on-call physician. Family Nurse Practitioner (FNP) gave okay to send to ER; -At 11:00 P.M., ambulance here to transport resident to hospital. Review of the resident's fall event detail report completed 12/11/18 at 5:12 A.M. showed the following: -Event date: 11/19/18 at 10:45 P.M.; -Resident exhibits or complains of pain related to the fall: yes (location)-facial injuries; -On a scale of 0-10, resident rates pain 7 (severe pain, horrible intense); -Location of injury: top and lower lip split open and above left eyebrow; -Note any injury to the head, extremities, or trunk: bruising, laceration, skin tear; -Level of consciousness: lethargic/drowsy. The resident does not perceive the environment fully; responds to stimuli appropriately but slowly and with delay; -Interventions-immediate measures taken: first aid. Review of the resident's fall scene investigation report, dated 11/19/18, showed initial interventions to prevent future falls: bed alarm? Review of the resident's care plan showed no evidence the resident fell on [DATE], and no evidence staff evaluated current interventions or modified/developed new interventions to prevent further falls after the resident fell on [DATE]. Review of the critical care hospital computerized tomography (CT; an X-ray image made using a form of tomography in which a computer controls the motion of the X-ray source and detectors, processes the data, and produces the image) neurology consult, dated 11/20/18 at 4:55 A.M., showed the following findings/impression: 1. Subarachnoid hemorrhage in the right temporal lobe; 2. [MEDICAL CONDITION]; 3. Displaced bilateral nasal bone fracture; 4. Impacted bony nasal septal fracture. Review of the critical care hospital admission note, dated 11/20/18 at 7:46 A.M., showed the following: -The resident had a [MEDICAL CONDITION] as well as lip laceration repaired at outside hospital and he/she was transferred here for higher level of care after imaging revealed a right temporal mild traumatic subarachnoid hemorrhage; -Additionally a nasal fracture of unknown age was also visualized, and resident has no nasal pain or obstructive symptoms at this time. Review of the CT head or brain, dated 11/20/18 at 2:18 P.M., showed stable right middle temporal gyrus subarachnoid blood products and probably cortical contusion (a bruise of the brain tissue). Review of the resident's progress notes, dated 11/21/18 at 12:45 P.M., showed the following: -Resident returned by ambulance; -Has sutures in bottom lip, upper lip and bridge of nose up across forehead; -Numerous bruising noted on face across both cheeks; -Left arm bruise from wrist to above elbow. Review of the resident's progress notes, dated 11/30/18 at 2:41 P.M., showed the following: -PIP meeting for falls on 11/18/18 and 11/19/18; -Resident getting up on his/her own and trying to go to the bathroom and sometimes restless in bed; -Education to staff on toileting schedule and placing at the nurses' station in the recliner for closer supervision when restless. Review of the resident's quarterly fall risk evaluation, dated 12/10/18, showed the resident was at high risk for falls. Review of the resident's progress notes, dated 1/2/19 at 9:30 A.M., showed the following: -Resident in recliner in day room; -Resident stood up then decided to sit back down; -Resident was not close enough to the chair, sat on front edge, and then slid to floor; -Resident bumped left temple on arm of chair causing ½ inch skin tear to left temple. Review of the resident's fall scene investigation report, dated 1/2/19, showed the following: -Describe initial interventions to prevent future falls: one-on-one closer supervision; -Care plan updated: blank. Review of the resident's fall event detail report, dated 1/2/19 at 10:00 A.M., showed the following: -Intervent

Based on observation, interview, and record review, the facility failed to provide care in a manner that enhanced residents' dignity and ensured full recognition of individuality for two residents (Resident #11 and Resident #55), in a review of 18 sampled residents, and one additional resident (Resident #48). The facility census was 75. 1. During interview on 3/7/19 at 3:20 P.M., the Director of Nursing (DON) said the facility had no policy regarding dignity. 2. Review of the facility employee handbook, dated 2019, showed the following: -The facility strives for the maximum potential and quality of life for each resident through care, love and patience; -Even if your job does not require you to serve the resident directly, he/she depends upon you and your work, and if your primary duty is the actual care of the resident, he/she is particularly dependent upon you; -Cell phones owned by staff members will have to be used on the back employee entrance porch and/or on the patio porch during break times or during their lunch time; -All employees and residents have a right to privacy and their break times/ lunch time uninterrupted by the ringing of cell phones and phone conversations; -The residents need to have our total attention while on the job; -No employee will be allowed to have their cell phone anywhere on the floor at anytime. 3. Review of Resident #11's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 2/28/19, showed the following: -Unclear speech; -Minimal difficulty hearing; -Short and long-term memory problem; -Moderately impaired cognitive skills for daily decision making; -Required extensive assistance from two or more staff for dressing, toilet use and personal hygiene; -Required extensive assistance from one staff for eating; -Always incontinent of bladder and bowel; -[DIAGNOSES REDACTED]. Review of the resident's care plan, last revised 3/4/19, showed the following: -I am incontinent of urine and stool; -I wear a brief all the time. I need staff to check and change it throughout the day and night; -I eat a pureed diet with thin liquids; -I can feed myself if you get everything ready for me but I sometimes spill food, so I will need you to monitor and help me if I am getting more on the floor than in his/her mouth; -I have dementia probably caused from a stroke. The stroke and dementia cause me to have poor safety awareness, problems communicating and moody behaviors; -I have some difficulty understanding, so I need you to speak to me slowly using short simple directions, and give me time to respond or complete task. Observation on 3/6/19 at 7:24 A.M. showed the following: -The resident lay in bed; -The resident was incontinent of urine; -Certified Nurse Aide (CNA) B's cell phone rang four times while CNA B provided incontinence care, assisted the resident with dressing, and transferred the resident to his/her wheelchair; -CNA B's cell phone played get back mother [***] you don't know me like that . whoa whoa why you all up in here talking[***]repeatedly as CNA B provided resident care; -CNA A told the resident, You're alright for a white guy/girl as he/she lifted the resident with the mechanical lift; -CNA B said That's racist; -CNA A said I don't care. During interview on 3/8/19 at 8:51 A.M., CNA B said the following: -He/she should not have his/her cell phone while doing resident care; -The ring tone was not appropriate for the resident to hear; -He/she didn't know his/her ringer was turned on. He/she should not have his/her ringer on. During interview on 3/8/19 at 8:53 A.M., CNA A said the following: -The facility has a policy on cell phones; -CNA B was not supposed to have his/her cell phone on him/her; -CNA B's ring tone was inappropriate in front of the resident; -He/she didn't think it was racist to say you're alright for a white guy/girl to a resident. Observation on 3/6/19 at 2:06 P.M. in the Special Needs Unit sitting area showed the following: -The resident sat in a recliner; -CNA C passed out afternoon snacks; -CNA C stood beside the resident's recliner and fed the resident a pudding cup from the standing position. 4. Review of Resident #48's quarterly MDS, dated [DATE], showed the following: -Unclear speech; -Short and long-term memory problem; -Severely impaired cognitive skills for daily decision making; -Required extensive assistance from one staff for eating; -[DIAGNOSES REDACTED]. Review of the resident's care plan, last revised 2/4/19, showed the following: -I eat a pureed diet with nectar thick liquids with a straw because I won't wear my teeth; -Please encourage and cue me to feed myself. If you give me the first bite and leave the spoon in my mouth, sometimes I will feed myself. Please try this a few times before you feed me yourself. Observation on 3/6/19 at 2:08 P.M. showed the resident sat in a recliner in the Special Needs Unit sitting area. CNA C stood beside the resident's recliner and fed the resident a pudding cup from the standing position. Observation on 3/7/19 at 2:02 P.M. showed the resident sat in a recliner in the Special Needs Unit sitting area. CNA C stood up beside the resident's recliner and fed the resident a pudding cup from the standing position. During interview on 3/7/19 at 2:20 P.M., CNA C said the following: -He/she works the 2:00-10:30 P.M. shift; -One of his/her duties was to pass afternoon snacks; -He/she stands while feeding residents afternoon snacks as it does not take long; -He/she sits down during feeding at meals. 5 .Review of Resident #55's quarterly MDS, dated [DATE], showed the following: -Unclear speech; -Sometimes understands verbal content; -Short and long term memory problem; -Moderately impaired daily decision making; -Inattention present, fluctuates; -Disorganized thinking present, fluctuates; -Wandering occurred daily; -[DIAGNOSES REDACTED]. Review of the resident's care plan, last revised 2/4/19, showed the following: -I am difficult to redirect; -Make sure I don't need to go to the bathroom, need a drink or snack; -The best thing to do is just leave me alone and periodically check on me; -Please use short phrases when speaking to me so I will hear you and understand better; -Monitor for any increases in anxiety and report to the charge nurse. Observation on 3/5/19 at 2:32 P.M. showed the following: -The resident sat in his/her wheelchair; -The resident wandered up and down the SNU hallways and throughout the common dining and sitting areas; -Activity Aide G tried to get the resident to sit beside him/her; -Activity Aide G told the resident to Chill out; -The resident continued to talk non-sensical and propel himself/herself throughout the unit. During interview on 3/8/19 at 3:20 P.M., Activity Aide G said he/she did not remember telling the resident to chill out. 6. During interview on 3/8/19 at 10:25 A.M., Licensed Practical Nurse (LPN) D said the following: -CNAs are not supposed to have their cell phones; -It was inappropriate for staff to have their cell phones playing curse words in the presence of a resident; -It was inappropriate for staff to tell a resident he/she was alright for a white guy/girl; -Staff should sit while feeding residents. During interview on 3/8/19 at 4:34 P.M., the DON said the following: -It would not be appropriate for staff to allow their cell phone to ring with profanity while providing resident care. This would be a dignity issue; -Staff should not have their cell phones on their person; -It would not be appropriate for staff to call a resident a white guy/girl; -It would not be appropriate for staff to tell a resident to chill out; -She would expect staff to sit while feeding residents. During interview on 3/8/19 at 5:27 P.M., the administrator said the following: -CNA staff should not have their cell phones in resident care areas; -Cell phones should be on silent; -It would not be appropriate for staff to allow their cell phone to ring with profanity while providing resident care; -It is probably not appropriate to tell a resident to chill out; -She would expect staff to sit while feeding residents.

