Every finding on record at Mt Vernon Nursing

Based on observation, interview, and record review, the facility failed to keep food safe from potential contamination at all times when staff failed to ensure glasses were fully air dried before stored/used. The facility census was 43. Review of the facility policy, Dish and Utensil Handling, revised January, 2016, showed the following: -All silverware, dishes, and glasses shall be handled to ensure sanitary conditions and infection control; -Dishes, cups, and glasses will be air-dried prior to storing; -Flatware is to be washed twice and air-dried. Review of the 1999 Food Code, issued by the Food and Drug Administration, showed the following information: -After cleaning and sanitizing, equipment and utensils shall be air-dried or used after adequate draining before contact with food. -Items must be allowed to drain and to air-dry before being stacked or stored. Stacking wet items such as pans prevents them from drying and may allow an environment where microorganisms can begin to grow. 1. Observation on 10/07/24, at 10:27 A.M., showed the following items were found to be wet, following being washed, and sitting upside down with no air flow to allow the dishes to completely dry: -Fifty-eight coffee cups; -Forty-four plastic bowls; -Thirty-eight glass plates; -Twelve glass bowls; -Ten glass saucers; -Four metal steam table pans Observation on 10/09/24, at 9:07 A.M., showed the following items were found to be wet, following being washed, and sitting upside down with no air flow to allow the dishes to completely dry: -Fifty-six small, clear, juice cups; -Fifty-seven medium, clear, tea/milk cups; -Thirty-two plastic bowls During an interview on 10/10/24, at 12:20 P.M., Dietary Aide (DA) A said he/she did not know that dishes could not be turned upside down and placed on the trays (prevent air flow) before being completely dry. During an interview on 10/10/24, at 12:20 P.M., DA B said he/she was not aware that dishes could be stacked in a manner to prevent air flow before being completely dry. During an interview on 10/10/24, at 12:20 P.M., the Dietary Manager, said he/she had not even realized this was how the dishes were being dried. The dishes should not be stored in a way to prevent air flow/drying. During an interview on 10/10/24, at 12:20 P.M., the Director of Nursing (DON) said the following: -He/she knew dishes could not be left wet, and placed in a position that airflow is not permitted; -He/she said the dishes should always be air dried before being put away. During an interview on 10/10/24, at 12:20 P.M., the Administrator said the following: -He/she was not aware that the dishes were not being air dried before being put away until the next use; -He/she did expect staff to completely dry the dishes, and once dry, they can be places elsewhere or stacked, but not when wet. 36974

Based on record review and interview, the facility failed to notify the resident and/or the resident's representative in writing of a transfer to the hospital for three residents (Residents #20, #40 and #36) of three sampled residents. The facility census was 43. Review of the facility form titled Resident Transfer Form to ER (emergency room ), dated December 2015, showed the following to be completed by facility staff: -Date of transfer to the ER; -Resident name, date of birth; -Next of kin or health care power of attorney name and telephone number and whether notified; -Resident's diagnosis, functional status; -Reason for transfer to ER. Review of the facility form titled Notice of Transfer/Discharge Missouri, undated, showed the following to be completed by facility staff: -Resident name, facility name, Administrator, and phone number; -Date of transfer, -Reason for transfer -Right to appeal with phone numbers and addresses to appeal. 1. Review of Resident #20's face sheet (brief information sheet about the resident) showed the following: -admitted [DATE]; -Diagnoses included quadriplegia (partial or complete paralysis (loss of the ability to move) of both the arms and legs especially as a result of spinal cord injury or disease in the region of the neck), heart failure (condition in which the heart doesn't pump blood as well as it should), schizophrenia (disorder that affects a person's ability to think, feel, and behave clearly), and neuromuscular dysfunction of bladder (loss of bladder control, inability to empty bladder). Review of the resident's progress notes showed staff documented the following: -On 09/12/24, at 10:02 A.M., the resident complained of feeling very weak. The certified nurse aide (CNA) reported the resident was leaning to left side while up in wheelchair. Vital signs taken showed blood pressure 152/92 (normal 120/80), pulse 90 (normal 60 to 100, pulse oximeter 61% (normal above 92%), respirations were even and unlabored. Staff reported that the resident had been very difficult to transfer due to weakness and the resident was unable to hold legs up while propelled in wheelchair. Physician notified and resident transferred to emergency room for evaluation. Review of the resident's medical record showed facility staff did not provide a written transfer notification letter to the resident or the resident's representative. Review of the resident's progress notes showed staff documented the following: -On 09/25/24, at 1:01 P.M., therapy staff reported to the nurse the resident's heart rate was reading at 237 on the pulse oximeter monitor. The nurse was unable to obtain a manual heart rate due to very fast and irregular heart rate. Heart rate now ranging from 160s to 230s. Oxygen level reading ranging from 76 to 86% on 3 liters of oxygen. Resident stated not in pain, just felt light-headed. Physician notified and EMS contacted. Face sheet, medication list, and transfer to ER paperwork sent with resident and EMS. Resident's responsible party notified by phone. Review of the resident's medical record showed facility staff did not provide a written transfer notification letter to the resident or the resident's representative. 2. Review of Resident #40's face sheet showed the following: -admitted [DATE]; -Diagnosis included pulmonary embolism (one or more arteries in the lungs become blocked by a blood clot), atrial fibrillation (fast and irregular and often very rapid heart rate that can lead to blood clots in the heart), heart failure (chronic condition in which the heart doesn't pump blood as well as it should), and iron deficiency anemia (too few healthy red blood cells due to too little iron in the body). Review of the resident's progress notes showed staff documented the following: -On 10/04/24, at 12:05 A.M., the CNA found the resident on the floor. The CNA notified the nurse. The resident was noted to be laying on the floor on his/her right side with pillow under his/her head. The resident stated he/she was going to the bathroom. Redness noted to the cheek, shoulder, ear, and hip. Resident also had a 3 by 1 centimeter (cm) abrasion to right lateral back and denied pain. Neuro checks (series of tests and questions that evaluate a person's nervous system) and range of motion was within normal limits. Two staff transferred with gait belt (device used to help people with mobility issues move safely) from floor to bed. Resident tolerated well. Oxygen saturation noted to be at 88%. Staff initiated oxygen and notified physician and administrator; -On 10/04/24, at 12:30 A.M., staff notified the physician by phone the resident's oxygen saturation went from 88% on room air to 75% with oxygen on at 3 L by nasal cannula (NC - device used to give additional oxygen through the nose) after fall and now resident complained of severe pain when breathing deep and coughing. New order was provided to send the resident to the emergency room to evaluate and treat. Notified resident's representative of fall, condition, and order to send to the hospital. Administrator was notified of hospital transfer; -On 10/04/24, at 1:00 A.M., emergency medical services (EMS) left with resident at 12:50 A.M. Review of the resident's medical record showed facility staff did not provide a written transfer notification letter to the resident or the resident's representative. 3. Review of Resident # 36's face sheet showed the following information: -admitted [DATE]; -Diagnoses included diabetes, viral hepatitis (an infection that causes liver inflammation and damage), pneumonia, depression, and obesity. Review of the resident's progress notes showed staff documented the following: -On 10/08/24, at 8:20 A.M., the nurse documented that the resident was displaying severe confusion and anxiety, continuously yelling out for help instead of using his/her call light and stating he/she can't breathe, doesn't know where he/she is, thought his/her leg had been stabbed and thought he/she was gushing blood. These behaviors were not normal for the resident. Vital signs taken showed all within normal limits. The resident was her own person and the resident requested that the nurse speak with the resident's daughter. The daughter was notified and requested that the resident be sent to the hospital for evaluation. The physician was notified. Emergency Medical Services were notified and arrived to transport the resident. Review of the resident's medical record showed facility staff did not provide a written transfer notification letter to the resident or the resident's representative. 4. During an interview on 10/10/24, at 1:20 P.M., Licensed Practical Nurse (LPN) E said the nursing staff have transfer packets that included a transfer form that was completed and given to the EMTs, along with copy sent to medical records office. The nurse contacted the family by phone for transfer notice. He/she did not send any information in writing to the resident or resident's representative. 5. During an interview on 10/10/24, at 1:30 P.M., the Infection Preventionist said that when a resident was sent to the hospital the nursing staff complete the transfer form and send with EMS. The nurse notified family by phone. He/she did not mail any information to family. He/she did ensure a copy of the transfer form was given to medical records. 6. During an interview on 10/10/24, at 1:40 P.M., the Director of Nursing (DON) said when a resident was sent to the hospital the nursing staff completed a transfer form and sent with EMS. This information included all resident pertinent medical history. The nurses contact the family/guardian by phone. 7. During an interview on 10/10/24, at 1:55 P.M., with the Administrator and Medical Records. The Administrator said the nursing staff complete a transfer form that was sent with EMS when transferring a resident. The form included all pertinent medical history. The nursing staff contact family and guardians by phone. 48187

Based on record review and interview, the facility failed to notify the resident and/or the resident's representative in writing of the bed hold policy for a transfer to the hospital for three residents (Residents #20, #40 and #36) of three sampled residents. The facility census was 43. Review of the facility policy titled, Bed Hold Policy and Agreement Form, dated February 2014, showed the following: -Purpose to establish policy and procedure for facility to notify the resident/responsible party of the bed hold policy and agreement to pay charges for bed hold; -The bed hold agreement is to be obtained for each occurrence, hospital or therapeutic home leave; -When hospital or therapeutic home leave is reported on the midnight census, the business office will notify the resident/responsible party to sign the bed hold agreement; -The business office will address weekend or holiday transfers on the next business day; -A telephone call may be documented as notification of bed hold agreement. 1. Review of Resident #20's face sheet (brief information sheet about the resident) showed the following: -admitted [DATE]; -Diagnoses included quadriplegia (partial or complete paralysis (loss of the ability to move) of both the arms and legs especially as a result of spinal cord injury or disease in the region of the neck), heart failure (condition in which the heart doesn't pump blood as well as it should), schizophrenia (disorder that affects a person's ability to think, feel, and behave clearly), and neuromuscular dysfunction of bladder (loss of bladder control, inability to empty bladder). Review of the resident's progress notes showed staff documented the following: -On 09/12/24, at 10:02 A.M., the resident complained of feeling very weak. The certified nurse aide (CNA) reported the resident was leaning to left side while up in wheelchair. Vital signs taken showed blood pressure 152/92 (normal 120/80), pulse 90 (normal 60 to 100, pulse oximeter 61% (normal above 92%), respirations were even and unlabored. Staff reported that the resident had been very difficult to transfer due to weakness and the resident was unable to hold legs up while propelled in wheelchair. Physician notified and resident transferred to emergency room for evaluation. Review of the resident's medical record showed facility staff did not provide a written transfer notification letter to the resident or the resident's representative. Review of the resident's progress notes showed staff documented the following: -On 09/25/24, at 1:01 P.M., therapy staff reported to the nurse the resident's heart rate was reading at 237 on the pulse oximeter monitor. The nurse was unable to obtain a manual heart rate due to very fast and irregular heart rate. Heart rate now ranging from 160s to 230s. Oxygen level reading ranging from 76 to 86% on 3 liters of oxygen. Resident stated not in pain, just felt light-headed. Physician notified and EMS contacted. Face sheet, medication list, and transfer to ER paperwork sent with resident and EMS. Resident's responsible party notified by phone. Review of the resident's medical record showed facility staff did not provide a written bed hold notification to the resident or the resident's representative. 2. Review of Resident #40's face sheet showed the following: -admitted [DATE]; -Diagnosis included pulmonary embolism (one or more arteries in the lungs become blocked by a blood clot), atrial fibrillation (fast and irregular and often very rapid heart rate that can lead to blood clots in the heart), heart failure (chronic condition in which the heart doesn't pump blood as well as it should), and iron deficiency anemia (too few healthy red blood cells due to too little iron in the body). Review of the resident's progress notes showed staff documented the following: -On 10/04/24, at 12:05 A.M., the CNA found the resident on the floor. The CNA notified the nurse. The resident was noted to be laying on the floor on his/her right side with pillow under his/her head. The resident stated he/she was going to the bathroom. Redness noted to the cheek, shoulder, ear, and hip. Resident also had a 3 by 1 centimeter (cm) abrasion to right lateral back and denied pain. Neuro checks (series of tests and questions that evaluate a person's nervous system) and range of motion was within normal limits. Two staff transferred with gait belt (device used to help people with mobility issues move safely) from floor to bed. Resident tolerated well. Oxygen saturation noted to be at 88%. Staff initiated oxygen and notified physician and administrator; -On 10/04/24, at 12:30 A.M., staff notified the physician by phone the resident's oxygen saturation went from 88% on room air to 75% with oxygen on at 3 L by nasal cannula (NC - device used to give additional oxygen through the nose) after fall and now resident complained of severe pain when breathing deep and coughing. New order was provided to send the resident to the emergency room to evaluate and treat. Notified resident's representative of fall, condition, and order to send to the hospital. Administrator was notified of hospital transfer; -On 10/04/24, at 1:00 A.M., emergency medical services (EMS) left with resident at 12:50 A.M. Review of the resident's medical record showed facility staff did not provide a written bed hold notification to the resident or the resident's representative. 3. Review of Resident # 36's face sheet showed the following information: -admitted [DATE]; -Diagnoses included diabetes, viral hepatitis (an infection that causes liver inflammation and damage), pneumonia, depression, and obesity. Review of the resident's progress notes showed staff documented the following: -On 10/08/24, at 8:20 A.M., the nurse documented that the resident was displaying severe confusion and anxiety, continuously yelling out for help instead of using his/her call light and stating he/she can't breathe, doesn't know where he/she is, thought his/her leg had been stabbed and thought he/she was gushing blood. These behaviors were not normal for the resident. Vital signs taken showed all within normal limits. The resident was her own person and the resident requested that the nurse speak with the resident's daughter. The daughter was notified and requested that the resident be sent to the hospital for evaluation. The physician was notified. Emergency Medical Services were notified and arrived to transport the resident. Review of the resident's medical record showed facility staff did not provide a written bed hold notification to the resident or the resident's representative. 4. During an interview on 10/10/24, at 1:20 P.M., Licensed Practical Nurse (LPN) E said the nursing staff have transfer packets that included a transfer form that was completed and given to the EMTs, along with copy send to medical records office. The nurse contacted the family by phone for bed hold. He/she did not send any information in writing to the resident or resident's representative. 5. During an interview on 10/10/24, at 1:30 P.M., the Infection Preventionist said that when a resident was sent to the hospital the nursing staff complete the transfer form and send with the EMTs. The nurse notified family by phone. She did not mail any information to family. She did ensure a copy of the bed hold was given to medical records. The bed hold consent was most of the time provided verbally by phone. 6. During an interview on 10/10/24, at 1:40 P.M., the Director of Nursing (DON) said when a resident was sent to the hospital the nursing staff completed a transfer form and send with EMS. This information included all resident pertinent medical history. The nurses contact the family/guardian by phone. The bed hold was filled out at the time of transfer and sent with the resident or they notified the family by phone. 7. During an interview on 10/10/24, at 1:55 P.M., with the Administrator and Medical Records. The Administrator said the nursing staff complete a bed hold form that was sent with EMS when transferring a resident. The nursing staff contact family and guardians by phone. 48187

Based on observation, interview, and record review, the facility failed to ensure each resident was provided access to drinks at palatable temperature when staff stored drinks on the Special Care Unit at room temperatures. The facility census was 43. Review showed the facility did not provide a policy related to drink storage/temperatures. 1. Observations on 10/07/24, starting at 12:03 P.M., showed the following: -Open (about half-full), 46 ounce (oz.) bottle of orange juice sitting on counter in the secure care unit (SCU) dining room. The exterior of the bottle felt the same as room temperature (approximately 72 degrees Fahrenheit (F)); -Open (about half-full), 46 oz. bottle of apple juice; -Large serving pitcher labeled as Kool-aid. Observation on 10/08/24, at 9:44 A.M., showed the Kool-aid, apple juice, and orange juice out on the counter of the SCU. All exteriors of the bottles felt approximately room temperature. Observation on 10/08/24, at 12:02 P.M., showed Certified Nurse Aide (CNA) D poured room temperature Kool-aid from the pitcher for a resident. Observation on 10/09/24, at 11:27 A.M., showed apple juice and orange juice containers out on the counter of the SCU and at about room temperature. Observations on 10/10/24, at 2:22 P.M., showed the following temperatures of drinks sitting on the counter in the dining area of the SCU: -Kool-aid that measured 70.1 degrees F; -Tea that measured 64.6 degrees F; -Orange juice that measured 72.8 degrees F; -Apple juice that measured 71.9 degrees F. During an interview on 10/10/24, at 1:47 P.M., the Registered Dietician (RD) said Kool-aid, juices, and teas can be left out for several days at room temperature without significant concern of bacterial growth. However, most people would prefer the drinks with ice, or cooled down. During an interview on 10/10/24, at 2:05 P.M., CNA C, said the following: -He/she used the drinks for the residents for any time they wished for something to drink; -The orange juice is normally used for those with blood sugar concerns; -He/she does not take temps of the juices; -He/she is unsure how long the juices and drinks are kept on counter; -There is no refrigerator in the unit. During an interview on 10/10/24, at 2:15 P.M., the Dietary Manager said she takes fresh drinks to the unit almost daily; -She has not done so today because she has not had a chance. The temperatures taken by the surveyor were not acceptable temperatures. During an interview on 10/10/24, at 2:45 P.M., the Administrator said the following: -Drinks should be kept cool or changed out frequently; -He/she did not realize the drinks were getting so warm and that was not okay.

