Every finding on record at NHC Healthcare, West Plains

Based on interview and record review, the facility failed to issue the Skilled Nursing Facility Advanced Beneficiary Notice (SNF ABN) form at least two calendar days before skilled Medicare services ended for one resident (Resident #81) out of three sampled residents. The facility census was 68.Review of the facility's policy titled, Advanced Beneficiary Notice (ABN), revised February 2023, showed:- Patient assessment determines the continuing medical necessity of services rendered;- The center is responsible for notification of Medicare insurance coverage decisions to the beneficiary and/or responsible party using the notice of Medicare non-coverage;- If the patient remains in the center on or after the last day, the SNF ABN form will also be issued to provide notice of financial liability;- In the event grace days are granted due to significant difficulties arising in discharge arrangements, a SNF ABN form would be issued on the last day of skilled coverage (the day before the grace days begin);- The social worker is responsible for assuring the technical criteria are met. 1. Review of Resident #8's medical record showed:- The resident discharged from skilled Medicare services on 02/04/26, and remained in the facility;- No documentation the resident and/or the responsible party received a SNF ABN form prior to the ending of the resident's skilled Medicare services;- The facility failed to provide the SNF ABN form to the resident and/or the responsible party at least two calendar days before the skilled Medicare services ended. During an interview on 06/10/26 at 10:57 A.M., and 1:32 P.M., the Social Service Designee (SSD) said the resident had Medicare days remaining and the resident remained in the facility after the discharge from his/her Medicare skilled services. He/She did not give the resident a SNF ABN notice because the resident was going to be Medicaid pending. During an interview on 06/11/26 at 11:02 A.M., the Administrator said if a Medicare resident was discharged from skilled therapy services and remained in the facility with Medicare days left, a SNF ABN notification should have been given to the resident and/or the responsible party for financial liability purposes.

Based on observation, interview, and record review, the facility failed to provide a safe, clean and comfortable homelike environment. This deficient practice had the potential to affect all residents in the facility. The facility census was 68.Review of the facility's policy titled, Homelike Environment, revised May 2017, showed:- Residents are provided with a safe, clean, comfortable homelike environment, and encouraged to use their personal belongings to the extent possible;- The facility staffing management shall maximize, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting;- These characteristics include a clean, sanitary and orderly environment. 1. Observations on 06/08/26 at 11:22 A.M., 06/09/26 at 8:22 A.M., and 06/10/26 at 8:12 A.M., of the dining room showed:- A ceiling tile with two large brown stains near a smoke detector near the activity door entrance;- A two foot (ft.) by two ft. ceiling vent with a buildup of a dark brown substance and brown stains near the food serving counter;- A window with a fog-like substance and several visible cracks covered with tape prevented visibility to the outside area on the right side near the kitchen entrance door;- Two battery-operated candles with a buildup of dust on a decorative wall sconce near the dining room entrance. 2. Observations on 06/08/26 at 11:26 A.M., 06/09/26 at 8:31 A.M., and 06/10/26 at 8:20 A.M., of the A Hall showed:- A ceiling tile with a large round brown stain near an intercom speaker by the Minimum Data Set (MDS - a federally mandated assessment instrument completed by the facility staff) office;- Three ceiling tiles with brown stains near the central supply room;- Two ceiling tiles with brown stains near the medication room; - Three ceiling tiles with black and gray stains near the double doors and a sprinkler head by the Director of Nursing's (DON) office. 3. Observations on 06/08/26 at 11:32 A.M., 06/09/26 at 8:52 A.M., and 06/10/26 at 8:32 A.M., of the B Hall showed:- A large area of peeled wallpaper on the upper left-side wall of the Certified Nurse Assistant (CNA) station between Rooms B1 and B2;- A window with a large area of a fog-like substance prevented visibility to the outside area in Room B7. 