Based on observation, interview, and record review, the facility failed to ensure nursing staff washed their hands after each direct resident contact; failed to wear gloves and change gloves during direct resident personal care and urinary catheter (sterile tube inserted to drain the bladder of urine) care and when indicated by professional standards during pressure ulcer (a localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and /or friction) care and during administration of medication through a gastrostomy tube (a tube inserted through the abdomen that delivers nutrition directly to the stomach) for four of 18 sampled residents (Residents #11, #25, #35 and #65) ). The facility census was 75. 1. Review of the facility's undated policy for hand washing showed the following: -Hand washing remained the single most effective means of preventing disease transmission; -Hands should be washed often and well, paying particular attention to around and under fingernails and between fingers; -Wash hands whenever they were soiled with body substances, before food preparation, before eating, and after using the toilet, before performing invasive procedures and when each resident's care was completed; -The use of antiseptic hand washing soaps were recommended during outbreaks, following gross contamination, and prior to performing invasive procedures. 2. Review of the facility policy Body Substance Precautions from the Infection Control Guidelines for Long Term Care Facilities, (MONTH) 2005 edition, Section 3.0, Subsection 3.2 Implementing the Body Substance Precautions System, showed the following regarding gloves and handwashing: -Instructions should be followed by ALL personnel at all times regardless of the resident's diagnosis; -Gloves: Wear gloves when it can be reasonably anticipated that hands will be in contact with mucous membranes, non-intact skin, any moist body substances (blood, urine, feces, wound drainage, oral secretions, sputum, vomitus, or items/surfaces soiled with these substances) and/or persons with a rash; gloves must be changed between residents and between contacts with different body sites of the same resident; -REMEMBER: Gloves are not a cure-all; they should reduce the likelihood of contaminating the hands, but gloves cannot prevent penetrating injuries due to needles or sharp objects; dirty gloves are worse than dirty hands because microorganisms adhere to the surface of a glove easier than to the skin on your hands; and handling medical equipment and devices with contaminated gloves is not acceptable; -Handwashing: Handwashing remained the single most effective means of preventing disease transmission; wash hands often and well, paying particular attention to around and under fingernails and between the fingers; wash hands whenever they are soiled with body substances, before food preparation, before eating, after using the toilet, before performing invasive procedures and when each resident's care is completed. 3. Review of the Certified Medication Technician Student Handbook, 2008 Revision, Lesson Plan 11 showed general principles of medication administration included the following: -Concentrate on safe preparation and administration of medications. Avoid distractions and interruptions; -Wash hands or cleanse hands with antibacterial gel before preparing medication and before and after resident contact. Use gloves when necessary. 4. Review of Resident #25's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument, completed by facility staff, dated 12/18/18, showed the following: -Required limited assistance of one staff member with personal hygiene; -Required an indwelling catheter (sterile tube inserted to drain the bladder of urine); -Always incontinent of bowel; -Had two Stage 3 unhealed pressure ulcers (a full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed). Review of the resident's care plan, revised on 12/19/18, showed the following: -The resident had pressure ulcers. Staff should provide wound care and dressing changes as physician ordered; -The resident required assistance with cares. The resident was mostly on bedrest to help wounds heal. He/she was able to move arms but had limited movement with both legs. The resident had a suprapubic urinary catheter (sterile tube surgically inserted through the lower abdominal wall into the bladder to drain urine) and was incontinent of feces. Staff should reposition the resident in bed and provide incontinence care. Review of the resident's Physician Order Sheet (POS), dated 2/22/19, showed the following: -[DIAGNOSES REDACTED]. -Dakin's Solution (a dilute solution of sodium hypochlorite used as an antiseptic to cleanse wounds in order to prevent infection) 0.125% (quarter percent), one application two times daily. Pack coccyx wound and right gluteal fold wound with Dakin's Solution moistened gauze, cover with dry gauze and secure with [MEDICATION NAME] (transparent occlusive dressing). Observation on 3/5/19 at 3:22 P.M. showed the following: -Licensed Practical Nurse (LPN) L obtained supplies from the treatment cart located in the hallway. LPN L and Certified Medication Technician (CMT) M entered the resident's room and put on gloves without washing their hands; -CMT M rolled the resident onto his/her left side. The resident was incontinent of feces. The resident had gauze wound dressings on his/her coccyx and right gluteal fold. The wound dressings were soiled with feces; -LPN L wiped the resident's buttocks and tailbone areas of feces and removed both of the resident's feces soiled wound dressings. The pressure ulcer on the resident's coccyx was approximately quarter size and the pressure ulcer on the resident's right gluteal fold was approximately nickel size. Both pressure ulcers were packed with gauze packing; -LPN L removed his/her gloves and washed his/her hands. He/she removed the gauze packing from the pressure ulcer on the resident's right gluteal fold; -LPN L removed his/her gloves, and without washing his/her hands, put on new gloves. He/she applied Dakin's solution on clean gauze and pushed the gauze packing into the pressure ulcer on the resident's right gluteal fold with his/her fingers. He/she covered the pressure ulcer with dry gauze and secured with transparent occlusive tape; -LPN L removed his/her gloves, and without washing his/her hands, put on new gloves, cut clean gauze into smaller pieces, and removed the gauze packing from the pressure ulcer on the resident's coccyx; -LPN L removed his/her gloves, did not washing his/her hands, put on new gloves, applied Dakin's solution on clean gauze packing, packed the pressure ulcer on the resident's coccyx with his/her fingers, covered the open ulcer with dry gauze and secured with transparent occlusive tape; -LPN L changed his/her gloves without washing his/her hands. LPN L and CMT M rolled the resident side to side. LPN L removed the feces soiled disposable bed pad and sheet and without washing his/her hands placed a clean disposable bed pad and sheet under the resident; -LPN L changed gloves without washing hands, adjusted the resident on his/her side, placed pillows behind the resident, adjusted his/her top sheet and blanket, adjusted the resident's pillow and bagged the trash. During interview on 3/7/19 at 3:25 P.M., LPN L said the following: -He/she should wash his/her hands or apply sanitizing gel every time he/she changed his/her gloves; -He/she changed his/her gloves without washing his/her hands all the time. 5. Review of Resident #65's Physician's Order Sheet, dated 2/12/19, showed the following: -Enteral feeding (tube feeding) of [MEDICATION NAME] (liquid nutrition) at 75 milliliters (ml) per hour for 20 hours continuous from 3:00 P.M. to 11:00 A.M. daily; -Nothing by mouth; -Check tube placement by verifying tube was at 4 centimeter mark prior to administration of mediations or feedings; -Mix each medication with 15 ml of water, administer medication, and then flush with 15 ml of water; -[MEDICATION NAME] (medication used for muscle spasms) 10 milligrams (mg) three times daily administer per gastrostomy tube; -[MEDICATION NAME] (antidepressant medication) 10 mg/5 ml, administer 10 ml daily per gastrostomy