Based on interview and record review, facility staff failed to maintain a complete infection control program when staff failed to ensure the required two step tuberculosis (TB-a communicable disease that affects the lungs characterized by fever, cough, and difficulty breathing) screening test was administered timely and correctly documented for three staff members (Business Office Manager (BOM), Certified Medication Technician (CMT) I, and Activity Director) of ten sampled staff. The facility census was 43. Review of the facility policy tilted, Infection Prevention and Control Manual, Employee Health, dated 2019, showed the following information: -Employee was defined as employees, consultants, contractors, volunteers, caregivers who provide care to the residents on behalf of the facility, and nurse or nurse aide students working in the facility; -Each new employee will undergo a two-step Tuberculin Skin Test (TST) or a TB blood test for detection of latent tuberculosis infection or disease or testing in accordance with State requirements; -Documentation of the results of the TST must be made available to the facility; -If a new employee has previously tested positive, they are exempt from repeat TST, but appropriate documentation is necessary to support freedom from infectious disease; -New employees who present a written report of a negative two-step TST within the previous 12 months require a one-step TST, and an employee screening tool will be completed; -New employees with a known, documented positive skin test will not receive a repeat TST but will undergo a chest x-ray (CXR) if they do not have a documented negative CXR after a positive skin test; -New employees will not be allowed to work until the Tuberculin Skin Test or CXR results are known; -Employees who will be receiving the two-step Tuberculin Skin Test may begin work after the first step results are negative; -Skin test results will be documented in the employee's medical record; -Skin test results will be documented in millimeters of induration rather than stating results is positive or negative; -The tuberculin manufacturer and lot number will be recorded; -The test is read between 48 and 82 hours after administration by someone trained in Mantoux reading and interpretation. Review of the Infection Prevention and Control Manual - Employee TB Screening Tool, dated 2019, showed the following: -Employee name, date of hire, department, date of birth; -Medical questions including: have you been told you have tuberculosis; -Test #1, date, manufacturer, lot #, right arm or left arm, given by, date read, time read, results, read by; -Test #2, date, manufacturer, lot #, right arm or left arm, given by, date read, time read, results, read by. General requirements for Tuberculosis testing for employees in Long Term Care Facilities, 19 CSR 20-20.100, reads as follows: -Long-term care facilities shall screen their employees for tuberculosis using the Mantoux method purified protein derivative (PPD - a skin test to determine if you have tuberculosis) two-step tuberculin test within one month prior to starting employment; -If the initial test is negative, the second test should be given as soon as possible within three weeks after employment begins unless documentation is provided indicating a Mantoux PPD test in the past and at least one subsequent annual test within the past two years; -It is the responsibility of the facility to maintain documentation of each employee's tuberculin status. 1. Review of the BOM personnel record showed the following: -Date of hire 01/02/24; -First-step tuberculosis skin test date administered 12/31/23 and read on 01/02/24; -The second-step tuberculosis skin test did not have a document administration date. It was read on 01/19/24. 2. Review of CMT I personnel record showed the following: -Date of hire 05/24/23; -First-step tuberculosis skin test date administered 06/08/23, with date read on read 06/10/23. (The first step was administered fifteen days after date of hire); -Second-step tuberculosis skin test with date administered on 10/16/23, with date read on 10/18/23. (The second-step administered four months after the first step.) 3. Review of the Activity Director personnel record showed the following: -Date of hire 06/28/23; -First-step tuberculosis skin test date administered on 06/26/23, with date read 06/28/23; -The second-step tuberculosis skin test did not have a document administration date. The date read was 07/15/23. 4. During interview on 10/10/24, at 1:30 P.M., Infection Preventionist said that TB skin testing should be started before the new hire starts working. Generally, the TB skin test if given two days before orientation and then the new hire comes in for orientation and the skin test is read at that time. The second test should be done about 2 weeks later. Staff should document the date given and the date read. The first-step should not be done several weeks after the date of hire. 5. During interview on 10/10/24, at 1:40 P.M., the Director of Nursing DON said that TB testing for new hires should be done two days before orientation so that it can be read at the date of orientation. The second-step is done a couple weeks later. The nursing staff should document the date given and the date read and the first-step test should be given before hire not after hire. 6. During interview on 10/10/24, at 1:55 P.M., the Administrator said she expected staff to correctly complete and correctly document new hire TB testing. The first-step TB testing should be done two days before orientation and read at orientation. The second-step should then be done 7 to 14 days and up to 21 days after hire date. 41787

Based on observation, record review, and interview, the facility failed to provide care per standards of practice when staff failed complete blood glucose monitoring by finger stick without a physician order to do so for one resident (Resident #25) when the Freestyle glucose monitor (continuous glucose monitoring device) was not available. The facility census was 43. Review showed the facility did not provide a policy related to physician orders. Review of the FreeStyle Libre Sensor prescribing information, dated 2021, showed the following information: -The FreeStyle Libre 14 day Flash Glucose Monitoring System is a continuous glucose monitoring (CGM) device indicated for the management of diabetes in persons age 18 and older; -It is designed to replace blood glucose testing for diabetes treatment decisions; -The System detects trends and tracks patterns aiding in the detection of episodes of hyperglycemia (high blood glucose levels) and hypoglycemia (low blood glucose levels); -Interpretation of the System readings should be based on the glucose trends and several sequential readings over time; -Check Sensor glucose readings by conducting a finger stick test with a blood glucose meter under the following conditions, when Sensor glucose readings may not be accurate and should not be used to make a diabetes treatment decision; if you suspect that your reading may be inaccurate for any reason; when you are experiencing symptoms that may be due to low or high blood glucose; when you are experiencing symptoms that do not match the Sensor glucose readings; during the first 12 hours of wearing a FreeStyle Libre 14 day Sensor; during times of rapidly changing glucose; when the Sensor glucose reading does not include a Current Glucose number or Glucose Trend Arrow; and in order to confirm hypoglycemia or impending hypoglycemia as reported by the Sensor. 1. Review of Resident #25's face sheet (a brief information sheet about the resident) showed the following: -admitted [DATE]; -Diagnoses included severe dementia (chronic or persistent disorder of the mental processes caused by brain disease or injury and marked by memory disorders, personality changes, and impaired reasoning), type 2 diabetes mellitus (chronic condition that affects the way the body processes blood sugar (glucose)) with hyperglycemia (high blood sugar levels), and heart failure (chronic condition in which the heart doesn't pump blood as well as it should). Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated comprehensive assessment completed by facility staff), dated 10/01/24, showed the following: -Severe cognitive impairment; -Use of wheelchair; -Dependent on staff for toileting hygiene, showering, dressing, personal hygiene, transfers, and mobility. Review of the resident's physician orders, current as of 10/10/24, showed the following: -An order, dated 08/02/24, for blood glucose monitoring with Freestyle monitor (measures glucose (sugar) levels through a small sensor - the size of two stacked quarters - applied to the back of your upper arm), four times a day; -No order for blood glucose monitoring by finger stick. Review of the resident's September 2024 and October 2024 Medication Administration Record (MAR) showed staff documented the freestyle glucose sensor as changed on 09/30/24 and scheduled to be changed on 10/14/24. Review of the resident's MAR showed staff documented blood glucose monitoring with freestyle glucose monitor four times day for the month of September 2024 and October 2024 to date. Observation on 10/09/24, at 11:32 A.M., showed the following: -Licensed Practical Nurse (LPN) G prepared supplies at the nurse treatment cart and applied gloves. The nurse entered the resident's room. The resident was seated in his/her wheelchair. The nurse wiped the resident's left index finger with an alcohol wipe and allowed to air dry. The nurse then poked the resident's finger with a lancet (small needle to prick the skin) and obtained a blood sample on the test strip (small, disposable plastic strips used to measure blood sugar levels). The nurse wiped the resident's finger with a cotton ball. The resident's blood glucose level was 87. -The nurse returned to the treatment cart disposed of the lancet and test strip, and wiped the glucometer with a disinfecting wet wipe. He/she then removed his/her gloves and used hand sanitizer. He/she charted the blood glucose reading and noted the resident required no insulin. During observation and interview on 10/10/24, at 1:15 P.M., the resident was in a wheelchair in the dining room. The resident did not respond to questions. Certified Medication Tech (CMT) H entered the room and said that the resident's Freestyle glucose monitor had fallen off the resident's arm and had not been on for two days. He/she said the nurse had been checking the glucose by finger stick. The CMT felt both arms of the resident had there was not glucose monitor on the right or left arm. During an interview on 10/10/24, at 1:20 P.M., LPN E said there were two residents in the facility with the Freestyle glucose monitoring sensor. He/she said that if the glucose sensor reading did not seem accurate or had fallen off the nurses should check the glucose reading by finger stick. He/she said there should be an order for glucose monitoring by finger stick. During an interview on 10/10/24, at 1:30 P.M., the Infection Preventionist said staff should obtain an order for finger stick blood glucose testing in case the Freestyle sensor was not working accurately or had fallen off. There should be a physician order for the test. During an interview on 10/10/24, at 1:40 P.M., the Director of Nursing (DON) said staff should obtain a physician's order for a finger stick glucose test for residents with Freestyle glucose monitors in the event glucose monitor was not working or had fallen off before the next time due to be changed. The insurance companies only allowed one glucose monitor every two weeks, so when if it had fallen off it cannot be replaced until the time period allowed. During an interview on 10/10/24, at 1:55 P.M., the Administrator said staff should follow physician orders for blood glucose monitoring and should contact the physician for finger stick orders if a glucose monitor did not work or had fallen off.

Based on observation, interview, and record review, the facility failed to ensure each resident's personal privacy was protected when a staff member (Certified Nurse Aide (CNA) A) posted a video to social media for public view that included one resident (Resident #1), of four sampled residents, without the resident or resident's responsible party's permission. The facility census was 45. On 08/19/24, the Administrator was notified by facility staff of the Past Non-Compliance that occurred on 08/19/24. The Administrator and Director of Nursing immediately began an investigation that included review the videos and interviews with residents and staff. The facility began inservice education with all staff on 08/19/24 regarding phone use and protecting resident privacy. The noncompliance was corrected on 08/20/24. Review of the facility's policy titled Employment Acknowledgement of Guidelines to Personal Social Networking, dated October 2011, showed the following information: -Social media must maintain resident, employee, and company confidentiality; -Posting pictures or any other information capable of identifying residents is prohibited. 1. Review of Resident #1's face sheet showed the following information: -admitted [DATE]; -Diagnoses included traumatic brain injury (TBI), unspecified dementia with behaviors, and anxiety disorder. Review of the resident's quarterly Minimum Data Sheet (MDS - a federally mandated assessment tool filled out by facility staff), dated 06/25/24, showed the following information: -Severe cognitive impairment; -Able to communicate to make needs known, but difficult to understand; -Dependent on staff for all personal cares and mobility. Review of the resident's care plan, created on 08/31/24, showed the following: -Use proper name and clearly identify self to the resident. Staff to make eye contact and use directive sentences; -Totally dependent on staff for all cares, including all mobility, such as turning, transferring, repositioning, and care tasks, such as bathing, dressing and all hygiene concerns. Review of the facility's investigation, dated 08/20/24, showed the following: -The occurrence (TikTok video made that showed back of resident) took place on 08/19/24, time unknown; -Resident had a mental status of confused, but alert to self; -Resident was shown from the back in profile in a social media post that was made by CNA A; -The video was found to be in violation of the facility; -Potential dangers showed someone in the public viewing the recording. Observation on 08/28/24, at approximately 2:30 P.M., showed the following: -A copy of the original TikTok recording was viewed; -A resident could be seen in the background; -What CNA A said could not be clearly understood; -The resident in the video was identifiable as Resident #1. During an interview on 08/28/24, at approximately 2:00 P.M., CNA A said the following: -He/she did film him/herself in a wheelchair, going down the hall in the memory unit; -He/she recorded this from his/her cell phone; -He/she denied saying anything in the video regarding the resident. During an interview on 08/28/24, at approximately 12:00 P.M., CNA D said the following: -On TikTok, he/she saw a picture in the top corner with who looked to be the resident; -He/she then saw the name of the account and saw two videos in which CNA A was in a wheelchair, rolling down the hall in the facility memory care unit; -As CNA A wheeled down the hall, the resident could be seen from the back of his/her head and profile angle; -CNA A said something about the resident having dementia and exit-seeking. During an interview on 08/28/24, at approximately 12:10 P.M., Certified Medication Tech (CMT) E said the following: -CNA D came to him/her upset saying they had just seen something on TikTok, posted by CNA A, and the resident could be seen in the video; -CNA D then pulled up the video and CMT E saw CNA A wheeling down the memory care hall, in an unknown resident's wheelchair; -CNA A tried to change his/her appearance in a humorous way, but did not alter the resident's identity in any way; -CNA A said the resident had dementia and was trying to leave the unit; -He/she said this is clearly a violation of the residents privacy. During an interview on 08/28/24, at approximately 11:25 P.M., Housekeeper B said the following: -He/she did see the TikTok video posted by CNA A; -He/she was aware of the contents and was able to name the resident as the resident in the background; -Staff are not supposed to have a phone out while working on the floor; -Staff are told when hired that no one can have out a phone or record anyone, especially a resident; -This was not protecting the resident's privacy. During an interview on 08/28/24, at approximately 11:45 P.M., CNA C, said the following: -Staff are updated about social media every year. Staff are not to video residents; -This is a privacy issue and the resident should not have been exposed for others to see him/her like that. During an interview on 08/28/24, at approximately 12:50 P.M., CNA G said the following: -He/she did see the video that CNA A posted to TikTok; -He/she said no one should be able to post someone living in a facility, which is private, onto social media; -He/she said they knew immediately who the resident was in the video and so will anyone else if they see it and have been in the building. During an interview on 08/28/24, at approximately 12:25 P.M., Licensed Practical Nurse (LPN) F said the following: -He/she was shown the video posted by CNA A by another staff member; -He/she said they did look and those were the only two videos posted by CNA A; -Anyone who has visited the facility could possibly recognize the resident; -The resident's privacy was violated and if it were his/her own family member, they would be extremely upset about it; -He/she was not sure what CNA A said in the video. During an interview on 08/28/24, at approximately 1:20 P.M., LPN H said the following: -He/she was shown the video and was very upset after seeing it; -He/she felt very bad for the resident; -He/she was not able to say what was said aloud on the video, but said he/she definitely could tell it was the resident; -He/she said that the resident's privacy was not protected that evening; -He/she said they know they would be very upset if it were her being filmed in their own home. During an interview on 08/28/24, at approximately 1:40 P.M., Registered Nurse (RN) I said the following: -He/she did see the video and said they could easily identify the resident; -He/she did look to see if there were any posted prior and that there were none; -This is a violation of the resident's right to privacy. During an interview on 08/28/24, at approximately 2:15 P.M., the DON, said the following: -Two staff brought the video to the Administrator's attention first; -He/she and the Administrator then both reviewed the videos; -The first video showed CNA A rolling down the hall in the memory unit; -As CNA A goes down the hall, the resident is in the background; -It is a side view, but they all are aware of who the resident is; -The second video is just a short blip and doesn't have anything but the CNA's her face for a second; -CNA A distorted his/her face in both videos, but not the resident's face; -CNA A did not protect the resident's privacy; -When the DON and Administrator questioned CNA A after calling him/her in to ask him/her about posting the video CNA A told the DON and Administrator that he/she did not know there was a resident in the background. During an interview on 08/28/24, at approximately 2:30 P.M., the Administrator said the following: -CNA A said This man has dementia; I'm exit seeking, headed for a door; -This is privacy issue; -Phones are not supposed to be on the floor, at all, when clocked-in. MO00240841

Based on interview and record review, facility staff failed to provide basic life support, including cardio-pulmonary resuscitation (CPR - an emergency procedure that is performed when a person's heartbeat or breathing has stopped) for one full code resident (Resident #47) when staff found the resident without a pulse or respirations. A sample of 17 residents was selected for review. The facility census was 43. The Administrator was notified on [DATE], at 3:00 P.M., of the Immediate Jeopardy (IJ) Past Non-Compliance which occurred on [DATE]. On [DATE], the Administrator became aware of the deficient practice to not administer CPR to a resident who wished to receive it. On [DATE], the staff member was counseled and the facility inserviced the staff on the cardio-pulmonary resuscitation policy and procedures. The IJ was corrected on [DATE]. Review of the facility's policy for CPR titled, Emergency Procedure-Cardiopulmonary Resuscitation, dated February 2022, showed the following: -The goal of early delivery of CPR is to try to maintain life until the emergency medical response team arrives to deliver Advanced Life Support (ALS); -If a resident is found unresponsive and not breathing normally, a licensed staff member will verify code status using the medical record; -If the resident is full code (residents request to have full resuscitation efforts/CPR in the event of respiratory or cardiac arrest) per the medical record a staff member that is certified in CPR will initiate CPR. 1. Review of Resident #47's face sheet (admission data) showed the following: -admitted [DATE]; -Diagnoses included emphysema (lung disease), atrial fibrillation (an irregular, often rapid heart rate that causes poor blood flow), and high blood pressure. -Code status was a full code. Review of the resident's code status form, dated [DATE], showed the following: -The resident wished to receive CPR; -The resident signed his/her name on the resident signature line on [DATE]. Review of the resident's physician's order sheet showed an order, dated [DATE], for full code status. Review of the resident's care plan, dated [DATE], showed the resident's current code status was full code and the resident wished for staff to perform CPR on him/her in the event it is needed. Review of the resident's nurses' notes, dated [DATE], at 5:14 A.M., showed Licensed Practical Nurse (LPN) A documented that staff came out and said the resident passed away. LPN A assessed the resident. The resident had no heart beat or pulse. LPN A notified the Director of Nursing (DON), Administrator, and the Medical Director. LPN attempted to call the resident's representative two times with no answer or voicemail set up. (Staff did not document initiation of CPR on the resident.) During interviews on [DATE] at 9:10 A.M. and 2:26 P.M., LPN A said the following:-Facility staff should find a resident's code status in a red binder located on top of the crash cart located at the nurses' station; -The overnight charge nurse prints out the code status report every night at midnight; -A resident's code status should be on the face sheet; -Certified Nurse Aide (CNA) F found the resident on [DATE] and asked him/her to check the resident; -He/she did not double check the resident's code status. He/She thought the resident was a Do Not Resuscitate (DNR - do not attempt cardiopulmonary resuscitation); -He/she said there were two admissions on [DATE] and one resident was a full code status and the other resident was a DNR. He/she thought the resident was a DNR based on the resident's condition and appearance; -He/she did not verify the resident's code status; -On [DATE], the resident did not have a heart beat or breath sounds and was warm to touch; -He/she did not perform CPR on the resident; -The Administrator-In-Training (AIT) called him/her the next morning on [DATE] and asked if he/she performed CPR on the resident. The AIT informed him/her that the resident's code status was full code. During an interview on [DATE] at 2:25 P.M., CNA F said the following: -Facility staff should ask the nurse or look in the chart for a resident's code status; -A resident's code status should be in the resident's electronic medical record (EMR), on the face sheet, and on the care plan; -The resident's code status should be in the book on the crash cart; -Facility staff should find a resident's code status if a resident if found not breathing or no pulse; -He/she completed normal rounds and on last rounds he/she found the resident deceased and a little warm; -He/she informed LPN A that he/she found the resident deceased ; -LPN A checked the resident's heart beat and respirations and thought the resident had a DNR code status and on hospice; -LPN A did not call EMS or perform CPR on the resident. During an interview on [DATE] at 9:35 A.M., CNA B said the following: -Facility staff should find a resident's code status on the face sheet; -Facility staff should yell for help if a resident is found unresponsive; -Facility staff should start CPR if not sure of a resident's code status. During an interview on [DATE] at 10:09 A.M., Certified Medication Technician (CMT) C said the following: -Facility staff find a resident's code status in the chart and binder on the crash cart; -If staff find a resident unresponsive with no pulse or respirations, staff should send a facility staff person to check the resident's code status. During an interview on [DATE] at 10:15 A.M., LPN D said the following: -Facility staff should find a resident's code status in the book on the crash cart; -The night charge nurse updates all the residents' code status every night on the code status list; -Facility staff should find a resident's code status in the EMR on the face sheet, medication sheet, and under the profile picture; -The charge nurse enters the code status order in the resident's electronic medical record; -If a resident is full code, staff should start CPR. During an interview on [DATE] at 10:25 A.M., CNA E said the following: -A resident's code status information is at the nurses' station; -Facility staff should get the nurse and code status if a resident is found unresponsive in the room. During an interview on [DATE] at 10:53 A.M., the Social Services Director (SSD) said the following: -She completes the resident's code status paperwork upon admission; -Full code status is on the face sheet; -The overnight charge nurse updates the code status list on the crash cart every night; -Staff should perform CPR if a resident is full code status. During an interview on [DATE] at 12:39 P.M., the MDS/Care Plan Coordinator said the following: -The SSD reviews a resident's code status upon admission and explains the difference of code status; -The resident or representative signs the full code status paper and facility staff scan it in the resident's electronic medical record; -The code status should be on the resident's face sheet and the care plan; -Facility staff should inform the nurse if they find a resident unresponsive or not breathing; -Facility staff should get the crash cart and call code blue; -The nurse should verify the resident's code status on the face sheet in the chart; -Facility staff should initiate CPR once the code status has been verified. During an interview on [DATE] at 10:06 A.M., the AIT said the following: -Staff should check a resident's code status and initiate CPR if a resident is full code status; -If a resident has full code status, staff should initiate CPR and wait until EMS arrives to the facility; -CPR involves chest compressions and rescue breaths; -SSD completes the code status paperwork with the resident and representative upon admission and uploads it into the computer; -Facility staff should find the code status in the binder and immediately find the nurse if a resident looks like they have died . Facility staff should get a nurse, the resident's chart, face sheet and code status list on the crash cart to double check the resident's code status; -CPR certified staff should start CPR if a resident has a full code status; -The resident had a full code status; -LPN A said he/she did not start CPR on the resident; -LPN A said he/she failed to look at the resident's medical record; -LPN A should have completed CPR. During an interview on [DATE] at 12:11 P.M., the Administrator said the following: -The SSD discusses the code status with the resident and/or representative upon admission; -A resident's code status should be in the resident record, on the face sheet and shows on the ribbon on the chart; -Full code status means staff should start CPR and continue chest compressions until EMS arrives at the facility and takes over CPR; -Facility staff should call the nurse if a resident is found not breathing and no pulse; -She expects staff to call the nurse and the nurse should double check the resident's chart for the code status; -She expects the aides to yell for the nurse and start CPR and get the crash cart; -As soon as the nurse says full code and verifies who is CPR certified, CPR should be started immediately; -The AIT notified her the following morning that LPN A did not do CPR on the resident; -LPN A said he/she did not perform CPR on the resident; -She expected staff to provide CPR for the resident due to full code status; -The resident's representative wanted the resident to be a full code status at the time. During an interview on [DATE] at 11:01 A.M., the Medical Director said the following: -Facility staff should initiate CPR if a resident is a full code status; -Facility staff should perform CPR no matter the resident's skin temperature unless a physician calls the time of death.