4. Observations on 06/08/26 at 11:42 A.M., 06/09/26 at 8:58 A.M., and 06/10/26 at 8:41 A.M., of the D Hall showed:- Two large brown stains on the ceiling in the hallway near Room D9;- A three inch (in.) x seven in. area of peeled wallpaper and exposed sheetrock on the right-side wall of the CNA station near Room D14;- A six in. long area of wallpaper cracked at the seam with exposed sheetrock on the left-side wall of the CNA station near Room D14. 5. Observation on 06/10/26 at 7:51 A.M., and 8:09 A.M., of the laundry room showed:- An electrical control box dangled from the rear of the commercial washing machine open and unsecured;- Internal wiring was exposed and visible;- A buildup of dust and lint on the wires, plug-in, and the surrounding areas;- An electrical cord plugged into an electrical box with a white zip tie around it;- The sink full of discolored water with a bleach-like odor;- A five-gallon bucket sat on the floor over half full beside the sink with dirty, wet kitchen rags. Review of the facility's Work Order form, dated 03/30/26 - 06/09/26, showed:- No documentation of areas of concern addressed. During an interview on 06/10/26 at 8:04 A.M., the Laundry Supervisor said the water in the sink was bleach water used to soak things that did not come clean out of the dryer. Laundry staff changed the water out every other day and the bucket on the floor contained dirty kitchen rags. He/She was not sure who cleaned behind the washer but believed it to be the maintenance department. The back of the washer area had not been cleaned in a long time. During an interview 06/10/26 at 11:02 A.M., Housekeeper A said he/she used a form to address any environmental concerns. The form was given to the maintenance department to address the area of concern. He/She had not reported any areas of concern to be addressed. During an interview on 06/11/26 at 10:47 A.M., Housekeeper B said he/she verbally told the maintenance department if there was an environmental issue and would also write out a work order form to address the concern. He/She had not reported any areas of concern to be addressed. During an interview on 06/11/26 at 10:49 A.M., the Assistant Maintenance Supervisor said broken windows and ceilings tiles were the responsibility of the maintenance department. Staff did not necessarily need to write down those areas of concern on a work order form. During an interview on 06/11/26 at 10:53 A.M., the Maintenance Supervisor said daily rounds were made for any environmental issues. There were work order forms staff could fill out for any concerns the maintenance department needed to address. The back of the washer area was cleaned once a month. The ceiling tiles, windows, peeled wallpaper, and exposed sheetrock were the responsibility of the maintenance department. During an interview on 06/11/26 at 10:57 A.M., the Administrator said ceiling tiles, windows, peeled wallpaper, exposed sheetrock, and other environmental areas of concern should be addressed by the maintenance department on a regular basis. Staff should use work order forms to address any environmental concerns as well.

Based on observation, interview, and record review, the facility failed to identify, assess, and provide supportive interventions for two residents (Residents #3 and #10) out of two sampled residents with a diagnosis of post-traumatic stress disorder (PTSD - a mental health condition triggered by a terrifying event - either experiencing it or witnessing it; symptoms may include flashbacks, nightmares and server anxiety, as well as uncontrollable thoughts to the event). The facility census was 68.Review of the facility policy titled, Trauma-Informed Care for Residents with PTSD, showed:- Purpose is to establish a standardized approach for screening, assessing, caring for, and monitoring residents with PTSD, and ensuring compliance with federal and state long-term care regulations;- During the admission process, the interdisciplinary team (IDT) shall complete a trauma and PTSD screening as part of the comprehensive admission assessment;- With the resident's consent, gather information from family members, prior medical records and previous caregivers to understand potential trauma history and triggers;- Within seven days of completion of the comprehensive assessment, the IDT will develop an individualized care plan;- The care plan shall clearly document specific triggers and include interventions. 