tube; -[MEDICATION NAME] (diuretic medication) 10 mg/ml, administer 2 ml two times daily per gastrostomy tube; -[MEDICATION NAME] (potassium supplement) 20 milliEquivilent (mEq), one packet two times daily administer per gastrostomy tube; -[MEDICATION NAME] (blood pressure medication) 200 mg one tablet every 12 hours administer per gastrostomy tube; -Montelukast (allergy medication) 10 mg daily administer per gastrostomy tube; -[MEDICATION NAME] (medication used for constipation) 17 grams daily administer per gastrostomy tube; -Therems-M (multivitamin) one daily administer per gastrostomy tube. Review of the resident's care plan, dated 2/19/19, showed the resident had a gastrostomy tube and did not take anything by mouth. He/she received all nutrition and medications through the gastrostomy tube. Observation on 3/7/19 at 9:00 A.M. showed the following: -LPN E cleansed his/her hands with alcohol based sanitizer, obtained the resident's medications from the medication cart in the hallway. He/she crushed [MEDICATION NAME], Montelukast and Therems-M individually and placed each in a separate medication cup. He/she poured liquid medications [MEDICATION NAME] and [MEDICATION NAME] into individual medications cups. He/she opened and poured [MEDICATION NAME] powder and [MEDICATION NAME] powder packets individually into a separate medication cup; -LPN E entered the resident's room and did not wash his/her hands or apply gloves. He/she sat the medication cups on the resident's bedside table, obtained two 4-ounce cups of water and added 15 ml of water to each cup of medication. He/she stirred each cup with a spoon and dissolved the medications; -LPN E opened a 60 ml syringe, removed the plunger and laid the plunger directly on the resident's bedside table; -The resident lay in bed. A continuous supplemental feeding infused from a pump through tubing into the resident's gastrostomy tube to the stomach; -LPN E did not wash his/her hands or apply gloves. He/she lifted the resident's gastrostomy tube stabilizing disk located next to the resident's abdomen, and checked the placement of the gastrostomy tube (read the measurement of length the gastrostomy tube was inserted inside the stomach). He/she stopped the continuous feeding and disconnected the pump tubing from the resident's gastrostomy tube; -Without washing his/her hands, LPN E inserted the 60 ml syringe into the open end of the resident's gastrostomy tube and poured each medication followed by 15 ml of water into the 60 ml syringe. While administering medications the gravity infusion ran slowly and LPN E with his/her bare hands touched the gastrostomy tube, pinched the tube, adjusted the stop cock mechanism and touched the stabilizing disk located next to the resident's abdomen. LPN E touched the insertion end of the pump tubing and inserted the end into the resident's gastrostomy tube open end. He/she turned on the feeding tube pump. LPN E rinsed the 60 ml plunger and syringe, inserted the plunger into the syringe for use later in the day. During interview on 3/8/19 at 10:00 A.M., LPN E said the following: -He/she should wash his/her hands prior to administering medication and prior to touching the resident's gastrostomy tube and pump tubing. He/she should wash his/her hands prior to providing any personal cares for a resident; -He/she used hand sanitizer while in the hall and did not wash his/her hands after entering the resident's room; -He/she did not wear gloves while administering the resident's medications through the gastrostomy tube. He/she did not think he/she needed to wear gloves while administering medications through a gastrostomy tube; -He/she should wash his/her hands and wear gloves prior to providing any resident care that involved potential contact with body fluids and while providing any resident care. He/she should not touch the pump tubing insertion end with soiled hands and insert the tube into the resident's gastrostomy tube; -He/she should wash hands and wear gloves before checking the resident's gastrostomy tube placement and before administering the resident's medications through the gastrostomy tube. 6. Review of Resident #11's quarterly MDS, dated [DATE], showed the following: -Required extensive assist of two or more staff for personal hygiene; -Always incontinent of bladder and bowel. Observation on 3/6/19 at 7:24 A.M. showed the following: -The resident lay in bed; -The resident's incontinence brief was saturated with urine; -Without washing his/her hands, Certified Nurse Assistant (CNA) B applied gloves and provided frontal perineal care; -With the same soiled gloves, CNA B assisted CNA A and rolled the resident to his/her right side; -CNA B provided rectal pericare and tucked the soiled incontinence brief under the resident's hips. Without removing his/her gloves, CNA B placed a clean incontinence brief under the resident's hips; -CNA B disposed of the soiled incontinence brief in the trash can and removed his/her gloves; -Without washing his/her hands, CNA B touched the resident's clean socks and sweatpants, and placed the cloth mechanical lift sling under the resident's hips. During interview on 3/6/19 at 7:40 A.M., CNA B said the following: -He/she normally washes his/her hands when entering a resident's room and before putting on gloves and after removing gloves; -He/she normally changes his/her gloves if they become dirty; -There was no reason why he/she did not change his/her gloves after performing perineal care and before placing the clean incontinence brief under the resident's hips; -He/she did not think about washing his/her hands after removing his/her gloves and before dressing the resident. 7. Review of the Resident #35's quarterly MDS, dated [DATE], showed he/she had an indwelling urinary catheter (tube inserted into the bladder to drain urine from the body). Review of the resident's care plan, last reviewed on 1/24/19, showed the following: -He/she had an indwelling urinary catheter; -He/she had frequent urinary tract infections (UTI, an infection of the urinary tract). Observation on 3/07/19 at 8:48 A.M. showed the following: -CNA P and nursing assistant (NA) Q transferred the resident from the wheelchair to the recliner; -CNA P grabbed the catheter's drainage bag (bag connected to the tubing of the catheter where urine is collected) to position it from the wheelchair to the walker. He/she then touched the catheter tubing to move the tubing out of the resident's path with non-gloved hands; -CNA P and NA Q exited the resident's room without washing their hands; -Immediately after CNA P and NA Q exited the resident's room, they entered Resident #23's room to assist him/her to the bathroom without sanitizing their hands. During an interview on 3/07/19 at 9:26 A.M., CNA P said the following: -He/she was expected to wash his/her hands when he/she entered and exited a resident's room and after touching anything dirty; -He/she was expected to wear gloves when he/she touched urinary catheters; -He/she did not wear gloves when he/she touched the resident's catheter because it was in a dignity bag, but should have worn gloves when he/she touched the catheter tubing. 8. During interview on 3/8/19 at 4:30 P.M., the Director of Nursing said the following: -Staff should wash their hands when entering residents' rooms, every time they change their gloves, and anytime their hands were soiled; -Staff should wear gloves any time they come in contact with body fluids; -Staff should change gloves and wash hands anytime their gloves were soiled and when they change from dirty to clean areas while providing cares; -Staff should wash hands before providing perineal care and before touching clean items. Staff should not touch the feeding pump tubing insertion end with bare soiled hands; -Staff should wash hands and wear gloves while administering gastrostomy tube medications. Staff should not touch the resident's gastrostomy tube insertion site with soiled hands; -Staff should wash hands prior to wound care dressing changes and wash hands every time they changed their gloves during the dressing change procedure; -Staff should wear gloves when they touched urinary catheters, including the tubing.