Based on interview, observation, and record review, the facility failed to keep food safe from potential contamination when dishes were stacked wet instead of air dried, potentially trapping water to promote bacteria growth. This deficient practice had the potential to affect all residents. The facility census was 43 . Review of the Food and Drug Administration (FDA) 2013 Food Code showed the following information: -After cleaning and sanitizing, equipment and utensils shall be air-dried or used after adequate draining before contact with food; -Items must be allowed to drain and to air-dry before being stacked or stored. Stacking wet items such as pans prevents them from drying and may allow an environment where microorganisms can begin to grow. Review of the facility's policy titled, Dish and Utensil Handling, undated, showed the following information: -All silverware, dishes and glasses shall be handled to ensure sanitary conditions and infection control; -Dishes, cups, and glasses will be air-dried prior to storing; -Flatware is to be washed twice and air-dried. 1. Observation on 4/03/23 at 9:20 A.M., showed the following dishes were left wet stacked on top of each other, trapping water inside: -50 glass plates; -84 small juice drinking glasses; -57 medium drinking glasses -47 plastic coffee cups; -Three medium sized, metal steam table pans. Observation on 04/05/23 at 12:09 P.M., showed the following dishes were left wet stacked on top of each other, trapping water inside: -16 medium drinking glasses; -44 glass plates; -Three medium sized, metal steam table pans. Observation on 04/06/23 at 8:13 A.M. showed the following dishes were left wet stacked on top of each other, trapping water inside: -16 medium drinking glasses; -16 clear, plastic dessert cups; -Three medium sized, metal steam table pan; -One large metal steam table pan; -12 plastic, serving trays. During an interview on 04/06/23 at 8:22 A.M., Dietary Aide J said the following: -He/She will let the dishes sit and air dry for a bit before putting them away; -He/She said the time allowed for the dishes to air dry is about five to ten minutes; -He/She will then put the dishes where they are supposed to go; -He/She said they may still have a little water in them, but that it is minimal. During an interview on 04/06/23 at 8:30 A.M., Dietary Cook K said all dishes need to be air dried and that it's important, because mold or something could grow from it. During an interview on 04/06/23 at 8:41 A.M., the Dietary Manager said the following: -He/she did not realize dishes were being put away while they were still wet; -He/she is aware bacteria could grow because of this practice. 34871 During an interview on 4/06/23 at 12:11 P.M., the Administrator said dietary staff should not put clean glasses and dishes away wet. Dietary staff should put the dishes away dry.

Based on interview, observation, and record review, the facility failed to have a process in place to ensure the facility staff knew how much water needed to be kept on-hand in case of emergency and where the emergency water was located. This deficient practice had the potential to affect all residents. The facility census was 43. Record review of the facility's Emergency Water Supply List, dated 11/09/18, showed phone numbers for local county/public contacts. The policy did not specify the amount of water that needed to be kept on-hand in case of emergency. Record review of the provider contract for water, dated 03/02/23, showed the following: -In the event of a disaster requiring an alternate water supply the provider provide emergency water; -The provider would deliver 3 cases of 1 gallon drinking water, or 24 bottles of water; -Based on the census and number of staff and visitors at the time of the emergency, 3 gallons (128 ounces) of water per resident and staff per day, will be delivered; -Food and water is guaranteed to be delivered within 24 hours. 1. Observation on 04/03/23 at 9:30 A.M., of the Dietary Manager's office showed the following for the facility on-hand emergency water supply: -Nine gallon jugs full of water (a total of 1,152 ounces); -Two, 24 count cases of 8 ounce single-serve bottles (384 ounces); -A total of 1,536 ounces of water. Review of the facility's water contract showed the the home needed a total of 5,504 ounces of water on hand to meet the residents need per day at the current census. During an interview on 04/03/23 at 9:45 A.M., the Dietary Manager said the following: -The water that was on the shelves and in the back office area was the emergency water supply for the facility; -This would be for the residents only; -Unsure what the facility should actually have on-hand. During an interview on 4/05/23 at 3:12 P.M., Dietary Cook K said the following: -He/she knew the facility should keep emergency water somewhere for the residents; -He/she said he/she did not know where the water was kept or if the facility had any. During an interview on 04/05/23 at 3:12 P.M., Medical Records said the following: -When looking at the contract, it appears the facility needs a lot more water; -He/she was able to show additional water, that totaled 16, 8 ounce bottles (128 ounces) and one case of 24, 8 ounce bottles (192 ounces), that were being kept in a cabinet in the facility library. During an interview on 04/05/23 at 3:55 P.M., the Dietary Manager said the following: -He/She was really unsure as to how much water was actually required; -Looking at the contract, he/she said the facility was too low in the water they have stored. 34871 During an interview on 04/06/23 at 12:11 P.M., the Administrator said the facility had an agreement with a company for three gallons of water per resident and staff per day. The company should deliver the water to the facility within 24 hours. The facility typically kept five cases of water and some gallons of water in the kitchen.

Based on interview and record review, the facility failed to ensure all medication regimens were free from unnecessary medications when the facility failed to provide adequate indications for usage and failed to have an appropriate diagnosis for use of an antipsychotic medication (Haldol) for one resident (Resident #29). A sample of five residents was reviewed in a facility with a census of 43. Review of the facility policy titled, Psychotropic Medication Use, dated 09/2022, showed the following: -Residents will only receive psychotropic medications when necessary to treat specific conditions for which they are indicated and effective; -Prior to starting psychotropic medications, informed consent will be obtained from resident/representative per state guidelines; -Residents who are admitted from the community or transferred from a hospital and who are already receiving medications will be evaluated for the appropriateness and indications for use; -Antipsychotic medications shall generally be used for only the following diagnoses as documented in the record: schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly), Tourette's disorder (a nervous system disorder involving repetitive movements or unwanted sounds), and Huntington's disease (an inherited condition in which nerve cells in the brain break down over time). Review of the website MayoClinic.Org showed the following information: -Haloperidol (generic Haldol) is used to treat nervous, emotional and mental conditions such as schizophrenia. It is also used to control the symptoms of Tourette's disorder. This medication should not be used to treat behavior problems in older patients who have dementia. 1. Review of Resident #29's face sheet showed the following: -admitted [DATE]; -Diagnoses included vascular dementia with agitation (brain damage caused by multiple strokes) and insomnia (persistent problems falling and staying asleep). Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment tool completed by facility staff), dated 02/24/23, showed the following: -Moderately cognitively impaired; -No physical or verbal behaviors documented from admission to the current evaluation period. Review of the resident's care plan, dated 03/06/23, showed the following: -The resident received psychotropic medications for depression, insomnia, and dementia with behavioral disturbance; -Staff should administer medications as ordered and monitor for any side effects and report any unusual behaviors to the charge nurse. Review of the resident's current physician orders showed the following: -An order, dated 01/17/23, for haloperidol tablet 0.5 milligram (mg), give 0.25 mg by mouth at bedtime related to insomnia. Review of the resident's March 2023 Medication Administration Record (MAR) showed the following: - An order, undated, for haloperidol tablet 0.5 mg, give 0.25 mg by mouth at bedtime related to insomnia; -Staff administered the haloperidol to the resident daily per the order. Review of the resident's Medication Administration Record (MAR), dated 04/01/23 to 04/04/23, showed the following: - An order, undated, for haloperidol tablet 0.5 mg, give 0.25 mg by mouth at bedtime related to insomnia; -Staff administered the haloperidol to the resident daily per the order. Review of the behavior folder located at the resident's nursing station showed no documented behaviors since the resident's admission. Review of the resident's medical record showed no documented behaviors since admission. During an interview on 04/05/23 at 11:03 A.M., Certified Nursing Assistant (CNA) H said he/she had never seen the resident have behaviors. The resident may not want to get up in the morning, but the CNA has not witnessed any behaviors. He/she has worked overnights and never witnessed the resident having any issues sleeping. During an interview on 04/05/23 at 1:19 P.M., CNA I said he/she had never witnessed the resident have any behaviors and he/she hadn't heard of him/her having any behaviors. If a resident does have behaviors it is documented in the behavior book on the nurses' station. He/she would tell the nurse if a resident had those behaviors. During an interview on 04/05/23 at 1:28 P.M., Licensed Practical Nurse (LPN) D said he/she had never seen the resident have any behaviors. The resident went through a period of time where he/she didn't want to get out of bed, but was able to be redirected. The nurse has not seen any other kind of behaviors from the resident. He/she is not sure why the resident is on the Haldol. That medication would not be given for insomnia. During an interview on 04/05/23 at 1:30 P.M., LPN G said he/she has not seen the resident have any behaviors. During an interview on 04/06/23, at 2:32 P.M., the Medical Director said Haldol is not used for insomnia. The resident was on it due to prior behaviors in another facility. During an interview on 04/07/23, at 9:24 A.M., the Administrator in Training (AIT) and Administrator said the behaviors they monitor for when a resident is on antipsychotics include mania, pacing, hitting kicking, punching, sexual behaviors, and wandering. When the resident first came to the facility he/she had some behaviors, however he/she had a urinary tract infection. He/she has had no behaviors since then. Haldol would not be an appropriate medication for insomnia.

Based on observation, interview, and record review, the facility failed to provide wound care in a manner to promote healing and prevent potential infection when staff failed to perform hand hygiene appropriately during wound care of one resident's (Resident #35) pressure ulcer (injuries to the skin and underlying tissue primarily caused by pressure on the skin). One resident was sampled in a facility with a census of 43. Record review of the facility policy titled, Infection Prevention and Control Manual, dated 2019, showed the following: -Appropriate hand hygiene is essential in preventing transmission of infectious agents; -Hand hygiene continues to be the primary means of preventing the transmission of infections; -The policy did not address when staff should perform hand hygiene. Review of the facility policy titled, Wound Care System Requirements, dated 03/2021, showed the policy did not address hand hygiene during wound care. Record review of the Centers for Disease Control and Prevention (CDC) website, updated 01/30/20, showed the following: -Hand hygiene (washing hands or using alcohol based hand rub) should be performed before putting on gloves; -Hand hygiene should be performed before moving from work on a soiled body site to a clean body site on the same resident; -Hand hygiene should be performed after body fluid exposure or assisting with toileting, performing wound care, or performing a finger stick; -Hand hygiene should be performed after direct contact with a resident; -Hand hygiene should be performed after removing gloves. 1. Record review of Resident #35's face sheet showed the following: -admitted [DATE]; -Diagnoses included Type 2 diabetes (a chronic condition that affects the way the body process blood sugar), paraplegia (paralysis of the legs and lower body), and stage 4 pressure ulcer (a wound caused by pressure, that may extend into the muscle, bone or tendon) of the right and left buttock. Record review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment tool completed by facility staff), dated 02/06/23, showed the following: -Cognitively intact; -Dependent on staff for activities of daily living (bathing, eating, transferring, etc); -Two stage 4 pressure ulcers. Record review of the resident's care plan, updated 02/23/23, showed the following: -The resident had stage 4 ulcers to the buttocks on admission; -Treatment to cleanse with wound cleanser, apply calcium alginate (a highly absorbent dressing derived from seaweed), and cover with super absorbent dressing. Staff to change twice daily and as needed. Record review of the resident's current Physician Orders showed the following: -An order, dated 02/02/23, to cleanse the left buttock with wound cleanser, apply Santyl (an ointment that removes dead tissue from wounds so they can start to heal), cover with calcium alginate, then cover with super absorbent dressing. Staff to change one time daily every day for wound care; -An order, dated 02/02/23, to cleanse the right buttock with wound cleanser, cover with calcium alginate, then cover with super absorbent dressing. Staff to change one time daily every day for wound care. Observation on 04/05/23 at 8:31 A.M., showed the following: -Licensed Practical Nurse (LPN) G entered the resident's room and put on gloves without performing hand hygiene. LPN D was in the room with gloves on; -LPN D rolled resident to right side and LPN G cleaned the resident's left buttock with wound cleanser: -LPN G removed his/her gloves and applied new gloves without performing hand hygiene; -LPN G reached in his/her pocket to get pen and wrote on the dressings, then removed the calcium alginate from package (the LPN did not complete hand hygiene); -LPN G placed the calcium alginate on the absorbent dressing then applied the calcium alginate and dressing to wound; -LPN G removed his/her gloves and applied new ones with no hand hygiene; -LPN D rolled the resident over further to his/her right side; -LPN G cleaned the wound on the resident's right buttock with wound cleaner and removed his/her gloves; -LPN G did not perform hand hygiene. He/she wrote on the dressing, applied new gloves, without performing hand hygiene; -LPN G applied Santyl to the second wound bed, and calcium alginate over Santyl; -LPN G placed the super absorbent dressing over the top of the Santyl and calcium alginate; -LPN G and LPN D removed their gloves and performed hand hygiene. During an interview on 04/06/23 at 8:25 A.M., LPN D said hand hygiene should be done before starting a task, between dirty and clean surfaces, before applying new gloves, and after completing tasks. It is not appropriate to not do hand hygiene when doing wound care. During an interview on 04/06/23 at 8:34 A.M., LPN A said hand hygiene should be done before starting wound care, when going from a dirty to a clean surface, when changing gloves, and when finishing task. It is not appropriate to not do hand hygiene when changing gloves. During an interview on 04/06/23 at 1:39 P.M., the MDS Coordinator said she would expect staff to perform hand hygiene before beginning wound care, between changing gloves, and when completing wound care. During an interview on 04/07/23, at 9:24 A.M., the Administrator and Administrator in Training (AIT) said they expect staff to do perform hand hygiene before beginning wound care after completing wound care, and any time they do a glove change. It is not appropriate to not do hand hygiene during wound care.

Based on record review, and interview, the facility failed to consistently provide restorative services to help improve and/or maintain range of motion and abilities, as recommended by therapy, for three residents (Resident #1,#2, and #3). The facility census was 47. Record review of the facility's policy titled Restorative Nursing Policy and Procedure, undated, showed the following: -It is the policy of this facility to provide restorative nursing which promotes the resident's ability to adapt and adjust to living as independently and safely as possible. Restorative nursing focuses on achieving and/or maintaining optimal physical, mental, and psychological function of the resident. The restorative nurse, restorative nursing assistant (RNA), along with the Interdisciplinary Team (IDT), will determine what programs will be initiated for the residents; -Restorative nursing services are provided by RNA,certified nursing assistants (CNA), and other individuals trained in restorative techniques, under the supervision of a licensed nurse; -Screen residents using restorative assessment in the medical record to identify appropriate candidates for programs. These may include, but are not limited to: any resident recently discharged from physical, occupational, or speech therapy; any new admission, quarterly, annual and with any significant change; any resident demonstrating decline in activities of daily living (ADL - dressing, grooming, bathing, eating, and toileting), range of motion (ROM) or other change in condition. Examples of significant change may include: multiple falls, more help with ADLs, wheelchair positioning deficit, changes in quality indicators/quality measures (QI/QM) such as decline in late loss ADL's or decline ROM; residents who have the potential for an increased level of functioning, or who require programs to maintain current level of functioning; and any resident who triggers an ADL care areas assessment (CAA) may be a candidate for a program. Review CAA which is completed by the restorative nurse or MDS Coordinator (MDSC); -Each restorative service is recorded in plan of care (POC ) with minutes provided per shift by the CNA or RNA. These minutes do not have to be provided consecutively as long as a minimum of 15 minutes per program are provided in a 24-hour period; -Restorative programs may be offered in groups as long as there is one group trained restorative staff member for every four residents participating; -Implement programs for a designated period of time. Re-evaluate quarterly at a minimum and revise and continue program and goal if indicated. Every resident who receives restorative nursing has a care plan with individualized, measurable goals and interventions. 1. Record review of Resident #1's face sheet (a document that gives a patient's information at a quick glance) showed the following: -admitted on 9/8/22; -Diagnoses included mood disorder, asthma, depression, muscle spasm, and anxiety. Record review of the resident's admission Minimum Data Set (MDS - a federally mandated assessment tool completed by facility staff), dated 9/15/22, showed the following: -Cognitively intact; -Required no assistance from staff for bed mobility, locomotion on the unit, eating and personal hygiene and extensive assistance from one staff member for transfers, locomotion off the unit, dressing and toilet use; -Used a wheelchair for locomotion; -Received no days of restorative nursing programs (RNP). Record review of the resident's physician's order sheet (POS), dated 11/2022, showed the following: -An order, dated 10/3/22, for physical therapy (PT) to evaluate to RNA program; -An order, dated 10/5/22, PT Clarification: Skilled PT evaluation only. Refer to established individualized RNP. Record review of the resident's Physical Therapy Plan of Care (Evaluation Only), dated 10/5/22, showed the following: -Resident admitted to this facility for long term care (LTC) on 9/8/22. Per resident's report he/she lived alone prior and required LTC secondary to inability to care for self at home. Resident reports progressive right lower extremity (RLE) and back weakness hindering independence and safety with functional mobility for one year. Resident reports he/she recently had a magnetic resonance imaging (MRI - a medical imaging technique used in radiology to form pictures of the anatomy and the physiological processes of the body) scheduled, however unfortunately due to lack of transportation the appointment was canceled. Resident referred to skilled PT for evaluation only secondary to lack of payer source for assessment and establishment of an individualized RNP; -Discharge Plans: Resident planned to remain in this facility LTC. Recommended individualized RNP; -The physician signed the evaluation on 10/7/22. Record review of the resident's Restorative Care Program, dated 10/5/22, showed the following: -Goals for restorative program included increase and prevent decline in functional mobility; -Perform program three times a week for twelve weeks; -Approach/recommendations for implementation of above goals included: bilateral lower extremity (BLE)therapeutic exercises sitting and standing (right lower extremity (RLE) weaker than the left lower extremity(LLE)) progress weights as able and ambulation with four wheeled walker; -Precautions or comments to this program included reports of RLE pain and numbness and report of his/her head floating with ambulation. Record review of the resident's Restorative Aide Notes showed the following: -In 10/2022, the resident received theraband (resistance band used for light strengthening exercises) exercises and ambulation on 10/6/22, 10/7/22, 10/20/22, 10/26/22 and 10/27/22. (Staff provided RNP was provided five out of nine recommended days). Record review of the resident's care plan showed the following added on 10/24/22: -He/she was at risk for falls related to gait and balance problems and medication use. He/she would be free of injuries related to falls through the review date. Encourage him/her to participate in activities that promote exercise, physical activity for strengthening and improved mobility such as group exercise. He/she would receive restorative services as ordered, -He/she had limited physical mobility related to weakness. He/she would increase level of mobility by using a walker with restorative services through the next review date. Invite him/her to activity programs that encourage activity and physical mobility such as exercise group and walking activities. He/she used an assistive device walker with restorative services for ambulation. Record review of the resident's Restorative Aide Notes showed the following: -In 11/2022, the resident received theraband exercises and ambulation on 11/1/22. (Staff provided RNP one out of six recommended days.) During an interview on 11/9/22, at 8:37 A.M., the resident said the following: -He/she did not receive his/her RNP program due to the RNA pulled to the floor to work; -He/she should receive RNP five days a week; -He/she did not believe he/she was getting better due to not receiving his/her RNP. During interviews on 11/9/22, at 8:58 A.M. and 12:34 P.M., RNA A said the following: -The resident should get his/her RNP three times a week, but hardly receives it. The resident received his/her RNP one day last week and one day the week before; -The RNA did not know if the resident had a physician's order for the RNP; -He/she documented when the RNP was completed and did not document any refusals of other staff by the resident. During an interview on 11/9/22, at 1:02 P.M., Licensed Practical Nurse (LPN) C said the following: -The resident complained of not receiving their RNP and stated they would not be able to walk if they did not receive it; -The resident had a RNP and should get it. During an interview on 11/9/22, at 1:52 P.M., the Interim Director of Nursing (DON)/MDS Coordinator said the following: -The resident had a RNP. The resident frequently walked him/herself; -If the resident's RNP said three times a week, he/she should receive the RNP three times a week. During an interview on 11/9/22, at 2:28 P.M., the Administrator said the following: -The resident had a RNP for three times a week. He/she should receive the RNP three times a week; -The resident only wanted to walk with the RNA. 2. Record review of Resident #2's face sheet showed the following: -admitted on [DATE]; -Diagnoses included chronic obstructive pulmonary disease (COPD - a group of lung diseases that block airflow and make it difficult to breathe), heart failure, diabetes, and anxiety. Record review of the resident's POS, dated 11/2022, showed the following: -An order, dated 9/9/22, for PT and Occupational Therapy (OT) to evaluate for RNA program; -An order, dated 9/12/22, for PT Clarification: skilled physical therapy evaluation only. Refer to established individualized RNP. Record review of the resident's Physical Therapy Plan of Care (Evaluation Only), dated 9/12/22, showed the following: -Resident was a LTC resident in this facility. Prior level of function was modified independent with bed mobility and transfers and utilized wheelchair for main mobility within the facility. Resident referred to skilled PT for evaluation only for RNP set-up secondary to insurance/payer source; -Discharge plans included to remain in this facility LTC. Resident reported he/she would like leg exercises and endurance activities for RNP; -The physician signed the evaluation on 9/13/22. Record review of the resident's Restorative Care Program for PT, dated 9/12/22, showed the following: -Goals for restorative program included prevention of functional decline; -Recommended three times a week for twelve weeks; -Approach/recommendations for implementation of above goals included BLE therapeutic exercise in sitting and/or standing, may participate in group exercise, standing balance and tolerance activities and if able, progress to ambulation with rolling walker an follow with wheelchair; -Precautions or comments to this program included continuous oxygen, resident became short of breath and obesity. Record review of the resident's POS, dated 11/2022, showed the following: -An order, dated 9/22/22, for OT Clarification: OT evaluation only completed for establishment of FMP (functional maintenance program (FMP - clinical programs that can be designed to augment or maintain a residents functional status and wellbeing)/RNA three times a week for twelve weeks. Record review of the resident's Occupational Therapy Plan of Care (Evaluation Only), dated 9/22/22, showed the following: -This is a LTC resident in this facility. Prior level of function: resident was modified independent with toileting, upper body dressing grooming and feeding. Resident reported he/she needed assistance with lower body dressing to get clothing over bilateral lower extremities due to inability to reach feet since he/she came to this facility. The resident's main source of mobility was his/her manual wheelchair. Resident referred to skilled OT for evaluation only for RNP set-up secondary to insurance/payer source; -Discharge plans: the resident planned to remain in the skilled nursing facility (SNF) with support/assistance from staff as needed and established FMP for bilateral upper extremity (BUE) exercise and endurance activities; -The physician signed the evaluation on 9/27/22. Record review of the resident's Restorative Care Program for OT, dated 9/22/22, showed the following: -Goals for restorative program included prevention of functional decline with transfers, improve independence with basic ADL's, improve BUE strength and improve endurance and activity tolerance; -Approach/recommendations for implementation of above goals included all functional transfers, UE/LE dressing with use of long-handled equipment, BUE exercises with theraband versus free weights and standing and seated activities; -Precautions or comments to this program included three times a week for twelve weeks, full code, continuous oxygen and obesity. Record review of the resident's care plan, revised 10/24/22, showed the following: -On 9/24/22, staff added resident had an ADL self-care performance deficit. He/she would maintain current level of function in bed mobility, transfers, eating, dressing, toilet use and personal hygiene through the review date. Record review of the resident's Restorative Aide Notes showed the following: -In 9/2022, the resident received standing for periods of time, group exercises, and theraband exercises on 9/29/22 and 9/30/22. (Staff provided RNP three out of nine recommended days.) Record review of the resident's annual MDS, dated [DATE], showed the following: -Cognitively intact; -Required no assistance from staff for bed mobility, transfers, walking in room, locomotion on and off the unit, dressing, eating and personal hygiene and extensive assistance from one staff member for toilet use; -Used a wheelchair for locomotion; -Received three days of range of motion RNP. Record review of the resident's Restorative Aide Notes showed the following: -In 10/2022, the resident received group exercises on 10/5/22, 10/20/22, 10/26/2 and 10/27/22, theraband exercises on 10/26/22 and 10/27/22, and standing for period of time on 10/20/22, 10/26/22 and 10/27/22. (Staff provided RNP four out of twelve recommended days.); -In 11/2022, the resident received ambulation and theraband exercises on 11/1/22. (Staff provided the RNP one out of six recommended days.) During interviews on 11/9/22, at 8:50 A.M. and 1:50 P.M., the resident said the following: -He/she had a RNP; -An aide assisted him/her with his/her RNP two times a week and he/she completed exercises on his/her own as well; -The RNA should complete his/her RNP two to three times a week. During an interview on 11/9/22, at 12:34 P.M., RNA A said the following: -He/she could document working with the resident on their RNP when working the floor, but did not. During an interview on 11/9/22, at 1:52 P.M., the Interim DON/MDS Coordinator said the following: -He/she did not know if the resident had a RNP, but if the resident did and it said three times a week, the resident should receive the RNP three times a week. During an interview on 11/9/22, at 2:28 P.M., the Administrator said the following: -The resident had a RNP for three times a week and should receive the RNP three times a week; -He/she did not know if the resident received the RNP three times a week, but saw the resident walk with the RNA at times. 3. Record review of Resident #3's face sheet showed the following: -admitted on [DATE]; -The resident had a responsible party; -Diagnoses included kidney disease, diabetes, depression, muscle weakness, abnormality of gait and mobility, and need for assistance with personal care. Record review of the resident's quarterly MDS, dated [DATE], showed the following: -Severe cognitive impairment; -Requires limited assistance of one staff member for bed mobility, transfers, waling in room, locomotion on and off unit, dressing, toilet use and personal hygiene and no assistance of staff for eating; -Used a walker and wheelchair for locomotion; -Received three days of therapy and no days of RNP. Record review of the resident's care plan, revised 8/12/22, showed the following: -He/she had falls. He/she would be free of injuries related to falls through the review date. He/she was at risk for falls related to gait and balance problems, psychoactive drug use and poor safety awareness at times. He/she had a history of fall prior to admission that resulted in a left hip fracture. He/she needed encouragement to participate in activities that promoted exercise, physical activity for strengthening and improved mobility such as morning stretches. He/she would receive physical therapy and restorative services as ordered; -He/she had ADL self-care performance deficit. He/she would maintain current level of ADL function through the review date. He/she had an ADL self-care performance deficit related to muscle weakness. He/she required extensive assistance from one staff for bed mobility, dressing and bathing. He/she required extensive assistance with transfers and toilet use. He/she was able to feed him/herself independently, perform personal grooming independently and could propel him/herself independently once in his/her wheelchair. He/she would receive therapy and restorative services as ordered Record review of the resident's POS, dated 11/2022, showed the following: -An order, dated 9/22/22, for OT Clarification: discharge summary completed. Resident at max rehabilitation potential. FMP established for three times a week for twelve weeks. Record review of the resident's OT Therapist Progress and Discharge Summary, dated 9/22/22, showed the following: -Resident participated his/her best in therapy and was at a new baseline at this time. Resident completed grooming from manual wheelchair with minimal assistance, toileting with moderate assistance, toilet transfers with moderate assistance, lower body dressing with maximum assistance and upper body dressing with minimal assistance. Resident was able to self-propel manual wheelchair. Staff had poor return demonstration and carryover of education on proper cues and position of resident when completing functional transfers for improved independence and carry over. Resident was at maximum rehabilitation potential and was appropriate for transition to FMP three times a week for twelve weeks. Discharge OT; -Discharge plans and instructions included the resident would remain in same SNF with 24/7 support/assistance from staff as needed and FMP established three times a week for twelve weeks. Record review of the resident's Restorative Care Program, dated 9/22/22, showed the following: -Goals for restorative program included prevent decline in function; -Approach/recommendations for implementation of above goals included BUE exercises, BUE fine motor and gross motor activities, upper and lower body dressing and toileting and transfer safety; -Precautions or comments to this program included three times a week for twelve weeks, do not resuscitate, fall risk and atrial fibrillation (an irregular, often rapid heart rate that commonly causes poor blood flow). Record review of the resident's Restorative Aide Notes showed the following: -The facility did not provide documentation for 09/2022; -In 10/2022, the resident received theraband exercises, dressing, toileting, grooming and transfer safety on 10/5/22, 10/6/22, 10/7/22, 10/20/22, 10/26/22 and 10/27/22. (Staff provided the RNP six out of twelve recommended days); -In 11/2022, the resident received transfer safety and theraband exercises on 11/1/22. (Staff provided the RNP one out of six recommended days.) During interviews on 11/9/22, at 9:20 A.M. and 1:48 P.M., the resident said the following: -He/she had a RNP; -He/she did not know how often he/she received the RNP and did not know what the RNP included. During an interview on 11/9/22, at 12:34 P.M., RNA A said the following: -He/she worked on transfers for the resident's RNP; -He/she could document working with the resident on their RNP when working the floor, but did not. During an interview on 11/9/22, at 1:52 P.M., the Interim DON/MDS Coordinator said the following: -The resident recently discharged from therapy and they placed him/her on a RNP; -If the residents RNP said three times a week, he/she should receive the RNP three times a week. During an interview on 11/9/22, at 2:28 P.M., the Administrator said the following: -The resident had a RNP for three times a week and should receive the RNP three times a week; -He/she saw the resident walk a few times with the RNA. Some days the resident could walk and someday they could not. 4. During interviews on 11/9/22, at 8:58 A.M., 12:34 P.M., and 1:45 P.M., RNA A said the following: -He/she worked the floor every day and had a hard time getting the RNP's done while working the floor; -He/she worked the floor this date due to a call-in. He/she worked Monday through Friday and worked the floor every day but one day in the last three weeks; -He/she received the RNP from therapy. The therapy director took the RNP to morning meeting and then gave him/her a copy; -If the RNP written for three times a week the resident should receive the RNP three times a week; -He/she had not told anyone he/she could not complete the RNP's; -The DON oversaw the RNP. The former DON and the Administrator asked for his/her RNP documentation once; -He/she had eighteen residents on a RNP; -He/she should communicate with the DON or Administrator about not completing the RNP's, but assumed they knew since he/she worked the floor. 5. Record review of the facility staffing sheets, dated 10/24/22 through 11/9/22, showed the following: -On 10/31/22, RNA moved to Certified Medication Technician (CMT); -On 11/7/22, RNA moved to CMT; -On 11/8/22, RNA moved to CNA on 300 hall; -On 11/9/22, RNA moved to CNA on 200 hall. 6. During an interview on 11/9/22, at 12:17 P.M., CNA B said the following: -He/she did not know which resident received a RNP; -The RNA worked the floor if another staff member called in. This happened maybe once every two weeks. 7. During an interview on 11/9/22, at 12:55 P.M., CMT D said the following: -He/she did not know who received a RNP; -The RNA worked the floor at least once a week. 8. During an interview on 11/9/22, at 1:02 P.M., LPN C said the following: -When therapy discharged a resident, they put the resident on a RNP; -If the RNP said three times a week, the resident should get the RNP three times a week; -The DON oversaw the RNA program; -The RNA worked the floor a lot. When the RNA worked as a CMT, they would not be able to complete the RNP's that day; -When staff called in, the nurse changed the staffing sheet. Sometimes the sheet was changed and sometimes it was not. 9. During an interview on 11/9/22, at 1:52 P.M., the Interim DON/MDS Coordinator said the following: -The physician wrote an order for PT and/or OT to evaluate and set-up a RNP. The PT and/or OT completed the evaluation and wrote recommendations on the Restorative Care Program form. The PT and OT generally wrote the RNP for three times a week for three months. The Rehab Director gave the RNP to the RNA and the RNA filled out the restorative aide notes; -He/she had not checked the restorative aide notes as he/she just took over as Interim DON; -The DON oversaw the RNP; -The facility had walk to dine as a program, but did not know if the CNA's documented this anywhere; -If the RNP said three times a week, the resident should receive the RNP three times a week; -The RNA worked five times a week and generally worked the floor two days a week so that left three days a week to complete the RNP's; -If a resident did not receive their RNP, the nurse should notify the physician due to the potential for the resident to decline from not receiving the services; -He/she care planned the RNP in the resident's care plan. 10. During an interview on 11/9/22, at 2:28 P.M., the Administrator said the following: -Therapy evaluated residents and brought a list of residents who received RNP to the morning meeting. Therapy wrote the physician's order and the RNP and gave the RNP to the RNA. The RNA completed the restorative aide notes and consulted therapy if he/she had any questions; -The DON oversaw the RNP. The former DON reviewed the restorative aide notes weekly and medical records reviewed them monthly; -When the RNA worked the floor, he/she still had time to complete the RNP's, even when he/she passed medications; -If a RNP said three times a week, the resident should receive the RNP three times a week. He/she expected the resident's to receive the ordered RNP unless the resident refused; -He/she did not know the resident's did not receive their RNP's as ordered; -If the RNA could not complete the RNP, they should report this to the DON or Administrator. The nurse should notify the physician. MO00208981 and MO00209657