Based on observation, interview, and record review, the facility failed to provide access or offer fluids to three residents (Resident #47, #70 and #77) dependent on staff for accessing fluids in a review of 24 sampled to maintain proper hydration and health. The facility census was 81. 1. Review of the facility's policy Nutrition and Hydration, Care, undated, showed the following: Watch for warning signs: -Has one or more of the following; -Dry mouth; -Cracked lips; -Needs help drinking from a cup or glass; -Has trouble swallowing liquids; -Is easily confused/tired; -Report and take action: -Encourage resident to drink every time you see the resident; -Offer 2-4 ounces of water or liquids frequently; -Make sure pitcher and cup are near enough and light enough for the resident to lift; -Offer the appropriate assistance as needed if resident cannot drink without help. 2. Review of the Nurse Assistant in a Long-Term Care Facility manual, 2001 Revision, showed the following: -Water is essential to life. A person can live only a few days without water. It provides minerals but no other nutrients. The body requires 2000 to 3000 milliliters (ml) daily; -The human body is 60% water; -Illness may upset water balance; -Dehydration is an excessive loss of water from body tissues. Symptoms may include thirst, dryness of skin and mucous membranes (inside of nose and mouth), constipation, little or no urination, fall in blood pressure, rise in temperature, loss of tissue elasticity, dizziness and mental confusion; -The following are some signs a resident may be at risk for or suffer from dehydration, drinks less than six cups of liquids per day, needs help drinking from a cup or glass, has trouble swallowing liquids, frequent vomiting, diarrhea, or fever and is easily confused/tired. 3. Review of Resident #77's care plan dated 12/7/17 showed the following: -November 2013 I had a stroke; -The stroke affected my speech and my swallowing; -I cannot speak clear or loud; -I cannot take care of myself; -My left side is weak; -I have difficulty grasping things; -It is almost like my whole body is spastic when I move it; -I have a hard time swallowing my food; -I have had swallowing difficulty from my stroke; -I am on a mechanical soft diet with honey thickened liquid by spoon; -I can have(NAME)free water protocol (allows residents who are on thickened liquids to have ice chips/water between meals) with trained staff and caregivers. Review of the resident's Quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 6/05/18 showed the following: -Moderately impaired cognition; -Requires physical assist of one for eating; -[DIAGNOSES REDACTED].) Review of the resident's physician orders [REDACTED]. -[DIAGNOSES REDACTED]. -Mechanical soft diet, continue with honey thick liquids by spoon; -Two cal (a dietary supplement) 90 (cc) (a measure of volume) honey thickened supplement three times a day; -May use(NAME)Free water protocol with supervision; -Oral care must be done prior to consuming water; -Resident should sit upright and use appropriate swallowing strategies. Observation on 6/18/18 at 2:30 P.M. in the resident's room showed the following: -The resident lay awake in bed; -The resident's water pitcher sat on the nightstand across the room; -There were no fluids available within the resident's reach. Observation and interview on 6/18/18 at 4:50 P.M. in the resident's room showed the following: -The resident lay awake in bed; -The resident's water pitcher sat on the nightstand across the room; -There were no fluids available within the resident's reach; -When asked if staff offer him/her a drink when they come into the room, the resident said, no; -When asked if he/she was thirsty, the resident said, yes. Observation on 6/19/18 at 4:55 P.M., in the resident's room showed the following -Certified Nurse Assistant (CNA) J and Nurse Assistant (NA) B entered the resident's room; -Staff transferred the resident from the bed to the wheelchair; -Staff transported the resident to the dining room; -Staff did not offer the resident a drink during or after providing care. Observation on 6/20/18 at 7:15 A.M., in the resident's room showed the following: -The resident lay awake in bed; -The resident's water pitcher sat on the nightstand across the room; -There were no fluids available within the resident's reach. Observation on 6/20/18 at 7:43 A.M. in the dining room showed the following: -The resident sat at the dining room table with no drink in front of him/her; -Glasses of non-thickened water and orange juice sat at an empty space next to the resident; -The resident reached over, picked up the glass of non-thickened water and drank; -He/she ate the ice; -No staff supervised the resident; -He/she continued to hold the empty water glass to his/her mouth, an unidentified nurse walked past him/her to another resident; -The same unidentified nurse returned and walked past the resident still holding the empty glass to his/her mouth; -The resident held the empty glass to his/her mouth from 7:43 A.M. to 7:47 A.M., a total of four minutes. Observation on 6/20/18 at 11:15 A.M., showed the following: -NA B propelled the resident in his/her wheelchair to his/her room; -CNA A and NA B assisted the resident to the toilet; -Staff transferred the resident to the recliner; -Staff did not offer the resident a drink during or after providing care; -The resident's water pitcher sat on the nightstand across the room; -There were no fluids available within the resident's reach. Observation on 6/20/18 at 12:45 P.M., showed the following: -The resident sat at the dining room table; -CNA A assisted the resident with drinking thickened juice; -CNA A did not offer the glass of thickened water (that was on the table next to the juice) to the resident to drink; -NA B propelled the resident to his/her room. Observation and interview on 6/20/18 at 1:15 P.M. in the resident's room, showed the following: -The resident lay in bed; -A water pitcher sat on the nightstand across the room; -There were no fluids available within the resident's reach; -When asked if staff offered fluids, the resident said no; -When asked if he/she was thirsty the resident said yes. Observation on 6/21/18 8:55 A.M., in the resident's room showed the following: -The resident sat upright with legs extended in his/her wheelchair; -A water pitcher sat on the nightstand across the room; -There were no fluids available within the resident's reach. 4. Review of Resident #70's Annual MDS dated [DATE] showed the following: -The resident is rarely/never understood; -The resident has both short and long-term memory loss; -Requires physical assist of one for eating; -[DIAGNOSES REDACTED]. Review of the resident's care plan dated 6/07/18 showed the following: -I have Alzheimer's, and [MEDICAL CONDITION], causing me to have poor safety awareness, poor memory, and difficulty communicating; -Speak to me using short simple phrases and yes or no questions; -I probably will not understand you; -Check on me frequently; -I eat a pureed diet with nectar-thickened liquids; -I receive nectar thickened two cal with meals; -The care plan did not direct staff to provide assistance to access fluids. Review of the resident's (MONTH) (YEAR) physician orders [REDACTED]. -Pureed diet (may have mechanical soft upon request); -Continue nectar thick liquids. Observation on 6/18/18 at 12:04 P.M. to 1:05 P.M., in the dining room showed the following: -The resident sat at the assisted table; -No drinks in reach of the resident; -Registered Nurse (RN) K administered medication with a one drink of thickened liquid at 12:34 P.M.; -Dietary staff served the resident's tray and nursing staff provided assistance at 1:05 P.M. Observation on 6/18/18 at 1:45 P.M., showed the following: -CNA O and NA B transferred the resident into his/her bed; -No fluid container in the resident's room; -The staff did not offer the resident a drink during or after providing care. Observation on 6/19/18 at 4:05 P.M in the resident's room showed the following: -The resident lay in bed with his/her eyes closed; -His/her lips had dry patches with white matter at the corner of his/her mouth; -No fluid container in the resident's room. Observation on 6/19/18 at 5:07 P.M., in the resident's room showed the following: -The resident lay in bed with his/her eyes open holding onto his/her blanket; -RN K went into resident's room and administered the resident's roommate medication but did not offer fluids to the resident; -The resident's mouth was dry with white matter at the corner of his/her lips. Observation on 6/20/18 at 6:55 A.M. in the resident's room showed the following: -The resident lay in bed on his/her back with his/her eyes open; -No fluid container in the resident's room; -CNA J and NA B transferred the resident from his/her bed to the wheelchair; -NA B placed resident at the nurse's station in his/her wheelchair; -Staff did not offer the resident a drink during or after providing care. Observation on 6/20/18 at 7:05 A.M., showed the following: -NA B transported the resident to the dining room; -NA B left the resident at the dining room table with no drinks; -The resident's lips were dry and cracked; -The resident sat at the dining room table without drinks from 7:05 A.M. to 8:20 A.M. Observation on 6/20/18 at 9:30 A.M., showed the following: -CNA A and NA B propelled resident in the wheelchair to his/her room; -CNA A and NA B transferred the resident to bed; -CNA A and NA B did not offer the resident a drink during or after providing care; -No fluid container in resident's room. Observation on 6/20/18 at 11:30 A.M., showed the following: -The resident lay in bed with his/her eyes open; -No fluid container in the resident's room. Observation on 6/20/18 at 12:45 P.M. in the resident's room showed the following: -CNA J, NA B and an unidentified therapy staff member assisted the staff with transfer training for the resident; -The resident sat in the chair by his/her bed. -Staff did not offer the resident a drink during or after providing care. Observation on 6/21/18 at 9:00 A.M. in the resident's room showed the following: -He/she lay in bed with his/her eyes open; -No fluid container in the resident's room. During interview on 7/1/18 at 12:55 P.M., NA B said the following: -He/she is to offer thickened liquid drinks at meals and in-between meals; -He/she had not been trained yet to pass thickened liquid drinks; -He/she did not know the process of passing thickened liquid drinks. During interview on 6/21/18 at 9:55 A.M., CNA C said the following: -Some residents