Based on interview and record review, the facility failed to ensure all staff treated all residents with respect and dignity when one staff (Certified Nursing Assistant (CNA) A) spoke in a loud, rude, and harsh manner towards one resident (Resident #1). The facility census was 52. Record review of the facility's policy titled Resident Rights, dated 2018, showed the following: -Employees shall treat all residents with kindness, respect, and dignity. Federal and state laws guarantee certain basic rights to all residents of this facility; -The facility will make every effort to assist each resident in exercising his or her rights to assure that the resident is always treated with respect, kindness, and dignity; -Federal and state laws protect the rights of residents in a long term care setting. 1. Record review of Resident #1's face sheet (a document that gives a patient's information at a quick glance) showed the following: -admitted [DATE]; -Diagnoses included chronic obstructive pulmonary disease (COPD - a group of lung diseases that block airflow and make it difficult to breathe), heart failure, anxiety, obesity, and depression. Record review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff), dated 7/3/22, showed the following: -Cognitively intact; -Required no assistance from staff members for all activities of daily living (ADL - dressing, grooming, bathing, eating, and toileting); -Used a wheelchair for locomotion; -Had no physical, verbal, or other behaviors. Record review of the resident's care plan, revised 7/24/22, showed the following: -He/she had a potential behavior problem related to a mood disorder. He/she would not have any episodes of yelling, cussing or being demanding by the review date. Staff to monitor behavior episodes and attempt to determine underlying causes. Staff to consider location, time of day, persons involved and situations and report behavior and potential causes to the charge nurse; -He/she had an ADL self-care performance deficit. He/she would maintain current level of function in bed mobility, transfers, eating, dressing, toilet use and personal hygiene through the review date. He/she required one staff participation with bathing. Record review of the resident's nurse's progress note dated 9/12/22, at 6:06 P.M., showed the following: -The nurse was notified by an employee to come to the 200 hall as the resident was upset and yelling at staff. The resident complained of a staff person yelling at him/her and ignoring his/her needs and did not want to help him/her. The resident said the employee became agitated when they were asked to put the resident's shoes on him/her. CNA A put one shoe on the resident and the resident reported the CNA then asked the resident when he/she stopped putting his/her shoes on by him/herself; -When the nurse went down 200 hall, the resident and CNA were in a confrontation in the hall yelling at each other. The nurse told them this was not the place to be yelling and discussing it. The resident said the CNA told him/her to f off and the CNA said they did no such thing which caused the incident to become aggressive. The nurse told the resident and CNA they would take this somewhere else; -The Administrator was notified of the issue and came to the facility to speak with the CNA and resident. The resident changed his/her story about when the CNA allegedly told him/her to f off twice then stated it was a few weeks ago when the CNA stated this, but he/she did not report it. The Administrator took statements from all involved. Record review of the facility's investigation, dated 9/13/22, showed the following: -On 9/12/22, the resident turned his/her call light on for assistance. CNA A responded and got hateful and rude with the resident about putting his/her shoes on. The argument continued into the hallway where staff and residents heard them yell at each other. The CNA yelled for Licensed Practical Nurse (LPN) G to come to the hallway. The CNA called the Administrator to notify them of the incident and the Administrator asked the CNA to wait outside the building until they arrived; -Staff and other residents verified hearing the argument and raised voices. The resident's roommate said the argument made him/her feel uncomfortable and that the CNA always had a bad attitude, was rude and their actions were uncalled for; -The Administrator interviewed other residents who described the CNA as rude, hateful, mean spirited and unapproachable. Record review of the facility's Resident's Rights Acknowledgement, signed by CNA A on 10/26/18, showed the following: - I hereby acknowledge that on the date noted below, I was informed on the rights of nursing home residents, which contained information including but not limited to the following; -The resident rights support the principles of dignity and respect for every person who lives in a long-term care setting; -Residents should be treated with consideration and respect, with full recognition of your dignity and individuality. Residents should not be required to do things against their will. Record review of an Abuse Investigation Investigative Questionnaire completed by the Administrator with the resident, dated 9/12/22, showed the following: -The CNA was nasty and hateful. This incident happened today and the CNA was rude when the resident asked for help. The CNA became angry with the resident because he/she asked for help putting his/her shoes on. The resident could not get them on by him/herself. The CNA told the resident he/she was pissing the CNA off. During an interview on 9/13/22, at 9:40 A.M., the resident said the following: -On 9/12/22, he/she asked the CNA to assist him/her with his/her shoes. The CNA told him/her he/she could put his/her own shoes on. The CNA put one shoe on him/her and the other shoe only half way on; -Later that day, the CNA came down the hall and asked how he/she was doing. He/she told the CNA not to talk to him/her and the CNA told him/her you are really pissing me off. He/she asked the CNA what they were going to do about it, tell me to f off again? The CNA denied saying this. The CNA did not use the f word on 9/12/22, but yelled at him/her. He/she went outside and cried. Record review of an Abuse Investigation Investigative Questionnaire completed by the Administrator with Resident #2, dated 9/12/22, showed the following: -CNA A was rude and hateful. He/she was present during the incident on 9/12/22. Resident #1 had the call light on and the CNA came in. Resident #1 asked for help putting on their shoes. The CNA had an attitude and told Resident #1 to put their own shoes on. He/she felt the CNA's attitude was uncalled for. The CNA was really rude and had a bad attitude. The incident made him/her feel uncomfortable when the CNA yelled at Resident #1. During interviews on 9/13/22, at 10:12 A.M. and 3:12 P.M., Resident #2 said the following: -On 9/12/22, Resident #1 put his/her call light on to get assistance with his/her shoes. CNA A came in the room and did not talk nicely to Resident #1. The CNA asked Resident #1 why he/she could not put his/her own shoes on. Resident #1 did not say anything to the CNA and the CNA did not curse at Resident #1, but raised their voice to Resident #1. The CNA had an attitude when they entered the room and their voice was elevated. This made Resident #2 uncomfortable because he/she did not like arguments; -Later that day in the hallway, he/she heard Resident #1 and CNA A arguing. Resident #1 said something (he/she did not know exactly what Resident #1 said) to the CNA and the CNA said they never said that. He/she thought the interaction from earlier in their room between the CNA and Resident #1 escalated in the hallway. Both Resident #1 and the CNA yelled in the hallway; -He/she thought the way the CNA treated Resident #1 was disrespectful. During an interview on 9/13/22, at 10:28 A.M., Resident #3 said the following: -On 9/12/22, he/she heard one of the resident's say one of the staff told them to f off and the staff member said they did not say that and the resident was lying. The resident said they would file a report and the staff member told them that was their right. LPN G told them this was not the place to do this and attempted to redirect them to an office. The staff member did not curse at the resident, but got loud with the resident. The resident yelled at the staff member. He/she did not see who the staff member or resident was. Record review of an Abuse Investigation Investigative Questionnaire completed by LPN G, dated 9/12/22, showed the following: -On 9/12/22, at 5:15 P.M., CNA A and Resident #1 were in the 200 hallway having a verbal disruption. The resident said the CNA never wanted the CNA to help them or care for them and the CNA had an attitude. The resident said the CNA told them to F Off. The LPN attempted to resolve and told them we aren't doing this in the hall. During interviews on 9/13/22, at 1:42 P.M. and 3:09 P.M., LPN G said the following: -On 9/12/22, he/she exited the Special Care Unit (SCU) and CNA A told him/her they needed him/her on the 200 hall now. He/she walked down the 200 hall and Resident #1 sat in their wheelchair. Resident #1 and CNA A began to [NAME]. The resident reported being tired of the CNA coming into their room and not assisting the resident and giving the resident dirty looks. The resident said they asked the CNA to assist them with their shoes and the CNA told them there was no reason they could not complete this task on their own. The resident told the CNA they needed help with the task. The resident then stated the CNA told them to fuck off. At this time the CNA exploded, got angry and said that's a lie and you are a liar. He/she told the CNA to calm down, lower their voice and come to his/her office. The CNA picked up their phone and called the Administrator. The CNA then came to the nurses' desk and the Administrator instructed him/her to get statements. -He/she felt like CNA was being disrespectful to the resident. The CNA should not have yelled at the resident. -Staff should treat residents with kindness, compassion and equal care. Staff should not yell at or argue with the residents. If he/she heard a staff member treating a resident inappropriately, he/she would intervene, quiet them down and take them to his/her office, get statements and notify the Administrator immediately. During an interview on 9/13/22, at 11:59 A.M., CNA D said the following: -He/she was in a room assisting another resident when he/she heard screaming coming from the hallway. He/she opened the door to look and CNA A, Resident #1, and LPN G stood in the hallway. The only thing he/she heard was the CNA state that's not true, that's a lie. The CNA was yelling; -Staff should treat residents good. They should not yell at or argue with the residents. If he/she heard a staff member treating a resident inappropriately, he/she ensured the resident's safety then reported the incident to the charge nurse immediately. During an interview on 9/13/22, at 2:13 P.M., Resident #4 said the following: -On 9/12/22, he/she heard two people yelling in the hallway. CNA A said you are a liar and they were in the room to help the resident's roommate. He/she did not know the resident's voice and did not hear anything else but yelling. He/she would report to another staff or Department of Health and Senior Services if any staff treated him/her inappropriately. During an interview on 9/13/22, at 2:18 P.M., Resident #5 said the following: -On 9/12/22, he/she heard loud voices in the hallway. He/she did not know what they said or who the voices belonged to. He/she said it was loud enough to get your attention; -If any staff treated him/her inappropriately, he/she would push his/her call light and report this to another staff member. During an interview on 9/13/22, at 10:46 A.M., CNA B said the following: -Staff should treat residents with respect. They should not yell or argue with residents. If he/she heard a staff member not treating a resident appropriately, he/she would ensure the safety of the resident then immediately report the incident to the charge nurse or the Administrator. During an interview on 9/13/22, at 11:05 A.M., CNA/Certified Medication Tech (CMT) C said the following: -Staff should treat the residents excellent. They should not yell at or argue with the residents. If he/she heard a staff member not treating a resident appropriately, he she would first protect the resident then immediately report the incident to the charge nurse. During an interview on 9/13/22, at 12:16 P.M., the Activity Aide said the following: -Staff should treat residents with respect. They should not yell at or argue with the residents. If he/she heard a staff member not treating a resident appropriately, he/she would ask the staff member to step away and reported this immediately to the charge nurse after he/she ensured the residents safety; -He/she heard CNA A be short and rude with residents. The CNA should not be short or rude to the residents. During an interview on 9/13/22, at 12:49 P.M., CMT F said the following: -Staff should treat residents with dignity and respect, kindness, compassion and care. Staff should not yell at or argue with a resident. If he/she heard a staff member treating a resident inappropriately, he/she removed the resident from the situation and reported the incident to the charge nurse immediately. During an interview on 9/13/22, at 3:26 P.M., the Director of Nursing (DON) said the following: -He/she did not witness the incident between Resident #1 and CNA A; -The Administrator removed CNA A from the building and suspended the CNA pending investigation; -He/she felt the CNA treated the resident disrespectfully and their actions were inappropriate; -During their investigation they found several residents comment about the CNA being rude and short; -The CNA took it too far in this incident; -Staff should treat residents with dignity, respect, kindness and compassion. Staff should not argue with or yell at residents; -Some residents were difficult and hard to get along with, but in health care, staff members have to learn how to handle these types of residents; -Staff should report any incidents to their immediate supervisor. During an interview on 9/13/22, at 3:38 P.M., the Administrator said the following: -On 9/12/22, at 5:25 P.M., CNA A called him/her and reported that Resident #1 accused them of telling the resident to f off. The CNA said they did not say this, but the resident said they did. The CNA had LPN G talk to the resident. He/she instructed the CNA to remove themselves from the situation and leave the building and wait for him/her. He/she arrived and started an investigation. After he/she spoke with several residents, he/she felt the CNA acted disrespectfully to the resident. It takes a lot for the resident to ask for help and the CNA should not have treated the resident like that. He/she planned to terminate the CNA based on his/her investigation; -Staff should treat residents with respect, like they cared for their families. Staff work for these residents; -Staff should never make a resident feel uncomfortable; -Staff should report to him/her immediately if they hear any staff being disrespectful. MO00206907

Based on observation, interview and record review the facility failed to post the State's Elder Abuse Hotline number for residents if they needed to file a complaint with the state survey and certification agency. The facility census was 41. Record review of facility's abuse, neglect, exploitation policy, showed the state abuse hotline phone number shall be posted. During a group interview of seven residents on 03/01/18 at 9:27 A.M., two residents said (five did not answer) they did not know where the Elder Abuse Hotline number was posted. Observations on 03/01/18 at 10:10 A.M., showed the facility did not post the name, address and toll free telephone number of the State Elder Abuse Hotline. During an interview on 03/01/18 at 10:34 A.M., Resident #24 said he/she knew the Elder Abuse Hotline number was posted, but she did not know where. During an interview on 3/1/18 at 10:50 A.M., Resident #16 said he/she thought he/she may have seen the Elder Abuse Hotline number somewhere, but did not know where. During an interview on 3/01/18 at 10:59 A.M., Certified Nurse's Aide/Certified Medication Technician (CNA/CMT) C said the Elder Abuse Hotline number should be posted somewhere in building, he/she looked for it and was unable to locate it. During an interview on 3/01/18 at 1:12 P.M., Certified Nurse's Aide/Restorative Aide (CNA/RA) D said the Elder Abuse Hotline number was posted in the employee break room and one other place, but he/she was not sure where. During an interview on 3/1/18 at 1:55 P.M., Licensed Practical Nurse (LPN) E said the Elder Abuse Hotline number was on the bulletin board behind another sheet of paper in the medical records room. He/she said it should be on the wall by the nurse's desk but he/she was unable to locate it. During an interview on 3/7/18 at 4:30 P.M., Administrator said: -The Elder Abuse Hotline number should be posted. It was posted by the nurse's desk; -Someone must have removed the Elder Abuse Hotline number; -She posted the number again on the wall 3/1/18.

Based on observation, interview and record review the facility failed to ensure food was stored and served in accordance with professional standards for food safety when dishes were not washed at the minimum temperature required by the manufacturer and dented cans were stored in dry storage area. This could lead to contamination of food and to food-borne illness potentially affecting all residents. The facility's census was 41. 1. Record review of the undated facility's cleaning and dishwashing policy, undated, showed: -The machine is ready when the wash temperature gauge on the machine reads a minimum of 140 degrees Fahrenheit (F); - If the temperatures are not correct, please report to the food service manager. Record review of Missouri Food Code published in 2013, showed the temperature of the wash solution in spray-type ware washers that use chemicals to sanitize, may not be less than one hundred twenty degrees F. During an interview on 3/1/18 at 3:00 P.M., Dietary Aide (DA) G said: -He/she documents the dishwasher temperatures on the Dish Machine Temperature Log. He/she obtains a glass of water from the dishwasher during the wash cycle and uses test strips to determine temperatures. There is also a temperature gauge on the machine. Record review of the (MONTH) (YEAR) Dish Machine Temperature Log showed staff documented the wash and rinse temperatures for 3/1/18 breakfast, lunch and dinner were 130 degrees. (dinner had not occurred). Observation on 3/1/18 at 3:10 P.M., showed the temperature, during the wash cycle, was 105 degrees F. Observation on 3/2/18 at 10:10 A.M. of manufacturer's plate on dishwashing machine showed: -Wash and rinse temperature should be minimum of 120 degrees F. Record review of the (MONTH) (YEAR) Dish Machine Temperature Log showed staff documented the following: -From 3/1/18-3/8/18 the wash and rinse temperatures for dishwashing after breakfast, lunch and dinner was 130 degrees. During an interview on 3/6/18 at 8:45 A.M., DA F said: -He/she did not know the dish washing machine manufacturer's temperature requirements; -He/she looked at the temperature gauge and documented its reading on the log; -After DA F looked at the (MONTH) (YEAR) Temperature Log and realized he/she documented each meal, from 3/1/18-3/8/18, he/she said he/she must have gotten ahead of himself/herself. Observation on 3/6/18 at 9:00 A.M., showed the temperature gauge during the wash cycle at 110 degree F. During an interview on 3/6/18 at 2:19 P.M., Dietary Manager (DM) said: -Staff read the temperature gauge on dishwashing machine when washing dishes after each meal and documented the temperature on the temperature log; -She did not expect staff to document temperatures in advance; -Dishwashing machine temperatures should be 130-140 degree F and she was not aware the dishwashing temperatures, on the facility's dishwashing machine, were below manufacturing requirements. 2. Record review of the undated facility's food storage and safety practices policy, undated, showed dented cans shall be removed from storage and returned to the vendor. Observation on 03/1/18 at 2:30 P.M., in the dry storage area, showed: -Two large dented cans of fruit with received date of 3/1/18; -One large dented can of pineapple tidbits with a received date of 2/28/18. During an interview on 3/1/18 at 2:45 P.M., DA F said he/she did not know where dented cans were kept. During an interview on 3/1/18 at 2:35 P.M., the DM said that he/she put stock away today from supplier delivery. All items in the dry storage area were ready to be used. During an interview on 3/6/18 at 2:19 P.M., DM said: -He/she places dented cans in her office for return to the vendor; -He/she does not use food from dented cans that have any indention.

Based on record review and interview the facility failed to provide a program for the prevention of the growth of the Legionella bacteria (a bacteria which causes a respiratory disease when breathing in small droplets of water in the air that contain Legionella. It can become a health concern when it grows and spreads in human-made water systems) in the facility water supply or where moist conditions existed. This deficient practice had the potential to affect all residents, staff and visitors in the event of a Legionella outbreak. The facility had a census of 41. 1. Review of the facility provided documentation on 3/2/18 at 11:00 A.M., showed no information for the prevention of the Legionella bacteria. During an interview on 3/2/18 at 2:00 P.M., the administrator said she had not finished gathering the information for the Legionella prevention plan.

Based on interview and record review, the facility staff failed to report a resident to resident altercation as an incident of abuse when Resident #34 pinched Resident #7 on the arm. A sample of 14 residents were selected for review in a facility with a census of 41. Record review of the facility's Abuse Prohibition Policy, undated, showed the following reporting instructions: -If resident to resident abuse occurs staff should separate the residents, then report to the charge nurse; -The facility will ensure that all alleged violations involving mistreatment, neglect or abuse, including injuries of unknown origin and misappropriation of resident property are reported immediately to the supervisor, the supervisor will then report to the administrator of director of nursing (DON); -The initial report will be filed to the state certification agency immediately (within 2 hours) without delay. 1. Record review of Resident #34's nurse's notes showed the following information: -On 1/21/18, at 10:50 A.M., a nurse documented Resident #34 pinched Resident #7 on his/her hand. Resident #7 hollered. Resident #34 let go and walked away with staff. -No evidence of injury to resident #7. Record review of Resident #7's nurse's notes showed the following information: -On 1/21/18, at 10:50 A.M., a nurse documented Resident #34 pinched Resident #7 on his/her left hand; -Resident #34 entered Resident #7's room, Resident #7 yelled at him/her; -Resident #34 left the doorway with staff; -Resident #7 had no signs of injury. -The administrator, Director of Nursing (DON), physician, and Minimum Data Set (MDS) coordinator were informed. During an interview on 3/7/18, at 11:30 A.M., Registered Nurse (RN) A said if residents have an altercation they should be separated and protected from injury. Each resident should be assessed. He/she reports it to the administrator, DON, and social services. He/she did not remember a specific incident. Resident to resident abuse should be reported to health and senior services if there is an injury. During an interview on 3/7/18 at 11:50 A.M., the DON said she was not the DON at the time of the incident. All resident to resident altercations should be reported within two hours. She did not know if this incident was reported. During an interview on 3/7/18 at 11:58 A.M., the administrator said she expected staff to report all resident to resident abuse to her, the DON, the physician and the responsible party. It should be reported within two hours to health and senior services, and charge nurses are in-serviced and instructed on after hours and weekend notifications.