are on special diets that need thickened liquid; -He/she can tell if someone is thirsty if they are licking their lips, their mouth was parched or if they had dry debris in the corner of their mouth; -He/she has worked at the facility almost a year and has never had to offer anyone a thicken liquid drink in their room; -The dietary manager makes up the thickened drinks. During interview on 6/21/18 at 8:50 A.M., CNA D said the following: -The residents are on a pureed diet and thickened liquids; -He/she does not know if the residents are supposed to have a water pitcher in his/her rooms; -Residents appear to be thirsty when they have parched lips; -All residents with thickened liquid have swabs in their drawers; -He/she swabs residents' mouths every time he/she gives care especially if their mouth is open and appeared dry. 5. Review of Resident #47's significant change MDS dated [DATE], showed the following: -Brief interview for mental status (BIMS) of seven indicating severe cognitive impairment; -Required limited assistance of one staff member with eating; -Had a mechanically altered diet. Review of the resident's Care Plan dated 5/17/18 showed the following: -Problem: difficulty in communicating due to cognitive impairment. Interventions: resident had a stroke making speech unclear, staff to listen closely; -Problem: difficulty in swallowing. Interventions: mechanical soft diet with pureed meat and honey thick liquids. Staff to serve drinks in a nosey cup (a modified cup making it easier to access), to allow resident to drink independently. Staff to take to assisted dining room to eat. Staff to assist eating and drinking at the assisted dining table. Staff to offer appropriate drinks throughout the day with supervision; -Problem: need staff assistance with all activities of daily living (ADLS). Review of the resident's physician order [REDACTED]. -[DIAGNOSES REDACTED]. -Mechanical soft with pureed meats with honey thickened liquids by nosey cup. Observation 6/18/18 at 10:42 A.M. in the resident's room showed the following: -The resident lay in bed on his/her back; -The resident's eyes were closed, mouth was opened, lips were shriveled and cracked; -There was no water by the resident's bed or by the sink. Continuous observation on 6/18/18 in the dining room showed the following: -At 12:04 P.M. an unidentified staff member pushed the resident up to the assisted dining room table, placed a clothing protector on the resident, sat three drinks in nosey cups covered with foil on the dining room table out of the resident's reach and left the resident sitting at the table. The resident sat at the table with his/her eyes and mouth open. The resident's lips were dry and cracked, reddened with white flakes and the resident's tongue appeared dry; -At 12:15 P.M. the resident sat at the table with his/her head in his/her hands and eyes closed. The resident's drinks covered with foil sat on the table out of reach of the resident; -At 12:34 P.M. NA L removed the foil from the resident's drinks and sat the drinks on the table in front of the resident. The resident sat in the chair at the dining room table. The resident held his/her head in his/her hands and his/her eyes were closed. NA L stood beside the resident, touched the resident's shoulder and asked if he/she wanted a drink. The resident opened his/her eyes but did not respond. The drinks sat on the table in front of the resident; -At 1:05 P.M. dietary staff brought a tray to the resident. NA L sat in a chair next to the resident and assisted the resident with eating and drinking. The resident drank two of the three nosey cups (one with the white liquid and one with the purple liquid) out of the three drinks staff assisted him/her with. Observation on 6/19/18 at 9:25 A.M. in the resident's room showed the following: -The resident sat in a high back wheel chair; -NA B and CNA O transferred the resident using the mechanical lift to his/her bed; -NA B and CNA O performed perineal care, covered the resident and exited the room; -NA B and CNA O did not offer the resident a drink; -There was no water in the room for the resident; -The resident's lips and skin on his/her arms and legs were dry with white and flaky skin. Observation on 6/19/18 at 3:57 P.M. in the resident's room showed the following: -CNA P and CNA N entered the resident's room; -The resident lay in bed on his/her left side, eyes closed and mouth open; -The resident's lips were cracked,white and flaky; -CNA P and CNA N provided perineal care for the resident and dressed the resident; -CNA P and CNA N used the mechanical lift and transferred the resident to his/her high back wheel chair; -CNA P wet a wash cloth and wiped the resident's face; -CNA P combed the resident's hair and pushed the resident out of the room; -There was no water in the room for the resident. CNA P and CNA N did not offer the resident a drink. Observation 6/20/18 at 5:31 A.M. in the resident's room showed the following: -The resident lay in bed with his/her mouth open and eyes closed; -There was no water in the room for the resident. Observation on 6/20/18 at 7:40 A.M. in the dining room showed the resident sat at the dining room table, his/her mouth was open and dry, his/her lips were dry with no drinks on the table or offered to him/her. Observation on 6/20/18 at 10:00 A.M. showed the resident did not have any water in his/her room to drink. Observation on 6/21/18 at 9:11 A.M. in the resident's room showed the resident did not have water at his/her bedside or in the room for him/her to drink. During interview on 6/21/18 at 3:00 P.M. CNA N said the following: -The resident required staff to provide all cares for him/her; -The resident was not able to verbally request a drink or help due to cognitive impairment; -Staff were to offer drinks to the resident; -The resident required thickened liquid to drink; -Staff were to get the thickened liquid drink from the dietary or the dining room for the residents that required thickened liquid to drink. 6. Observation and interview 6/20/18 at 9:47 A.M. showed the following: -Hydration aide H pushed a cart down the hall with cups, a container of regular water, and cooler of ice; -Hydration aide H said he/she did not pass thickened liquid to residents that required thickened liquid to be hydrated; -Hydration aide H said the licensed nurses were responsible for passing thickened liquids to the residents that required them. Observation and interview on 6/21/18 at 9:15 A.M. showed the following: -Hydration aide I pushed a cart down the hall with cups, container of regular water, and a cooler of ice; -Hydration aide I said he/she was responsible for passing water to all the residents in the building; -He/she gave thickened liquids to the residents that required it but he/she did not have any on the cart and could not remember who the residents were that required thickened liquid; -He/she had not passed any thickened water to the residents in the building that morning; -Hydration aide I said he/she forgot to get the thickened liquid water for those residents that required it. Observation on 6/21/18 at 9:20 A.M. showed the following; -The residents' refrigerator in the clean utility closet had one open Thick and Ready Care container of thickened liquid with an expiration date of 1/6/18; -One covered cup of thickened water, dated 6/19/18. During interview on 6/21/18 at 8:55 A.M., CNA F said the following: -The facility has thickened drinks in the residents' refrigerator in the clean utility closet; -He/she has never given thickened drinks from the resident refrigerator; -If residents' lips and mouth were dry, he/she would wipe their lips off and apply Chap Stick. During interview on 6/21/18 at 10:54 A.M., Licensed Practical Nurse (LPN) E said the following: -Some residents are on special diets with thicken liquid; -He/she has worked at the facility almost a year and has never given thickened liquids to residents in their room unless it was a room tray; -The residents get thickened liquid drinks at meal times; -There is thickened liquid in the resident refrigerator behind the nurses' station. During interview on 6/21/18 at 10:00 A.M. RN R said the following: -The resident required total care from staff for all cares; -The resident required staff assistance to eat and drink; -The residents that required thickened liquid were not to have it in the room or at the bedside due to swallowing and choking risk; -The CMTs, CNAs, and licensed nurses were to offer drinks when providing cares or giving medications; -The CNAs typically go to dietary to get a drink of thickened liquid for residents that required thickened liquid to drink when they got residents up from bed; -The residents that received thickened liquid drinks received them at the dining room during meals. During interview on 6/21/18 at 9:27 A.M. Cook M said the following: -The dietary personnel were responsible for making thickened liquid for the hydration aides to pass to the residents; -He/she makes the thickened liquid, placed it in the refrigerator in the kitchen and the hydration aides had to request it; -The hydration aides had not requested thickened liquids for the residents to have in their rooms from 6/18/18 to 6/21/18. During interview on 6/21/18 at 12:15 P.M., the Dietary Manager (DM) said the following: -Nursing staff ask for thickened liquid drinks for the residents to drink in between meals; -No staff has asked for thickened liquid drinks in the past 30 days. During interview on 6/21/18 at 3:17 P.M., Director of Nursing (DON) said the following: -She would expect staff to give residents who require thickened liquids drinks in their room between meals; -Staff can make the thickened drinks or get them from the kitchen; -Hydration Aide H was not qualified and should not thicken liquid drinks to the residents that required thickened liquid; -Hydration Aide I was qualified to pass thickened liquid water to the residents that required thickened liquid; -She expected Hydration Aide I to have thickened liquid water available on his/her cart while passing the water to the residents and to offer a drink to the residents that required thickened liquid when he/she was passing the water; -Signs and symptoms of dehydration included dry mouth, dry skin, dry lips, decreased or no urine out put which is considered a no void; -She expected the nurses to give drinks when passing medications; -The residents were not being offered thickened liquid drinks in their rooms this week; -The charge nurse ensures the residents are getting drinks in between meals.