Based on interview and record review, the facility failed to thoroughly investigate an allegation of abuse involving two residents (Resident #7 and Resident #34). A sample of 14 residents was selected in a facility with a census of 41. Record review of the facility's policy titled: Abuse Prohibition Policy, undated, showed the following investigation instructions: -Facility will investigate all types of abuse (physical, mental, sexual, financial, involuntary seclusion) and report; -If resident to resident abuse occurs staff should separate the residents, then report to the charge nurse; -The initial report will be filed to the state certification agency immediately (within 2 hours) without delay; -Follow up findings within five days of the incident; -If the allegation is verified corrective action will be taken. 1. Record review of the resident's care plan with interventions initiated on 11/29/17, showed the following: -Intervene as necessary to protect the rights and safety of others; -Minimize potential for disruptive behaviors by offering tasks which divert attention such as offering a snack. Record review of Resident #34's nurse's notes showed the following information: -On 1/21/18, at 10:50 A.M., a nurse documented Resident #34 pinched Resident #7 on his/her hand. Resident #7 hollered. Resident #34 let go and walked away with staff. -No evidence of injury to Resident #7. Record review of Resident #34's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by the facility staff, dated 2/5/18, showed the following information: -Severely impaired cognition; -No behaviors; -Extensive assistance with dressing and grooming; -Minimal assistance with transfers and mobility. 2. Record review of the resident's care plan with interventions initiated on 6/25/17, showed the following: -Monitor/record/report to physician as needed the risk for harming others; increased anger, mood changes or agitation; -Observe for signs and symptoms of mania. Record review of Resident #7's quarterly MDS, dated [DATE], showed the following information: -Cognitively intact; -Minimal assistance with activities of daily living (ADLs); -No behavioral problems. Record review of Resident #7's nurse's notes showed the following information: -On 1/21/18, at 10:50 A.M., a nurse documented Resident #34 pinched Resident #7, pinched on his/her left hand; -Resident #34 entered Resident #7's room, Resident #7 yelled at him/her and Resident #34 left the doorway with staff; -Resident #7 had no signs of injury. -The administrator, Director of Nursing (DON), physician, and MDS coordinator were informed. During an interview on 3/6/18, at 12:00 P.M., Certified Nurse Aide (CNA) B said staff should separate residents if there are any altercations, and notify the charge nurse. Resident #34 is combative and if he/she is in a bad mood will hit, kick or pinch staff and other residents. Staff try to monitor Resident #34's whereabouts. During an interview on 3/17/18, at 10:20 A.M., CNA/Certified Medication Technician (CMT) C said if residents have an altercation they should be separated and monitored. It must be reported to the charge nurse. Resident #34 is moody and will hit and pinch staff and other residents. During an interview on 3/7/18, at 11:30 A.M., RN A said if residents have an altercation they should be separated and protected from injury. Each resident should be assessed. He/she reports it to the administrator, DON, and social services. He/she said Resident #34 can be aggressive with staff and other residents. He/she did not remember a specific incident. During an interview on 3/7/18 at 11:50 A.M., the DON said she was not the DON at the time of the incident. All resident to resident altercations should be reported within two hours. She did not know if this incident was investigated. During an interview on 3/7/18 at 11:58 A.M., the administrator said she expected staff to report all resident to resident abuse to her, the DON, the physician and the responsible party. It should be reported within two hours to health and senior services, and staff are in-serviced and instructed on after hours and weekend notifications. A full investigation should be completed within five days, including staff and resident statements and witness statements and forwarded to health and senior services.

Based on interview and record review, the facility failed to provide proper treatment per professional standards for one resident (Resident #16) with a [DIAGNOSES REDACTED]. of the low blood sugar. A sample of 14 residents was selected for review in a facility with a census of 41. Review of the American Diabetes Association recommendations for blood glucose testing showed the following: -Blood glucose targets for diabetics, before a meal, are 80-130 mg/dl; -[DIAGNOSES REDACTED] is a condition characterized by abnormally low blood glucose (blood sugar) levels, usually less than 70 mg/dl; -Some of the signs and symptoms of [DIAGNOSES REDACTED] are nervousness, anxiety, irritability, and impatience, confusion including [MEDICAL CONDITION], anger, stubbornness, or sadness. Review of the facility's undated policy titled hypoglycemic (low blood glucose) protocol showed the following: -If the resident's blood sugar is 50-70, give a snack with a carbohydrate and protein and an early meal (may give a health shake, peanut butter and crackers); -If the resident's blood sugar is less than 50 and the resident is responsive, give the resident 15 gram glucose solution or oral glucose gel, or 16 grams of glucose tabs (4 tablets). Review of the facility's undated policy titled condition change (observing, recording, and reporting) showed the following: -It is the responsibility of the licensed nurse to observe, record, and report any condition change to the attending physician so proper treatment will be implemented. 1. Review of Resident #16's care plan, revised on 10/28/17, showed the following: -Potential nutritional problem related to diabetes and obesity; -Carbohydrate consistent diet; -Staff to perform blood glucose checks and administer insulin as ordered. Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 1/06/18, showed the following: -admitted to facility on 9/28/16; -Cognitively intact; -[DIAGNOSES REDACTED].>-Received insulin every day. Review of the resident's (MONTH) (YEAR) physician order [REDACTED]. -Blood glucose checks twice a day; -[MEDICATION NAME] (long-acting insulin) 55 units twice a day; -[MEDICATION NAME] (a medication used to lower the blood sugar) 1000 mg, twice a day. Review of the resident's (MONTH) (YEAR) Medication Administration Record [REDACTED] -On 3/03/18, staff documented the resident's morning blood glucose was 41 mg/dl; -At 7:00 A.M., staff documented administration of 55 units of [MEDICATION NAME] subcutaneously (an injection of medication under the skin). Review of the resident's medical record showed staff did not document administration of glucose after obtaining the low blood sugar as per the facility protocol, did not document monitoring the resident's blood sugar level or document obtaining a follow-up blood sugar, and did not contact the physician regarding the resident's low blood glucose. During an interview on 03/07/18 at 09:34 A.M., Licensed Practical Nurse (LPN) J said the following: -On 3/03/18, at approximately 6:00 A.M., the nurse entered the resident's room and checked the resident's blood sugar. The nurse thought the resident's blood sugar was around 51 mg/dl, but she could not recall for sure. The resident was acting normally and was getting ready to eat breakfast. The resident was sitting up eating grape jelly out of a squeeze bottle; therefore, the nurse gave the resident her insulin ([MEDICATION NAME] 55 units); -The facility has a [DIAGNOSES REDACTED] protocol, located in the front of the MAR, that instructed staff on when to hold insulin, but the nurse could not recall how low a resident's blood sugar would have to be in order to hold insulin. The nurse thought it was approximately 40 mg/dl. If a resident's blood sugar was that low (40 mg/dl), staff would give the resident a snack and recheck his/her blood sugar. If a resident's blood sugar was really low, he/she would give the resident [MEDICATION NAME] tabs or orange juice and recheck his/her blood sugar. If the nurse gave the resident glucose tablets or rechecked the resident's blood sugar, she would document it in the resident's MAR. If the nurse gave a resident [MEDICATION NAME], he/she would stay with the resident and ask another nurse notify the physician; -The nurse did not have to do anything for Resident #16's blood sugar because she was sitting up in bed and acting normal. During an interview on 03/07/18 at 9:50 A.M., the Director of Nursing (DON) said the following: -If a resident's blood sugar was below 60 or above 400, the DON expected the nurse to notify the physician; -If a resident's blood sugar was low, depending on the resident's physician orders, a nurse should give the resident 8 ounces of juice and a protein. -The facility has a standing order or protocol for a nurse to give an injection of [MEDICATION NAME], if the resident's blood sugar was less than 60 mg/dl. The DON said that was a nursing judgement; -The DON thought Resident #16 had oral glucose tablets. -If a resident had a blood sugar of 41 mg/dl, the nurse should hold the resident's insulin and contact the resident's physician for further orders; -The DON did not know the resident's morning blood sugar was 41 mg/dl; the nurse should have called the physician. During an interview on 03/07/18 at 10:37 A.M., Licensed Practical Nurse E (LPN E) said the facility has a hypoglycemic protocol that shows nurses what to do if a resident's blood sugar is low. If the resident's blood sugar was 41 mg/dl and the resident was alert and oriented, he/she would give the resident four oral glucose tabs and orange juice or milk and notify the physician. The nurse would wait approximately 15 minutes and re-check the resident's blood sugar. During an interview on 03/07/18 at 11:16 A.M., a family nurse practitioner (FNP) said she worked with the resident's physician who is currently on vacation. The physician generally visits the facility one time per week. The FNP did not come to the facility, but did receive faxes from the facility. The physician's office did not receive any notifications/faxes about the resident's low blood sugar. If the resident's blood sugar was 41 mg/dl and the resident was responsive, the nurse should have called the physician and given the resident a snack or maybe [MEDICATION NAME] and rechecked the resident's blood sugar. The facility not following up on the resident's low blood sugar was concerning. During an interview on 03/07/18 at 1:14 P.M., Certified Medication Technician (CMT) K said the following: -She passed medications at the facility on 3/03/18; -At approximately 8:00 A.M., she entered the resident's room and gave the resident's her morning medications, including [MEDICATION NAME]. The resident was finished with breakfast and was in bed. -That morning for breakfast, the resident had French toast with syrup, cold cereal, one sausage patty and milk. The CMT was unsure, but thought the resident ate 100% of breakfast. The CMT spoke with the resident about the day's activities and the resident acted fine.

Based on observation, interview and record review, the facility failed to identify, assess and implement treatments and interventions for pressure ulcers for two residents (Resident #1 and #2) and failed to to prevent the deterioration of a pressure ulcers for one resident (Resident #2). The facility failed to perform treatments in a manner protective of the resident's skin condition consistent with professional standards of practice and to prevent new ulcers from developing in one resident (Resident #1). Nine sampled residents and two additionally selected residents were reviewed in a facility with a census of 40. Record review of the Prevention and treatment of [REDACTED]. -Pressure ulcers are defined as localized injury to the skin and/or underlying tissue; -[MEDICATION NAME] (a wafer type dressing that adheres to the skin) dressings should be used in body areas where the dressing will not roll or peel; -[MEDICATION NAME] dressings should be carefully removed to reduce skin trauma; -Position the resident off of the pressure ulcer whenever possible, continued positioning on a pressure ulcer can result in increased pressure, pain and damage to the area; -Avoid postures that increase pressure on the ulcer, avoid raising the head of the bed greater than 30 degrees. Record review of the facility's undated protocol titled, Weekly Skin Assessment showed direction for facility staff to do the following: -Skin assessments are to be done weekly by the wound nurse/charge nurse; -Skin assessments are to be done in the event of any reported findings; -Notifications will be sent to the physician, the Director of Nursing (DON), the Assistant Director of Nursing (ADON), the resident's family/guardian and the Department of Health and Senior Services (DHSS) (if required). Record review of the facility's pressure ulcer policy (undated) showed the following information: -Stage II pressure wound defined as a partial thickness loss of dermis (inner layer of skin) presenting as a shallow open ulcer with a red pink wound bed, without slough (layer of skin that comes off). May also present as an intact or open/ruptured serum (fluid) filled blister. 2. Record review of the Resident #2's Minimum Data Set (MDS - a federally mandated comprehensive assessment tool completed by facility staff), dated 10/20/16, showed the following information: -No cognitive deficits; -Moderate staff assistance required for bathing, dressing, and personal cares; -The resident was at risk for developing pressure ulcers; -No pressure ulcers or open [MEDICAL CONDITION] on the skin. Record review of resident's hospital physician's history and physical, dated 10/10/16, showed the physician documented the resident's skin as warm and dry. The physician did not document any skin discolorations or open areas. Record review of the resident's admission record, dated 10/12/16, showed staff admitted the resident to the facility with [DIAGNOSES REDACTED]. Record review of the initial nursing evaluation sheet dated, 10/12/16, showed the resident's skin was dry with no discoloration or open areas noted. Record review of the resident's nurses' notes, dated 10/12/16, showed the resident admitted to the facility and his/her skin was warm, dry and pink. Record review of the October 2016 weekly skin assessments showed staff documented the following: -On 10/17/16, skin pale, warm, dry and intact; no open areas, swelling, or redness noted; -On 10/24/16, skin pale, warm, dry and intact; no open areas, swelling, or redness noted. Record review of the resident's physician's telephone order sheet, dated 10/25/16, showed the following information: -Cleanse left heel with wound cleanser; -Apply 4X4 (gauze used for absorbing fluids as well as dressing and protecting wounds) and wrap with a bandage; -Change dressing daily until healed. Record review of the facility form titled, Seven Day Daily Wound Log showed staff documented the following: -On 10/25/16, the treatment nurse documented left heel. She failed to document a the description of the resident's left heel pressure ulcer (any lesion caused by unrelieved pressure that results in damage to the underlying tissue) to include dressing exudate, odor, appearance wd surrounding wound edges and skin color or pain; -On 10/26/16, the treatment nurse documented left heel. She staff failed to document a description of the resident's left heel pressure ulcer. Record review of the resident's nutritional assessment, dated 10/26/16, showed the Registered Dietitian (RD) documented no pressure ulcers were reported by nursing, though a skin treatment to the resident's left heel was recently ordered. Record review of the resident's nurses' notes, dated 10/26/16, showed the following information: -At 10:25 A.M., staff documented the weekly pain meeting was held and the resident utilized his/her pain medication nine days during the month for foot and leg pain; -At 5:00 P.M., staff sent the resident to the emergency department due to a fever of 102.9 degrees Fahrenheit (F) and slurred speech; -The nurse did not document he/she identified the pressure ulcer on the left heel, or an assessment of the pressure ulcer to include stage, color, type of tissue present in the wound bed and the appearance of the surrounding tissue. The nurse did not document notification to the DON or the physician of the resident's pressure ulcer. Record review of the resident's hospital discharge summary, dated 10/29/16, showed the following information: -admitted to hospital [MEDICAL CONDITION] (a potentially life-threatening complication of an infection in the bloodstream) due to a left heel stage II (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) pressure ulcer and surrounding [MEDICAL CONDITION] (a common, potentially serious bacterial skin infection) after presenting from the nursing home with fever and increasing weakness; -On admission the resident had a fever of 104.4 degrees Fahrenheit (F), a heart rate of 103 beats per minute (BPM), and white blood cell (WBC- a blood test which is elevated with an infection, normal range is 4,500-11,000) count of 20,000; -Treated with antibiotics and intravenous (IV) fluids. Record review of the facility's re-admission nursing evaluation sheet, dated 10/29/16, skin assessment showed a pressure ulcer on the resident's left heel measuring 4.0 centimeters (cm) x 5.0 cm. Record review of the resident's nurses' notes, dated 10/29/16, showed the following: -Resident readmitted to the facility with a [DIAGNOSES REDACTED]. -Left heel pressure ulcer, measured 4.0 cm by 5.0 cm, the wound bed was beefy red with a scant amount of drainage; -Resident on antibiotics for a skin infection. Record review of the resident's re-admission treatment order, dated 10/29/16 , instructed staff to wash the resident's left heel with vashe wash, cover the area with dry gauze and secure; change the dressing twice a day until the area healed. Record review of the re-admission POS dated 10/28/16, showed an order for [REDACTED]. Record review of the resident's weekly skin assessment, dated 10/31/16, showed the treatment nurse documented the following information: -Treatment continued to left heel; -Left heel beefy red with slight drainage. Record review of the resident's care plan, revised date of 10/31/16, showed the following: -Potential for pressure ulcer development related to immobility; -The goal to have intact skin, free of redness, blisters or discoloration by the next review date; -Interventions directed staff to inform the charge nurse of any new area of skin breakdown and a licensed nurse to perform weekly skin inspections; -The care plan did not show the resident had any open skin areas. Record review of the November 2016 physician's orders [REDACTED]. -On 11/8/16, physician orders [REDACTED]. day until the pressure ulcer was seen by the wound team or the wound doctor; -On 11/14/16, orders to discontinue the current treatment; cleanse the left heel with wound cleanser, apply calcium alginate (a highly absorbent topical wound dressing), cover the pressure ulcer with 4x4's, wrap with gauze and change the dressing daily until healed. Record review of the resident's November 2016 weekly skin assessment's showed the nurse documented the following: -Continue treatment to the left heel. The left heel pressure ulcer wound bed was pink with granulation tissue (the pink-red moist tissue that fills an open wound, when it starts to heal); -On 11/14/16, treatment continued to the left heel pressure ulcer with no swelling or redness noted; -On 11/21/16, treatment continued to the left heel pressure ulcer with no swelling noted; -On 11/28/16, treatment continued to the left heel pressure ulcer. The wound bed had granulation tissue present and no swelling noted. Record review of the facility form titled, Non-Pressure Skin Condition Report dated November 2016, showed the treatment nurse documented the following information on the resident's left heel pressure ulcer: -No documentation on the pressure ulcer prior to 11/14/16; -On 11/14/16, the physician debrided (removed damaged tissue) the pressure ulcer. The pressure ulcer measured 3.0 cm x 4.0 cm and 0.2 cm in depth with scant, serous (thin, watery) drainage. The pressure ulcer wound bed was beefy red with slight maceration (softened skin tissue caused by moisture) of the edges and the surrounding skin color was pink. A new treatment initiated for previous blister; -On 11/15/16, changes to the pressure ulcer showed a measurement of 3.0 cm x 3.8 cm and 0.2 cm in depth . The pressure ulcer wound bed with granulation tissue. Record review of the resident's history and physical, dated 11/21/16, showed the following: -Primary visit [DIAGNOSES REDACTED]. -The left heel showed a very slow healing process and it is severe enough to warrant a consultation with the Wound Care Center; -Will refer resident to the Wound Care Center; -Possible need for debridement. Record review of the facility form titled, Non-Pressure Skin Condition Report dated November 2016, showed the treatment nurse documented the following information on the resident's left heel pressure ulcer: -On 11/22/16, the nurse documented the pressure ulcer had deteriorated to an unstageable (full thickness tissue loss in which the base of the pressure ulcer wound bed is completely covered by dead tissue) wound. The wound measured 3.8 cm x 4.0 cm with scant, serosanguinous (containing blood and the liquid part of blood) drainage. The pressure ulcer wound bed was beefy red with some areas of eschar (thick, leathery, dark dead or devitalized tissue). The wound edges were slightly macerated and the surrounding skin color was pink. Record review of the resident's medical record showed staff did not schedule an appointment for the resident to be seen by the Wound Care Center. Record review of the Non-Pressure Skin Condition Report, dated December, 2016 showed the treatment nurse documented the following information on the resident's left heel pressure ulcer wound: -On 12/2/16, the pressure ulcer wound measured 3.0 cm x 2.4 cm and 0.1 cm in depth with scant serosanguinous drainage. The pressure ulcer wound bed was beefy red with granulation tissue, macerated wound edges, and the surrounding skin was white. Staff to continue with the current treatment; -On 12/8/16, changes to the pressure ulcer wound showed a measurement of 3.0 cm x 2.0 cm and 0.1 cm in depth. The pressure ulcer wound bed was pink with granulation tissue and the surrounding skin was pink. Staff to continue with the current treatment. Record review of the resident's nurses' notes, dated 12/14/16, showed the following: -The resident's Power Of Attorney (DPOA) requested the resident be sent to a wound clinic; -The nurse spoke with the physician about the resident being sent to a wound clinic. Record review of the resident's POS, dated 12/14/16, showed the following information: -Arterial Doppler to bilateral lower legs; -Set up appointment for wound clinic. Record review of the resident's medical record showed staff did not schedule an appointment with the Wound Care Center. Record review of the Non-Pressure Skin Condition Report, dated December, 2016 showed the treatment nurse documented the following information on the resident's left heel pressure ulcer wound: -On 12/19/16, changes to the pressure ulcer wound showed a measurement of 3.0 cm x 2.2 cm and 0.2 cm in depth and a slight odor. The pressure ulcer wound bed showed some areas of slough (dead tissue in the process of separating from the viable portions of the body) and the nurse documented the wound had deteriorated. Staff to continue the current treatment. During an interview on 12/14/16, at 2:10 P.M., the DON said the resident had a blister not a pressure area on his/her left heel. During an observation on 12/15/16, at 9:10 A.M., the treatment nurse began to remove the prior dressing from the resident's left heel pressure ulcer. The dressing was adhered to the pressure ulcer with dried serosanguinous drainage. The nurse moistened the dressing with wound cleanser to remove it easier. The nurse measured the wound at 2.2 cm x 3.5 cm. The nurse described the wound bed as beefy red with some areas of granulation tissue and some areas of slough. The nurse described the wound edges as macerated and the skin surrounding the wound as pink. The nurse cleansed the heel with wound cleanser, placed calcium alginate on the wound, covered the wound with a 4x4, wrapped the heel with gauze, and secured the gauze roll with tape. During an interview on 12/16/16, at 2:00 P.M., Certified Medication Technician (CMT) H said the area on the resident's heel started as a blister before the resident was discharged to the hospital, but he/she was unsure when the blister developed. During an interview on 12/16/16, at 2:05 P.M., Certified Nurse Aide (CNA) B said the resident was admitted with a heel problem. CNA B said the resident had the blister on his/her left heel for approximately a week before he/she was discharged to the hospital. CNA B said when he/she identified a new area of concern on a resident's skin, then he/she would notify the charge nurse. During an interview on 12/16/16, at 2:15 P.M., Licensed Practical Nurse (LPN) I said he/she thought the resident was admitted with a blister on his/her heel. LPN I said when a resident was admitted , the nurse should assess the resident from head to toe. The nurse should document the initial skin assessment on the nursing evaluation sheet. If the resident had an area on his/her skin the nurse should document a description including size, color, drainage, old or new, or pressure related. During an interview on 12/16/16, at 2:50 P.M., the resident said he/she had a painful area on his/her left heel prior to his/her first admission to the facility. The area became a blister, ruptured and became an open wound a few days before he/she was discharged to the hospital. During an interview on 12/19/16, at 2:15 P.M., the treatment nurse said the resident did not have a pressure ulcer on his/her heel on admission. The resident wore shoes that rubbed his/her feet for a few days after admission. The treatment nurse said the resident was admitted to the hospital for stroke symptoms. The treatment nurse said he/she did not review the hospital discharge notes, but said that would be important information to know. The treatment nurse said the resident was readmitted with a blister on his/her left heel, and since the blister was intact he/she did not measure it. The treatment nurse said he/she would normally measure a blister and document the measurements on a residents heel. The nurse said the resident's left heel wound was slowly healing, and the resident would benefit from going to a wound clinic. During an interview on 12/20/16, at 1:06 P.M., the DON said the resident did not have any open areas or blisters on his/her feet on the first admission to the facility. The DON said the resident did wear shoes without socks that rubbed his/her feet. The DON said the resident developed a blister on his/her heel but was not sure if the resident developed the blister before or after the resident readmitted to the facility from the hospital. The DON said she would consider a fluid filled blister a Stage I pressure ulcer. The DON said the resident admitted to the hospital for stroke symptoms, but he/she did not review any records from the hospital after the resident's readmission to the facility. 2. Record review of Resident #1's face sheet showed the following: -admission date of [DATE]; -[DIAGNOSES REDACTED]. Record review of the resident's admission MDS, a federally mandated comprehensive assessment instrument completed by facility staff, dated 06/26/16, showed the following: -Severely impaired cognition; -Continent of bladder and bowel; -No pressure ulcers on admission. Record review of the resident's care plan, dated 10/04/16, showed the resident developed a pressure ulcer related to immobility and directed the staff to do the following interventions: -Licensed nurse to inspect the resident's skin weekly; -Monitor, document and report any changes in the status of the resident's skin to the physician; -Administer treatments as ordered and monitor for their effectiveness; -Monitor the dressing daily to ensure the dressing was intact and adhering; -Assess, record and monitor the wound healing weekly; -Ensure the use of a pressure reducing device on the resident's wheelchair. Record review of the resident's December 2016 POS showed the following: -A weekly skin assessment every Tuesday; -Dated 09/16/16, an order to cleanse the resident's coccyx (tailbone) with wound cleanser and apply a [MEDICATION NAME] dressing on Monday's and Thursday's and as needed. Record review of the facility's form titled Wound Rounds Worksheets, completed by the treatment nurse, showed the following: -On 10/06/16, staff documented the resident's coccyx pressure ulcer measured 1.0 cm by 0.1 cm and to continue the [MEDICATION NAME] dressing and the resident's left buttock pressure ulcer measured 0.8 cm by 0.3 cm with no measurable depth and this is a new open area noted; -On 10/13/16, staff documented the resident's pressure ulcer on the coccyx was closed; -On 11/11/16, staff documented the resident's left buttocks pressure ulcer was closed; -On 12/01/16, staff documented the resident's coccyx pressure ulcer reopened and measured 0.5 cm by 0.5 cm with 0.1 cm depth. Review of the resident's Wound/Skin Healing record showed the following: -On 12/01/16, staff documented a reopened stage II pressure ulcer to the resident's coccyx area; -On 12/02/16, the pressure ulcer measured 0.5 cm in length by 0.5 cm in width and 0.1 cm in depth; -On 12/08/16, the pressure ulcer measured 0.5 cm in length by 0.3 cm in width and 0.1 cm in length. -The treatment for [REDACTED]. Observations on 12/13/16, at 2:45 P.M., showed the resident was in bed on his/her back with the head of the bed raised 60 degrees. Observation on 12/13/16, at 3:35 P.M. showed the following: -The treatment nurse vigorously peeled the [MEDICATION NAME] dressing off of the resident's coccyx pressure ulcer and the resident yelled out and moaned (potentially damaging skin around the wound); -The resident had one pressure ulcer on his/her coccyx and one pressure ulcer on the left buttock, both were approximately dime-sized and round in shape; -The treatment nurse sprayed wound cleanser on a gauze and directly on the pressure ulcers, patted the areas dry and applied a clean [MEDICATION NAME] dressing to the pressure ulcers. Observation on 12/13/16, at 4:56 P.M., showed the resident was in bed with the head of the bed raised up 60 degrees. Observations on 12/14/16 showed the following: -At 9:20 A.M., the resident was in bed on his/her back with the head of the bed raised up 60 degrees; -At 10:00 A.M., the resident lying on his/her back with the head of the bed raised up to 60 degrees. Staff entered to perform incontinent care on the resident. -At 2:00 P.M., the resident was in bed on his/her back with the head of the bed raised up 60 degrees. Observation on 12/15/16 at 9:20 A.M., showed the resident was in bed on his/her back with the head of the bed raised up 45 degrees. During an interview and observation on 12/15/16, at 10:40 A.M., showed the following: -The treatment nurse peeled the [MEDICATION NAME] dressing off of the resident's coccyx pressure ulcer and the resident moaned Ow; -The treatment nurse inserted her finger into the coccyx pressure ulcer and measured the pressure ulcer to be 0.8 cm in length and 0.6 cm in width (an increase in size); -The treatment nurse measured the wound on the left buttock to be 1.0 cm in length by 0.4 cm in width; -Staff placed the resident flat on his/her back and raised the head of the bed 45 degrees when the treatment was completed. -The treatment nurse said the resident's left buttock wound looks like an indentation, but it could be where the [MEDICATION NAME] dressing was, calling it an open area at this time. During an interview on 12/19/16, beginning at 2:15 P.M., the treatment nurse said the following: -Some of the thick [MEDICATION NAME] dressings have to be removed slowly; -She did not see the second open area on the resident's left buttock when she completed the treatment on 12/13/16; -Removing a [MEDICATION NAME] dressing vigorously could tear the resident's skin and cause on open wound; -Raising the head of a resident's bed creates more pressure on the resident's coccyx; -She did not complete a wound assessment for the resident during the week of 12/12/16 because she could not get to her wound book or to the residents' charts. 3. During an interview on 12/16/16, at 1:25 P.M., the Assistant Director of Nursing (ADON) said the facility does not have a policy for the resident's weekly skin assessments. 4. During an interview on 12/16/16, at 2:15 P.M., LPN I said the nurses do weekly skin assessments on each resident and document them on the back of the treatment administration record (TAR). The LPN said when he/she identified a new area on a resident's skin he/she would notify the physician and the treatment nurse, initiate a treatment, and document the description of the wound in the nurses' notes. If the treatment nurse was unavailable, the charge nurse should complete a wound notification form and place the form in the treatment nurse's assigned box at the nurses' station. The nurse should put the treatment order on the TAR, document the identified area in the nurse's notes, and notify the oncoming nurse. 5. During an interview on 12/19/16, beginning at 2:15 P.M., the treatment nurse said the following: -She completed primarily all of the resident's weekly skin assessments; -She documented her findings on the back of the treatment sheets; -She only measured open areas, but does not diagram any areas of concern; -Preventative measures to avoid developing a pressure ulcer included repositioning the resident frequently, turning the resident from one side to the other, avoid having the resident up in a chair for an extended period of time and use of barrier creams to protect the resident's skin; -She notifies the resident's responsible party whenever a new area of concern is identified on the resident's skin and documents this in the nurse's notes; -She did not complete a wound assessment for the resident during the week of 12/12/16 because she could not get to her wound book or to the residents' charts. 5. During an interview on 12/20/16, at 10:45 A.M., Registered Nurse (RN) D said if a new area on a resident's skin is identified, the nurse should first assess the area, notify the physician, and create an intervention. The nurse should document the description of the skin and notification of the physician and responsible party in the nurses' notes. The nurse would also document the treatment order in the TAR. 6. During an interview on 12/20/16, beginning at 1:05 P.M., the DON said the following; -She would expect the nurse to measure an identified area on a residents skin if it was big enough to measure. The DON said she would expect the nurse to measure a Stage I pressure ulcer; -She expects the treatment nurse and/or the charge nurse to complete the residents skin assessments every week; -She expects the treatment nurse and/or the charge nurse to document the weekly skin assessment findings on the back of the TAR; -The skin assessments should include a complete head to toe assessment with the resident's clothing removed, trying to coordinate the assessment to be done on the resident's scheduled shower day; -It is not acceptable for the treatment nurse to not complete a skin assessment every week; -It is not acceptable for the treatment nurse to fail to do a weekly skin assessment because she did not have access to a resident's chart; -She expects the treatment nurse to document skin color, the integrity of the skin and any areas of abrasions or redness; -She expects the treatment nurse to document measurements of any areas of concern that was large enough to measure; -She expects the measurements to be documented in the nurses' notes; -She expects the treatment nurse to complete the treatments listed on the residents' TARs and document the treatment performed; -She expects the treatment nurse to document the treatments on the resident's wound sheet and on the wound assessment sheet; -She expects the nurse to remove a [MEDICATION NAME] dressing slowly because any dressing removed incorrectly could damage the skin; -She would expect the treatment nurse to document any skin injuries obtained during a dressing change; -A nurse could traumatize or contaminate a resident's wound and cause further damage to a wound by sticking their finger in the wound.