Based on observation, record review, and interview, the facility failed to monitor one resident (Resident #30), who the facility had identified at risk for falls and who had a history of [REDACTED]. for falls, assess and develop a plan of care with interventions to prevent falls for one residents (Resident #3) and failed to ensure staff used proper technique during gait belt (special belt, used to provide assistance during transfer, ambulation, or positioning in a chair) transfers for four residents (Residents #1, #2 #6, and #11) in a review of 14 sampled residents and one additional resident. The facility census was 83. 1. Review of Resident #30's patient transfer form, dated 5/11/09, showed the resident was transferred from the hospital to the nursing home with a [DIAGNOSES REDACTED]. Review of the resident's transfer form, dated 6/27/10, showed the following: -[DIAGNOSES REDACTED]. -The resident got up on own, chair alarm did go off, and resident fell to the ground. The resident was able to move all upper and lower extremities without difficulty and without pain. The resident was bleeding from back of his/her head. Pupils were sluggish and equal; -Impairments with hearing and vision; -The resident needed assistance with standing, tub and toilet. Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument required to be completed by facility staff, dated 1/13/11, showed the following: -Usually understands; -Severely impaired cognitive skills for daily decision making; -Limited assists of one staff with transfers, walking in room and corridor, locomotion on unit and toilet use; -Not steady, only able to stabilize with human assistance with moving from seated to standing position, walking (with assistive device if used), turning around, moving on and off toilet and surface-to-surface transfer (transfer between bed and chair or wheelchair). Review of the care plan, updated 1/14/11, showed the following: -The resident needs supervision to extensive assist with activities of daily living; -The resident can pivot transfer with contact guard assist of staff, gait belt and wheeled walker. He/she is on the walk to dine program; -The resident is occasionally incontinent of bowel and bladder usually at night. He/she wears a brief at all times. He/she needs limit assist of one staff to toilet before and after meals and on request; -The resident had a fall on 6/27/10 hitting his/her head causing a laceration and had to have staples. His/her family member was spoken to and it was agreed that trying the special nursing unit (SNU) would be beneficial for increased supervision; -The resident will use a body alarm in the dayroom and a bed sensor alarm when in his/her room; -The staff will answer the alarms quickly and investigate what the resident was doing at the time; -The staff will monitor the working condition of alarm each shift daily. Notify charge nurse if it is not working and they are to replace it or have maintenance repair it; -Be sure the resident is wearing comfortable and well fitting shoes; -If the resident should fall, do vital signs. Do neurological checks if he/she hits his/her head; -Keep the resident's call light within reach and remind him/her to call if he/she needs anything; -The staff will answer the call light quickly so he/she will not get what he/she needs himself/herself; -Remind the resident to not get up by himself/herself; -Visual checks often to see what the resident is doing. Review of nurse notes showed the following: -On 1/11/11 at 7:30 A.M., the resident had taken personal alarm off twice, staff had cautioned him/her about falling and getting hurt; -On 1/29/11 at 1:00 P.M., the resident had tried to get up and alarm sounded. Table was nearby and resident caught himself/herself. Resident did not fall but may have some bruises on side and back; -On 2/07/11 at 1:50 P.M., the resident had no sense of safety with multiple attempts to stand without assist, increased confusion noted with one-on-one conversation; -On 2/10/11 at 1:35 P.M., at dinner the resident unpinned personal alarm and stood up, did not understand he/she couldn't walk because he/she had been walking for many years. The resident had set off alarms two times during the shift and was found sitting on side of bed. The resident had been getting up at night with delusional thoughts and statements; -On 2/11/11 at 10:15 A.M., the resident had no sense of safety and got up without assist. Required a lot of line of sight to ensure safety; -On 2/16/11 at 3:30 A.M., the resident had taken off body alarm at beginning of shift and was found walking to chair in room with the bed mat alarm going off. For his/her safety, the resident was taken to the desk; -No further nurse note entries from 2/23/11 at 9:30 A.M. until 4/05/11 at 1:00 P.M.; -On 4/07/11 at 9:30 A.M., at 9:00 A.M. the resident was up in dining room from straight back chair with no sense of safety and fell to floor. The resident was in dining room and lying on the floor on his/her back. Blood was noted to back of the resident's head. Blood masked appearance of laceration approximately two and a half to three inches long. The resident was taken to the hospital by ambulance. Observation in the SNU on 4/07/11 at 8:50 A.M. showed the following: -A loud crashing sound in the dining room that sounded like a large piece of furniture had fallen and hit the floor; -There were no staff in the dining room or day area; -Registered Nurse (RN) I opened the door from the restroom to look in the dining room and he/she walked quickly to the resident lying on the floor; -The resident was lying on his/her back and his/her hearing aid was lying on the floor by the left side of his/her head; -There was no personal alarm noted on the resident or on the chair; -The resident had house slippers on; -There was bleeding from the back of the resident's head and he/she was complaining of the back of his/her head hurting; -The resident complained of a terrible headache; -RN I assessed the resident; -Staff placed a gait belt around the resident's waist and assisted him/her to a sitting position on the floor; -Staff applied a dressing and pressure to the back of the resident's head; -A large hematoma was noted to the left side on the back of the resident's head; -Staff wrapped the resident's head with guaze; -Three staff lifted the resident to a chair; -At 9:20 A.M., the ambulance arrived to take the resident to the hospital. Review of the patient transfer form, dated 4/07/11, showed the following: -[DIAGNOSES REDACTED]. -Needed assistance with standing, toilet and wheeled walker; -Hard of hearing; -Resident with no sense of safety got up out of chair with attempt to ambulate by himself/herself. The resident lost balance and fell to the floor. The resident was assessed with [REDACTED]. Pressure dressing applied with noted bright red blood which masked view of laceration, appeared to be approximately three inches long. 911 was notified and on the way. During an interview on 4/07/11 at 10:30 A.M., RN I said the resident did not have his/her personal alarm on. During an interview on 4/07/11 at 10:55 A.M., Certified Medication Technician (CMT) G said the resident did not have his/her personal alarm on. During an interview on 4/07/11 at 11:50 A.M., CMT G said the following: -The resident would get up from anywhere without assist because the resident had no concept of safety; -The resident was able to remove the personal alarm from himself/herself; -The resident was supposed to be in direct line of vision; -CMT G did not know why the resident did not have personal alarm on; -When the resident is on the unit, he/she ambulates with a wheeled walker and uses a wheelchair for long distances only. The resident's walker is removed at meal time to deter the resident from getting up; -When staff see the resident getting up they go right to him/her and ask if he/she needs to use the bathroom, go for a walk or find out what his/her needs are; -The resident was at risk for falls, that is why he/she was on the unit; -The staff were in the process of taking other residents to the bathroom but hadn't got to Resident #30 because he/she was one of the last ones up in the morning. The first residents to get up in the morning are taken to the bathroom first; -The resident is up ad lib; -CMT G was in the bathroom with another resident when the resident fell . During an interview on 4/07/11 at 12:00 P.M., Certified Nurse Assistant (CNA) J said the following: -He/she did not remember if he/she had brought the resident from the recliner to dining room chair this morning; -The resident is always to be in direct line of site; -The resident is a fall risk. He/she had come to the unit from the East wing because he/she was at risk for falls; -CNA J was with another resident in the bathroom when Resident #30 fell . During an interview on 4/07/11 at 12:05 P.M., RN I said the following: -There are to be two personnel on the unit at all times due to the residents with increased risk for falls; -There is a list of residents with alarms and Resident #30 usually wears a personal alarm. -Resident #30 was transferred from the East wing due to his/her decreased safety and need for more supervision. Supervision means the resident is to be in line of sight; -RN I was in the bathroom with CMT G assisting another resident when Resident #30 fell in the dining room. He/she wasn't sure if the activity aide exited the unit before or after the fall. During an interview on 4/07/11 at 1:00 P.M., the director of nursing (DON) said the following: -In general, every resident is a fall risk; -When residents are admitted , an admission assessment is completed within a few days and therapy screens the residents. If the resident has a history of falls, they are given a personal alarm; -If the resident is on the SNU, they are to be monitored closely; -When residents attempt to get up, staff are to document in the nurse notes and followed up in the care plan with interventions; -The reason residents are on the SNU is for supervision with direct line of site because they are unsafe; -The activity aide is to supervise the residents on the SNU when the nurse and nurse assistants are busy. All areas on the unit should be supervised; -Residents have the right to fall. When a resident attempts to stand that is unsafe, he/she expects staff to ask the resident why he/she wants to get up and try and meet their needs; -Unable to prevent Resident #30 from falling, he/she would have expected the activity aide to have been on the unit. During interview on 4/07/11 at 1:45 P.M., the DON said the activity aide had left the SNU before Resident #30 fell to take dirty dishes from the SNU to the kitchen. Review of Patient Transfer Form, dated 4/08/11, showed the resident was transferring from the hospital to the nursing facility. A primary [DIAGNOSES REDACTED]. This may occur spontaneously, usually from a ruptured cerebral aneurysm, or may result from head injury) and laceration, secondary [DIAGNOSES REDACTED]. Additional pertinent information showed 4/07/11 admit after fall, CT (A computed tomography (CT) scan is an imaging method that uses x-rays to create cross-sectional pictures of the body) head equal subarachnoid bleed, seven stitches in head, post fall. 4/8/11 CT of head follow up negative for bleed. 2. Review of Resident #3's quarterly MDS dated [DATE], showed the following: -Vision adequate with glasses; -Severe cognitive impairment; -Mild depression; -Independent (no help or staff oversight at any time) for bed mobility, transfer, walk in room, walk in corridor, locomotion on and off unit; -Limited assistance of one staff member for toilet use; -Balance not steady, but able to stabilize without human assistance when moving from seated to standing position, walking, turning around, moving on and off toilet and surface-to-surface transfers; -No functional limitations in range of motion; -Used walker or wheelchair for mobility; -Frequently incontinent of bladder; -Two falls with no injury since prior assessment 10/25/10; -Received antidepressant; -Did not receive any physical therapy, occupational therapy, or restorative therapy. Review of the ongoing care plan last reviewed 8/12/10 showed: -Resident has a potential for falls; -Resident has an unsteady gait and tires easily; -Monitor for decreased mobility or unsteady gait and report to the physician any changes; -Administer medications and monitor for side effects; -Antidepressant side effects included headache, dizziness, nervousness, insomnia, and blurred vision; -Monitor for decline in condition, changes in sleep pattern; -Staff to do visual checks often to see what the resident is doing; -fell on [DATE] and 1/03/11; -10/27/10, Resident gets depressed due to his/her decline in physical condition; -1/19/11, Assist resident to toilet before and after meals, at bedtime, and as needed; -2/10/11, Physical therapy 5 times a week for 90 days for gait training, therapeutic activities and procedures, neuro re-education modalities for right knee range of motion/pain, and group therapy; -3/09/11, Continue physical therapy 5 times a week for 30 days for gait training, therapeutic activities and procedures, neuro re-education modalities for right knee pain and range of motion. Review of physician's orders [REDACTED]. -[DIAGNOSES REDACTED]. -Celexa (central nervous system depressant also selective serotonin reuptake inhibitor) 40 milligram (mg) one tab daily started on 1/19/11; -Sinemet (antiparkinson agent) CR (continuous release) 50/200 mg one tab three times a day started on 3/9/11; -Lexapro (central nervous system depressant also selective serotonin reuptake inhibitor) 20 mg one tab daily restarted on 3/23/11; -Ambulate as needed with wheeled walker or cane; -Restraints: Half rails up x 2 per resident's request for bed parameters and positioning; -Restorative therapy up to 5 times weekly for bilateral upper and lower extremity therapeutic exercise started on 12/9/09; -On 3/23/11, physical therapy 3 times a week for 30 days for gait, therapeutic exercise, modalities for right knee range of motion/pain, therapeutic activities group, and neuromuscular re-education. Record review of the nurse's notes showed: -On 11/17/10 at 7:00 P.M., the resident was found sitting on the floor, no injury noted; -On 1/03/11 at 6:00 P.M., the resident slid off of the bed while trying to change his/her pants, no injury noted; -On 1/21/11 at 10:25 A.M., the resident reports he/she fell backward in room, denies striking his/her head; -On 1/22/11 at 11:30 A.M., the resident complained of being dizzy at lunch after walking down to lunch from room. After lunch the resident had trouble getting out of his/her chair to walk back to room; -On 1/22/11 at 6:00 P.M., the resident was very weak, needed help with all activities of daily living (ADLs), couldn't do anything for himself/herself. (No documentation to show if the resident's physician was notified of the decline in ADLs as directed in the resident's care plan); -On 2/08/11 at 6:10 P.M., nurse was called to the resident's room. The resident was on the floor by the door, assessment done, assisted the resident up with the help of two staff and use of gait belt; -On 2/17/11 at 2:10 P.M., resident's strength down and gait unsteady. (No documentation to show if the resident's physician was notified of the unsteady gait as directed in the resident's care plan); -On 3/12/11 at 8:45 A.M., the resident required assistance from sitting to standing; -On 3/16/11 at 1:30 P.M., the resident ambulated to lunch, gait unsteady and weak. (No documentation to show if the resident's physician was notified of the unsteady gait as directed in the resident's care plan); -On 3/26/11 at 2:00 P.M., the resident was getting more difficult to transfer, continued to decline. (No documentation to show if the resident's physician was notified of decreased mobility as directed in the resident's care plan); -On 3/29/11 at 4:30 P.M., nurse called to the resident's room, the resident was on the floor. Pupils reactive and equal but sluggish. Grips weak. The resident informed the nurse that he/she hit his/her head and complained of right hip/leg pain. External rotation noted to right lower extremity. Physician notified; -On 3/29/11 at 4:45 P.M., 911 called, ambulance in route; -On 3/29/11 at 7:00 P.M., received call from hospital, resident being admitted for right hip fracture. Review of the care plan showed staff did not revise or implement new interventions following the falls on 11/17/10, 1/03/11, 1/21/11, and 3/29/11 (which resulted in a hip fracture). During an interview on 4/07/11 at 2:00 P.M., the DON said the department heads and therapy staff meet weekly to review falls and develop new approaches. She expects staff to update the care plan with each fall and to add new approaches after each fall. 3. Review of Mosby's Nursing Drug Reference, 2010 edition, showed: -Common side effects for Celexa included- headache, dizziness, poor concentration, nervousness, anxiety, asthenia (body weakness); -Perform assistance with ambulation during use of medication, since drowsiness and dizziness occur; -Use caution with activities requiring alertness because of drowsiness, dizziness, and blurred vision; -Perform safety measures primarily in the geriatrics (old age); -Avoid other central nervous system (CNS) depressants; -Common side effects for Sinemet CR included- involuntary choreiform (rapid jerky) movement, fatigue, headache, numbness, weakness, confusion, orthostatic hypotension; -Nursing considerations for Sinemet CR included-assess orthostatic blood pressure; -Change positions slowly to prevent orthostatic hypotension; -Assess for tremors and impaired body movement; -Common side effects for Lexapro included-headache, drowsiness, dizziness, tremor, fatigue, asthenia, poor concentration; -Another side effect for Lexapro although not common included postural hypotension (form of low blood pressure that happens when you stand up from sitting or lying down); -Perform assistance with ambulation during use of medication since drowsiness and dizziness occur; -Perform safety measures primarily in the geriatrics; -Use caution with activities requiring alertness because of drowsiness, dizziness, and blurred vision; -Avoid other CNS depressants. Review of the Physician Desk Reference (PDR) showed: -The concomitant use of Lexapro with other selective serotonin reuptake inhibitors in not recommended; -Increased risk of serotoni[DIAGNOSES REDACTED] like reactions with use of other serotonergic drugs; -Symptoms of serotoni[DIAGNOSES REDACTED] include mental status changes, nausea, vomiting, diarrhea, and incoordination; Review of the Department of Health and Human Services, Agency for Healthcare Research and Quality, falls management program for long-term care showed the following: -There are five areas of fall risk and they include medications, orthostatic hypotension, vision, mobility, and unsafe behavior; -There are five drug classes that potentially impact fall risk and should be reviewed which included antidepressants (medication used to alleviate mood disorder); -List under antidepressant included Celexa and Lexapro; -Postural vital signs should be taken after meals or when the resident complains of light headedness or dizziness; -Assess the resident for unsafe behaviors; -List under unsafe behaviors included trying to stand, transfer, or walk alone unsafely, trying to climb over bed rails or get out of bed alone unsafely, walks or paces alone when too tired to be safe, and propels or walks alone in unsafe areas; -Often in nursing facilities there are residents who fall two or more times however careful assessment and care planning can reduce risk of additional falls in most residents; -Staff must have a good picture of the resident's baseline function such as known periods of weakness during the day and side effects of the medications used. From this staff can determine routine measures and respond appropriately when the resident's condition worsens. 