Based on record review and interview the facility failed to notify the physician with a change in condition for one resident (Resident #1), with a history of urinary tract infections with rapid decline, when the resident's vital signs were outside of parameters for four days, displayed increased confusion, and a change in behaviors . The facility failed to notify the physician when the urinalysis with culture and sensitivity was not performed in a timely manner for one resident (Resident #1). As a result of this deficient practice Resident #1 experienced a rapid decline in condition that required emergency transfer to the hospital. Staff failed to notify the physician with a change in condition for one resident (Resident #2) with a [MEDICAL CONDITION] (surgical opening in the trachea to help with breathing). The resident had an increase and change in the color of sputum, and elevated temperature. Staff did not administer ordered medication to assist with breathing and inflammation for 10 days. The resident was sent to the hospital with a [MEDICAL CONDITION] purulent (yellow/green sputum containing pus). Upon return to the facility, staff failed to administer the same medications for 77 days. Twelve residents were sampled in a facility with a census of 48. 1. Record review of the undated facility policy titled, "Documentation Guidelines for Nurses", showed the policy directed registered nurses (RN) and licensed practical nurses (LPN) to document in the resident's medical record after the following "incidental situations": -Any change in the resident's physical, mental or behavioral status; -Any change in the resident's vital signs (blood pressure, pulse, respirations or temperature); -Development of acute resident problems; -During significant changes the nurses should document routinely every shift for the number of days designated by the policy; -The nurse should document fever, changes in continence, odor or foul smelling urine, complaints of frequency, urgency or burning and mental status changes related to urinary tract infections [MEDICAL CONDITION] for ten days; -The nurse should document infection, dehydration and changes in clinical status related to fevers for ten days; -The nurse should document call and faxes to the physician with reason and information reported and the physician response; -The nurse should document he/she notified of the physician regarding lab work and x ray results; -The policy did not direct nurses on when to notify the physician with changes in condition or after incidental situations. Record review of the undated facility policy titled, "Follow up on Lab Order", showed the following: -After receiving orders from the physician to perform the lab the nurse is to call Boyce and Bynum with the lab order; -Boyce and Bynum will take the order and fill out the requisition; -The next morning when medical records performs follow-up of the orders, medical records will call the lab and assure that the nurse called in the order, if not medical records with place the order; -The next day medical records will go to the Boyce and Bynum website and check for results; -If there are no results, medical records will call Boyce and Bynum for the results or reason they are not completed; -After medical records obtain the results, he/she will report to the Director of Nursing (DON); -The policy did not direct nursing on how to follow-up on labs after business hours Monday through Friday, weekends or holidays. Record review of the physician's standing orders for the facility showed the facility nurse should obtain a urinalysis with culture and sensitivity if the resident exhibited signs of a UTI. The facility staff should notify the physician of heart rates greater than 100. 2. Record review of Resident #1's prospective payment system (PPS) 60 day scheduled Minimum Data Set (MDS), a federally mandated comprehensive assessment tool, completed by facility staff, dated [DATE], showed the following: -The resident had [DIAGNOSES REDACTED]. -The resident showed inattention, disorganized thinking and psychomotor [MEDICAL CONDITION] on and off during the assessment period; -The resident required extensive assistance from staff for bed mobility, transfers, eating, toileting and personal hygiene; -The resident was frequently incontinent of urine and always continent of bowel. Record review of the care plan, last reviewed on [DATE], showed the following: -The resident required extensive assistance with toileting and hygiene; -The care plan directed staff to toilet the resident every two hours; -On [DATE] the staff hand wrote the resident is continent throughout the day of bowel and the resident will ask to be toileted, but is usually already wet from urine; -The care plan indicated the resident had the potential for alteration in nutritional status and fluid maintenance related to the [DIAGNOSES REDACTED]. -On [DATE] the staff hand wrote the resident is prone to UTI and directed staff to continue to encourage the resident to drink fluids; -The care plan did not direct staff to monitor or report signs or symptoms of UTI, to the nurse or physician. The care plan did not direct staff to obtain a urinalysis if the resident showed signs or symptoms of a UTI. Record review of the [DATE] physician's orders [REDACTED]. -An order dated [DATE] for [MEDICATION NAME] 650 milligrams (mg) by mouth three times daily (would affect the resident's temperature readings); -An order dated [DATE] for oxygen at three liters, via nasal cannula, as needed. Record review of the facility form titled, "Vital Sign and Weight Flow Sheet" showed from [DATE] through [DATE] the following: -The resident blood pressures ranged from ,[DATE] to ,[DATE]; -The resident's temperature was below 98.6 degrees; -The resident's pulse ranged from 57 beats per minute to 110 beats per minute; -The resident respirations ranged from 16 per minute to 33 per minute. Record review of the facility form titled, "Vital Sign and Weight Flow Sheet" showed on [DATE] on the 10:00 P.M. to 6:00 A.M. shift staff documented the resident's blood pressure was ,[DATE], temperature of 99.6, pulse 78, respiration 18 and oxygen saturation of 92%. A normal oxygen saturation range is ,[DATE]%. Record review of the nurses' notes showed the following: -On [DATE] on the 10:00 P.M. to 6:00 A.M. shift, LPN A documented the resident slept well that night and voiced no complaints of pain. The nurse documented he/she collected urine from the resident for a urinalysis with culture and sensitivity due to reports of the resident having confusion and change in his/her behaviors; -On [DATE] at 4:00 A.M. LPN A documented the lab picked up the urine specimen. During an interview on [DATE] at 2:00 P.M., LPN A said the resident had a [DIAGNOSES REDACTED]. The resident was alert and oriented and could verbalize his/her needs. On [DATE] he/she received in report that the resident was experiencing an increase in confusion. With this resident, any change in confusion is cause to obtain a urinalysis. The resident had a history of [REDACTED]. LPN A did not see any changes in the resident that night. Record review of the facility form titled, "Vital Sign and Weight Flow Sheet" showed the following: -On [DATE] the staff did not document the resident's vital signs on the day shift; -On the 2:00 P.M. to 10:00 P.M. shift, staff documented the resident's blood pressure was ,[DATE], temperature of 97.7, pulse 78, respirations 20 and oxygen saturation of 92%. Record review of the nurses' notes showed on [DATE] the staff did not document in the nurses' notes on the day or evening shift although the resident demonstrated confusion and change in behavior the day prior. Record review of the facility form titled, "Vital Sign and Weight Flow Sheet" showed on [DATE] the 10:00 P.M. to 6:00 A.M. staff documented the resident's blood pressure was ,[DATE], temperature of 100.4, pulse 130. The staff did not document the resident's respirations or oxygen saturations. Record review of the nurses' notes showed the following: -On [DATE] on the 10:00 P.M. to 6:00 A.M. shift, LPN B documented the resident had rested well most of the night but had an elevated temperature of 100.4 and needed oxygen at two liters per minute via nasal cannula through the night. LPN B documented he/she attempted to decrease the oxygen but the resident's oxygen saturations would drop when the nasal cannula was removed. LPN B gave the resident Tylenol with good benefit. The LPN did not document the resident's oxygen saturations during times when he/she was attempting to decrease the oxygen; -On [DATE] at 2:00 A.M. LPN B documented the resident's blood pressure was ,[DATE], temperature of 100.4, pulse 121, respirations 32 and oxygen saturation of 93%. LPN B documented he/she paged the on-call physician and was awaiting a return call; -From 2:00 A.M. to 6:00 A.M., LPN B did not document if the on-call physician returned the page or further assessments of the resident. Record review of the facility form titled, "Vital Sign and Weight Flow Sheet" showed the following on [DATE]: -The 6:00 A.M. to 2:00 P.M. staff documented the resident's blood pressure was ,[DATE], temperature of 99.4, pulse 122, respirations 16 and oxygen saturation of 91%; -The 2:00 P.M. to 10:00 P.M. staff documented the resident's blood pressure was ,[DATE], temperature of 100.3 axillary, pulse 112, respirations 32 and oxygen saturations of 93%. Record review of the nurses' notes showed on [DATE] on the 6:00 A.M. to 2:00 P.M. shift, LPN C documented the following: -LPN C notified the resident's family of the urinalysis that staff obtained; -The resident's blood pressure was ,[DATE], temperature of 99.4, pulse 122, respirations 16 and oxygen saturations of 91%; -The lab refused to perform the previously obtained urinalysis due to the resident's misspelled last name on the specimen cup. LPN C notified the DON and obtained a second urinalysis specimen from the resident. LPN C did not document if he/she notified the physician regarding the delay in lab results due to the refusal of the lab company and of the resident's elevated temperature and pulse. During an interview on [DATE] at 1:45 P.M., RN F said he/she assisted LPN C obtain the second urine specimen on Friday, [DATE] after the lab company called to say they could not perform the urinalysis due to the resident's name being misspelled on the specimen cup. RN F said he/she went to the former DON and asked if they could call the lab company and see if anything could be done to get the firs urinalysis ran. The resident tolerated the procedure well and drank well that day. RN F did not assess the resident. Record review of the facility form titled, "Vital Sign and Weight Flow Sheet" showed on [DATE] the 10:00 P.M. to 6:00 A.M. staff documented the resident's blood pressure was ,[DATE], temperature of 102.5 axillary, pulse 125, respirations 36 and oxygen saturation of 91%. Record review of the lab results for the urinalysis showed the following: -The staff collected the urine specimen on [DATE] at 1:15 P.M., lab received on [DATE] at 10:33 P.M., the results reported on [DATE] at 9:49 A.M. and the results printed on [DATE] at 12:29 P.M. by remote printer; -The urine culture showed a colony count greater than 10,000 and less than 100,000 of Escherichia coli (bacteria) and positive for Extended spectrum beta lactamase (ESBL) (specific bacteria that produce enzymes). Record review of the facility form titled, "Vital Sign and Weight Flow Sheet" showed the following: -On [DATE] the 6:00 A.M. to 2:00 P.M. staff did not document vital signs; -On [DATE] the 2:00 P.M. to 10:00 P.M. staff documented the resident's blood pressure was ,[DATE], temperature of 98.4, pulse 82, respirations 16 and oxygen saturation of 92%. Record review of the nurses' notes showed the following: -On [DATE] at 11:45 P.M., LPN A documented the resident had a temperature of 101.5. The staff was giving fluids every hour to the resident. The resident's oxygen saturation was 93%. LPN A gave the resident Tylenol and would recheck the resident's temperature. LPN A did not document if he/she notified the physician regarding the resident's elevated temperature, pulse and respirations; -On [DATE] at 1:15 A.M., LPN A documented the resident's temperature was 97.3 and staff continued to offer fluids. LPN A did not document if he/she notified the physician regarding the resident's elevated temperature, pulse and respirations; -On [DATE] RN D documented on the 6:00 A.M. to 2:00 P.M. shift the resident's blood pressure was ,[DATE], temperature of 98.1, pulse 96, respirations of 17 and oxygen saturation of 94%. The staff continued to encourage the resident to drink fluids every hour and with meals. Record review of the nurses' notes showed on [DATE], LPN A documented on the 2:00 P.M. to 10:00 P.M. shift the resident's blood pressure was ,[DATE], temperature of 98.4, pulse 82, respirations 16 and oxygen saturation of 92%. The resident was up in his/her recliner and had a non productive cough. LPN A documented the resident did not have rales (crackles) or rhonchi (sounds similar to snoring and can occur with fluid in the lungs) with inspiration, but could hear the resident wheezing during respirations without a stethoscope. The resident had two liters of oxygen via nasal cannula and declined to eat. LPN A documented the resident drank 580 cc (cubic centimeters) of fluids during the shift and was more oriented to the staff and surroundings. LPN A called the lab company for results of the urinalysis and the lab staff told LPN A the results were not ready. LPN A did not document if he/she notified the physician regarding the resident's wheezing with respirations, inability to obtain lab results or the resident's refusal to eat. Record review of the facility form titled, "Vital Sign and Weight Flow Sheet" showed on [DATE] the 10:00 P.M. to 6:00 A.M. staff documented the resident's blood pressure was ,[DATE], temperature 98.2, pulse of 103, respirations 40 and oxygen saturations of 91% with two and a half liters of oxygen via nasal cannula. Record review of the nurses' notes showed on [DATE], LPN B documented the resident's blood pressure was ,[DATE], temperature 98.2, pulse 103, respirations 40 and oxygen saturations of 91% with two and a half liters of oxygen via nasal cannula. LPN B documented the resident was resting with his/her eyes closed and staff encouraged fluids throughout the shift. LPN B did not document if he/she notified the physician regarding the resident's elevated pulse and respirations. During an interview on [DATE] at 1:00 P.M., LPN C said the resident had a history of [REDACTED]. The resident would exhibit signs and symptoms such as increased pulse, increased temperature and lethargy. The resident would decline rapidly with UTIs and would require IV antibiotics, so the staff tried to stay ahead of them. On [DATE] he/she received in report from the night shift they sent out a urine specimen. Late that morning the lab company called to say they were not able to run the urinalysis because the resident's name was spelled incorrectly on the specimen cup. LPN C went the former DON and informed him/her. The former DON said, "What do you want me to do about it?" LPN C asked the wound nurse to assist with obtaining another urine specimen. On [DATE] the resident was alert and oriented during the day shift and could verbalize needs. The resident did not exhibit any respiratory symptoms during the day shift. Record review of the nurses' notes showed the following on [DATE]: -At 12:00 P.M., LPN E documented the resident's temperature was 100.4 and he/she applied cool wash cloths to the resident's head and axillaries (underarms). LPN E gave the resident Tylenol and assessed the resident's abdomen as soft and distended with tenderness to palpation. The resident's last bowel movement was on [DATE] with minimal meal intake of between ,[DATE] percent. LPN E documented the staff continued to encourage the resident to drink fluids. LPN E notified the physician and received orders for a chest x ray. LPN E attempted to notify the family and was awaiting call back from them; -At 12:30 P.M., LPN E documented the family called back to the facility and was upset that the results from the urinalysis were not back yet and with the reoccurring symptoms. The family wanted a call from the staff with lab results and x ray results when available. The staff continued to encourage the resident to drink fluids. Record review of the facility form titled, "Fax to a Physician" showed on Sunday [DATE], LPN E faxed the resident's physician regarding the resident. LPN E documented on the fax to the physician that the resident's temperature was 100.5, pulse 88, respirations 22 and shallow, blood pressure was ,[DATE] and oxygen saturations of 90% with three liters on oxygen via nasal cannula. The resident had rhonchi and wheezing throughout his/her lungs and was pale in color. The resident was difficult to arouse and respond. The resident's abdomen was distended, soft and his/her bowel sounds were hypoactive (sluggish) with the last bowel movement on [DATE] and minimal intake during meals the past few days between ,[DATE] percent. LPN E documented he/she called the on-call physician and received orders for a chest x ray today. The physician's office is closed on Sunday and was unable to respond to the fax. Record review of the radiology report, dated [DATE], for the chest x-ray showed the resident had pneumonia in his/her lower right lobe. The findings showed the resident had a modest right pleural effusion (excess fluid that accumulates between the two pleural layers) and the findings appeared worse than a previous chest x-ray completed on [DATE]. The resident had bilateral upper lobe infiltrates. Record review of the [DATE] POS showed the following: -On [DATE] the on-call physician ordered [MEDICATION NAME] (antibiotic) 100 mg by mouth twice daily for seven days for the [DIAGNOSES REDACTED]. -On [DATE] the on-call physician orders [REDACTED]. -On- [DATE] the on-call physician ordered [MEDICATION NAME] ([MEDICATION NAME][MEDICATION NAME] used to treat [MEDICATION NAME]) every four hours. Record review of the [DATE] Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED].M. the resident received the first dose of [MEDICATION NAME] 750 mg. Record review of the facility form titled, "Vital Sign and Weight Flow Sheet" showed the following on [DATE]: -The 2:00 P.M. to 10:00 P.M. staff documented the resident's blood pressure was ,[DATE], temperature 99.4 axillary, pulse 103, respirations 52 and oxygen saturations of 89%; -At 6:15 P.M., LPN A documented the resident's blood pressure was ,[DATE], temperature 99.0, pulse 90, respirations 26 and oxygen saturations of 91% after [MEDICATION NAME] treatment; -At 6:45 P.M., LPN A documented the resident's blood pressure was ,[DATE], temperature 99.0, pulse 96, respirations 36 and oxygen saturations 89% before ambulance crew took resident from facility. Record review of the nurses' notes showed the following on [DATE]; -At 5:45 P.M., LPN A documented the chest x ray results received and faxed to the physician. LPN A gave the resident the [MEDICATION NAME] treatment per order; -At 6:15 P.M., LPN A documented the resident's blood pressure was ,[DATE], temperature 99.0, pulse 92, respirations of 26 and oxygen saturations of 91 % after [MEDICATION NAME] treatment. The resident was up in his/her recliner and answering yes/no questions. The resident denied pain. LPN A documented the resident had elevated respirations and encouraged the resident to slow his/her breathing. The resident was on oxygen at two liters per minute via nasal cannula and his/her skin was pale and warm. The resident's capillary refill time in his/her finger tips was slow. LPN A documented the resident's heart rate had occasional irregular beats and he/she was unable to get the resident to take deep enough breaths to hear air movement in the resident's lungs. LPN A could hear wheezing after the [MEDICATION NAME] treatment without a stethoscope. The resident did not have a cough and was ready to go to bed; -At 6:25 P.M., LPN A documented he/she was requested to come to the resident's room by an aide. The resident was in bed with the head of the bed elevated all the way. The resident had oxygen on at two liters per minute via nasal cannula with increased respirations and breathing through his/her mouth. LPN A moved the nasal cannula to the resident's mouth and increased to five liter per minute. The resident's oxygen saturation was 86%. The resident had shallow labored breathing and LPN A was unable to assess breath sounds. The resident had non blanching nail beds. LPN A call 911 immediately; -At 6:35 P.M., LPN A documented the ambulance had arrived and the resident's blood pressure was ,[DATE], temperature 99.0, pulse 96, respirations 38 and oxygen saturation of 90%. The paramedics transferred the resident immediately to their oxygen and a non rebreather (mask used for delivering high concentrations of oxygen) mask. The EMT connected the resident to electrocardiogram (EKG). LPN A gave the appropriate paperwork, including the chest x-ray dated [DATE] to the paramedics and they took the resident immediately out of the building; -At 6:45 P.M., LPN A notified the family of the resident being taken to the hospital in Springfield. The family asked, "Why his/her sudden change?" LPN A said he/she was not sure but he/she felt the resident needed emergency assistance. LPN A did not document if he/she notified the physician of the resident's emergency status or the transfer to the hospital. During an interview on [DATE], at 2:00 P.M., the resident's family said they received a call on Sunday [DATE], from facility staff who said the resident was extremely ill and they transferred the resident to the hospital in Springfield. The family said the facility called them on Friday [DATE], and said they obtained a urinalysis. The resident was life flighted to the hospital in Springfield and expired at approximately 1:00 A.M. Monday, [DATE] [MEDICAL CONDITION] related to a UTI. The family said the resident had a history of [REDACTED]. The family said since the facility knew the resident's recent history of UTIs and rapid decline to the point of needing intravenous (IV) antibiotics, staff should have reacted faster on Friday [DATE]. During an interview on [DATE] at 11:00 A.M., RN D said he/she cared for the resident on Saturday ([DATE]) day shift and was in the facility Sunday day shift. The resident experienced a change in confusion and the nurse on Friday obtained a urinalysis. On Saturday the resident was stable during his/her shift and did not experience any vital signs outside of parameters. On Sunday, the nurse called the on-call physician and obtained an order for [REDACTED]. The staff constantly had to encourage him/her to drink. During an interview on [DATE] at 1:15 P.M., RN D said he/she did not remember listening to the resident's lungs on Saturday [DATE]. The resident did not have any respiratory issues on Saturday. He/she was told in report to watch the resident's vital signs throughout the day. The resident was normal that day and got up for meals. Nurses should notify the physician if the residents experience an increase in temperature or vital signs outside of parameters. RN D said he/she would have called the physician immediately if the resident's pulse was above 100 beats per minute because the resident also was on [MEDICATION NAME] (blood thinner). During an interview on [DATE] at 2:00 P.M., LPN A said on [DATE], outside of the elevated temperature, everything else was normal for the resident. The resident argued with the nurse about why he/she was getting Tylenol and the resident didn't want the Tylenol. The aides reported the temperature of 102.5 to him/her. LPN A went immediately to the room and retook the temperature and it was 101.5. LPN A said the Tylenol lowered the resident's temperature to below normal. LPN A said the resident was up and dressed for breakfast the next morning before the day shift arrived. LPN A told the day shift nurse on [DATE] about the elevated temperature. On [DATE], LPN A came into work at 5:30 P.M. and worked half the evening shift and all the night shift. LPN A received in report from LPN B the resident had been sick all day and had a new order for a maxi mist (breathing treatment) and they had obtained a chest x-ray. When LPN A came on duty, aides told him/her the resident was not doing well. LPN A went to the resident's room to assess him/her. LPN A listened to the resident's lungs and documented the resident was trying hard to breath and had heavy labored breathing. LPN A asked the resident if he/she had a breathing treatment and the resident shook head no. LPN A obtained a machine and started the breathing treatment. LPN A said he/she was appalled at how the resident looked, but the resident was still responding appropriately to questions. LPN A said it was very apparent the resident needed to go to the hospital. Prior to Sunday [DATE], the resident did not exhibit any respiratory issues. LPN A said he/she would have sent the resident out earlier that day. LPN A called 911, and sent the resident out immediately. LPN A said he/she attempted to notify the on-call physician prior to sending the resident out. LPN A told the operator at the hospital to let the on-call physician know he/she would not be waiting on a return call to send the resident out. During an interview on [DATE] at 2:40 P.M., LPN B said he/she received his/her license in [DATE]. After he/she started at the facility he/she shadowed another nurse. As he/she became more comfortable he/she was on his/her own. The resident was somewhat oriented. The resident was not always agreeable, but could verbalize needs and was aware of surroundings. LPN B had never seen the resident on oxygen prior to [DATE]. LPN B attempted to page the on-call physician on [DATE] due to the elevated temperature. The on-call physician never returned his/her call. LPN B said he/she attempted a second page that was also unsuccessful. LPN B said he/she put the resident on every 15 minute checks. It was not unusual for the resident's pulse to be elevated. LPN B reported to the day shift that he/she paged the on-call physician twice with no return call. On [DATE] the resident was the exact same; there had been no change from the prior day. LPN B said he/she trusted the experience of the nurses that worked on the other shifts to know if the resident needed to be sent out. On Sunday [DATE], the resident was the exact same, no changes in status. The resident was sitting up in his/her room and appeared to be stable. During an interview on [DATE] at 7:38 A.M., LPN C said he/she thought the resident's physician was on vacation during the week the resident showed changes in his/her condition. He/she did not contact the physician's office or the on-call physician regarding the delay in labs on [DATE]. LPN C only worked the day of [DATE]. The DON was aware of the resident's condition and the delay in the labs. During an interview on [DATE] at 7:43 A.M., LPN B said he/she did not attempt to notify the DON or administrator the night of [DATE] when the on-call physician did not return the page. During an interview on [DATE] at 9:51 A.M. LPN A said the lab company did not tell him/her why there was a delay in the lab results. The lab did not show any labs for the resident in their system. The day shift has better experiences getting lab results. The facility does get preliminary results and final results, but it depends on how quickly the lab shows in their system. LPN A has never been shown how to access the lab results in the computer. LPN A said he/she never notified the on-call physician regarding the delay in labs or vital signs outside of parameters. The resident did not appear to be in acute distress, the resident was normal until Sunday. Nurses should call the physician with vital signs outside of parameters, but he/she looks at the big picture and the resident did not display any acute distress. LPN A did not feel he/she needed to notify the physician until Sunday, [DATE]. During an interview on [DATE] at 1:06 P.M., the physician said he/she saw on the computer the resident was in the hospital on [DATE]. The physician was on vacation from [DATE] through [DATE]. The physician has three nurse practitioners in the office Monday through Friday that are available for contact with concerns. If the nurse practitioners feels it is out of their scope of practice, they will contact the on-call physician at the hospital. On nights and weekends, the staff are to page the on-call physician at the hospital with any concerns. The nurse practitioners in the office did not mention anything about being contacted for concerns with the resident. The resident had frequent UTIs, moderate dementia, [MEDICAL CONDITION] and had experienced a general decline in health over the last year. In the last three months the mental and physical condition of the resident had declined. With this resident if not acting him/herself the physician expected the staff to get a urinalysis. The physician said the resident had two separate infections going on, a UTI and pneumonia, that would cause a rapid decline in health. The physician [MEDICAL CONDITION] would cause a rapid decline in health and that the resident's international normalized ratio (INR) (laboratory test used to monitor people who are taking oral blood-thinning medicines) was elevated at the hospital which was indicative [MEDICAL CONDITION]. The staff started the antibiotics on Sunday. The physician would expect the staff to contact him/her with vital signs outside of parameters depending on the situation and the resident. If the resident's pulse is over 100 and he/she had a [DIAGNOSES REDACTED]. It depended on what the resident's blood pressure looked like. The physician would expect the staff to notify him/her with respirations above ,[DATE] and if the resident was requiring more oxygen than usual. The physician said it was unreasonable for it to take four days to obtain a urinalysis, but he/she would not expect the facility to contact him/her for a delay in labs. During an interview on [DATE] at 1:40 P.M., LPN E said he/she has worked as needed at the facility for the last 2 years. On Sunday, [DATE], he/she was told in report the resident ran a fever the day prior, but nothing over night. The aides came and told him/her the resident was not looking like him/herself. LPN E went to the resident's room and assessed him/her. The resident was pale, had coarse lung sounds throughout, and the resident's abdomen was distended with hypoactive bowel sounds. LPN E said he/she faxed the physician and called the on-call physician. The on-call physician ordered a chest x-ray. LPN E called the family and found out about the urinalysis that was obtained and that no results had been received yet. LPN E went and found the MDS nurse in the office who assisted in calling the lab to find urinalysis results. LPN E called the on-call physician with the results of the urinalysis. The on-call physician ordered [MEDICATION NAME] and LPN E gave immediately. LPN E did not recall any other vital signs out of parameters for the day shift on [DATE]. If the resident would have had respirations of 52 and a pulse of 103, he/she would have called the on-call physician immediately. The resident appeared stable, but sick. The resident did not appear to need emergency transfer to the hospital. The resident got both the [MEDICATION NAME] and the [MEDICATION NAME] as soon as the physician ordered them. Both medications were in the emergency kit and the certified medication tech (CMT) pulled and gave immediately. During interviews on [DATE] at 2:00 P.M. and on [DATE] at 1:30 P.M. the administrator and the new DON (previous MDS coordinator) said no one contacted them on [DATE] about the resident having a change