4. Review of Resident #1's quarterly MDS, dated [DATE], showed the following staff assessment of the resident: -Required extensive assist of two staff with bed mobility and transfers; -Required extensive assist of two with toilet use; -Not steady, only able to stabilize with human assistance with moving from seated to standing position, walking (with assistive device if used), turning around, moving on and off toilet and surface-to-surface transfer (transfer between bed and chair or wheelchair). Observation on 4/06/11 at 4:20 P.M. showed: -CMT N and CNA O transferred the resident from the wheelchair to the toilet using a gait belt; -Staff placed gait belt loosely under the resident's chest. As the staff assisted the resident to his/her feet, the belt slid up across the resident's breast; -When CMT N and CNA O assisted the resident to his/her feet, the gait belt slid up to under the resident's arms. The assistants continued to transfer the resident by holding the gait belt under the resident's armpits. -CMT N and CNA O failed to properly apply and utilize the gait belt during the transfer. During an interview on 4/06/11 at 4:25 P.M., CNA O said the gait belt should be low and snug across the resident's waist, not over the resident's breasts or under his/her arms. 5. Review of Resident #2's significant change MDS, dated [DATE], showed the following: -Severely impaired daily decision making; -Extensive assist of two staff with transfers and toilet use; -Was not steady when moving from seated to standing position, moving on and off toilet, or surface-to-surface transfer (transfer between bed and chair or wheelchair), only able to stabilize with human assistance. Review of the resident's care plan, dated 2/11/11, showed the resident was unsteady on his/her feet and needed assistance from two staff for transfers. Review of the resident's physician order [REDACTED]. Observation on 4/04/11 at 6:10 P.M. showed the following: -CNA P and LPN E transferred the resident from the recliner to the wheelchair; -Staff put a gait belt around the resident's waist; -The resident would not extend his/her legs or stand up straight. He/she remained in a semi-sitting position while CNA P and LPN E struggled to get the resident in the wheelchair; -The gait belt slid to the resident's chest. LPN E had one hand on the gait belt and the other hand under the resident's arm; -During interview, both staff said the resident was approximately 50% weight bearing at this time, and at other times he/she will bare weight and assist with transfers; -CNA P and LPN E attempted to transfer the resident from his/her wheelchair to the toilet, the gait belt was around the resident's chest, the resident would not stand up straight and was digging his/her heels into the floor, resisting the transfer. Staff placed the resident on the toilet but were unable to pull his/her pants down. CMT N had assisted with the transfer and was able to pull the resident's pants down while the other two staff stood the resident up by holding onto the gait belt that was positioned around the resident's chest; -LPN E said therapy had seen the resident and recommended two to three staff with the resident during transfers or use a Hoyer lift as needed because the resident was not safe with all transfers; -CNA P and CMT N attempted to stand the resident up from the toilet and the resident would sit back down on the toilet. CMT N and CNA P held the gait belt under the resident's armpits and the gait belt was resting between their thumb and forefingers, they transferred the resident into his/her wheelchair. During interview on 4/04/11 at 6:10 P.M., LPN E and CNA P said the resident was approximately 50% weight bearing at this time, and at other times he/she will bare weight and assist with transfers. The gait belt should fit snuggly around the resident's waist and never be across the resident's chest or under his/her arms. 6. Review of Resident #6's quarterly MDS, dated [DATE], showed the following staff assessment of the resident: -Required limited assistance of one staff member for transfer; -Not steady, only able to stabilize with human assistance when moving from seated to standing position, on and off the toilet, and when transferring between bed and chair or wheelchair. Review of the resident's care plan, dated 5/03/10 and review on 1/14/11, showed the following: -Resident pivot transfers with limited assist of one; -Entry, dated 5/17/10, refuses gait belt and will not allow companion to use it; -Potential for falls, discontinued 10/20/10. Observation on 4/04/11 at 2:15 P.M. showed the following: -CNA Q and NA R assisted the resident to transfer from the toilet to the wheelchair; -CNA Q placed a gait belt around the resident's waist; -NA R placed his/her right arm under the resident's right arm, grasped the gait belt with his/her left hand at the resident's back, and assisted him/her to stand in front of the toilet; -With his/her right arm under the resident's right arm, NA R held the resident in an upright position while CNA Q grasped the gait belt with his/her left hand and cleansed the resident's peri-area (perineal) with his/her right hand; -The gait belt slid up under the resident's breast; -The resident's knees were bent and his/her feet slid on the floor during the peri-care; -NA R and CNA Q assisted the resident to turn and lowered him/her to the wheelchair. During telephone interview on 4/19/11 at 7:25 A.M., NA R said the following: -The gait belt should be placed under the resident's breast; -He/She holds the belt in the front and back when transferring a resident; -Staff should not hold a resident under the arms during a transfer. Observation on 4/06/11 at 11:45 A.M. showed the following: -CNA S transferred the resident from the wheelchair to the toilet; -CNA S placed a gait belt around the resident's waist, grasped the belt, and pulled the resident to a standing position; -The resident was unable to stand while CNA S pulled down his/her slacks and briefs and CNA S lowered the resident to the toilet; -CNA S tightened the gait belt around the resident's waist, assisted the resident to stand, and held the resident while CNA T pulled his/her slacks and briefs down; -The resident's knees were bent and his/her feet slid on the floor as CNA S held him/her with the gait belt and lowered him/her to the toilet; -CNA S assisted the resident to stand and held him/her with the gait belt while CNA T cleansed his/her peri-area; -CNA S turned and lowered the resident to the wheelchair. During interview on 4/06/11 at 11:50 A.M., CNA S said the following: -Resident #6 did not bear much weight during the transfers; -The resident does not like the gait belt and sometime refuses to allow staff to use it during transfers; -He/She always uses a gait belt when transferring the resident. During interview on 4/07/11 at 10:55 A.M., the DON said she has talked to Resident #6 about the benefits of gait belt use and the risk of not using one. She also said she did not document the conversations. 7. Review of Resident #11's annual MDS, dated [DATE], showed the following: -Severely impaired daily decision making; -Limited assist of two staff with transfers; -Extensive assist of one with toilet use; -Is not steady when moving from seated to standing position, moving on and off toilet, or surface-to-surface transfers (transfer between bed and chair or wheelchair) only able to stabilize with human assistance. Review of Resident #11's care plan dated 2/02/11, showed the resident required limited to maximum assist with activities of daily living, extensive assist of one with repositioning and was dependent for toileting. Observation on 4/06/11 at 3:30 P.M. showed the following: -LPN E and CNA O assisted the resident to transfer from the wheelchair to the toilet; -Staff placed a gait belt above the resident's waist and just below his/her breast; the gait belt was loose; -LPN E and CNA O grasped the gait belt with one arm under the resident's arm and the other arm holding onto the gait belt, pulled the resident to standing position and the gait belt slid up to over the resident's breasts. Staff continued the transfer with the gait belt over the resident's breasts. During interview on 4/06/11 at 3:35 A.M., CNA O said the following: -Staff should not place a gait belt on the resident's upper rib cage, under his/her breast; -He/She would expect the belt to stay in place and not slip up under the resident's arms. 8. During interview on 4/07/11 at 2:00 P.M., the DON said she expects staff to use a gait belt with transfers and ambulation if resident allows. He/she expects gait belt to be snug around resident's waist and not up under their arms if the resident will allow. 9. Review of the Nurse Assistant in a Long Term Care Facility student reference manual, 2001 Revised Edition, showed the following: -The nurse assistant should never transfer or ambulate residents by grasping their upper arms or under their arms; -Such a transfer could result in skin tears, damage to nerves and arteries, and possible shoulder dislocation; -Do not attempt to transfer a resident who cannot bear any weight by yourself. Determine beforehand how may people are need to transfer the resident. If it takes more than two persons to transfer the resident, use a mechanical lift; -The gait belt increases the comfort and safety of the resident during the transfer procedure; -The belt is to be applied snugly around the resident's waist over clothing below the ribs so that the nurse assistant's fingers may grasp the belt securely; -The gait belt prevents injury to the resident that could be caused by pulling on his/her arms, shoulders, or wrist; -A gait belt is required for all residents when performing transfers, ambulation, or repositioning in a chair.