1. Review of Resident #3's medical record showed:- admission date of 04/06/26;- Diagnoses of PTSD and insomnia (a common sleep disorder that can make it hard to sleep);- admission Minimum Data Set (MDS - a federally mandated assessment instrument required to be completed by facility staff), dated 04/10/26, with a diagnosis of PTSD. Review of the resident's Pre-admission Screening and Resident Review (PASARR), dated 04/03/26, showed:- No diagnosis of PTSD. Review of the resident's care plan, dated 04/13/26, showed:- PTSD not addressed;- No goals to maintain the resident's psychosocial and mental health;- No documentation of the resident's past trauma, or any triggers that could cause the resident trauma;- No interventions for how the facility would address the behaviors if they occurred or how the facility would provide support to the resident. During an interview on 06/10/26 at 11:30 A.M., the resident said he/she had triggers at home but hadn't had any issues at the facility so far. His/Her triggers were helicopters and airplanes. 2. Review of Resident #10's medical record showed:- admission date of 05/18/26;- A diagnosis of PTSD, dated 05/18/26;- No documented informed consent related to PTSD;- No evidence of PTSD-related triggers was addressed. Review of the resident's admission MDS, dated [DATE], showed:- Diagnosis of PTSD. Review of the resident's PASARR, dated 08/20/25, showed:- No diagnosis of PTSD; Review of the resident's care plan, revised on 03/04/26, showed:- PTSD not addressed;- No goals to maintain the resident's psychosocial and mental health;- No documentation of the resident's past trauma, or any triggers that could cause the resident trauma;- No interventions for how the facility would address the behaviors if they occurred or how the facility would provide support to the resident. During an interview on 06/10/26 at 10:30 A.M., the resident said staff had never asked about his/her PTSD history or triggers. His/Her triggers were loud noises, and when staff or residents got too close to his/her personal space. During an interview on 06/11/26 at 12:10 P.M., the Director of Nursing (DON) said she would expect the residents' care plan to address PTSD and have triggers/interventions in place. During an interview on 06/11/26 at 12:15 P.M., the Administrator said she would expect PTSD to be on the care plan with triggers and interventions in place.

Based on observation, interview, and record review, the facility failed to follow infection control precautions by not following Enhanced Barrier Precautions (EBP - precautions for use during high-contact resident care activities for residents infected with a multidrug-resistant organism (MDRO - microorganisms that are resistant to one or more classes of antimicrobial agents) or any resident who has a chronic wound and/or indwelling medical device) and failed to perform appropriate hand hygiene and glove changes during wound and incontinent care for one resident (Resident #16) out of three sampled residents. The facility census was 68.Review of the facility's policy titled, Enhanced Barrier Precautions, no revision date, showed:- Personal protective equipment (PPE) is required when providing personal care, transferring in a room, when accessing any ostomy, peg tube, catheter or wound, and when providing showers. Review of the facility's policy titled, PPE, no revision date, showed:- Objectives are to prevent the spread of infection, protect wounds from contamination, and protect hands from potentially infectious material. Review of the facility's policy titled, Handwashing/Hand Hygiene, revised August 2015, showed:- Perform hand hygiene before applying non-sterile gloves;- Hand hygiene is the final step after removing and disposing of PPE. 1. Observation of Resident #16's wound care and incontinent care on 06/10/26 at 3:20 P.M., showed: - EBP signage on the outside of the door and PPE stored outside the resident's door;- Registered Nurse (RN) D and Certified Nursing Assistant (CNA) E entered the resident room without gowns;- RN D performed hand hygiene and applied a gown and gloves;- CNA E did not perform hand hygiene, did not put on a gown, and put on gloves;- RN D unfastened the resident's brief soiled with fecal material and wadded it up at the base of the resident's buttocks, removed the wound dressing, performed incontinent care, performed hand hygiene, changed gloves, and performed the wound care;- CNA E removed the wadded-up brief soiled with fecal material from under the resident's buttocks, did not perform hand hygiene, did not change gloves, and placed a clean brief under the resident's buttocks;- RN D removed the gloves, gathered the bag filled with the incontinent care and wound care trash in his/her bare hands, did not perform hand hygiene, did not remove the gown, touched the resident's inner door knob with his/her bare hand, exited the room, touched the outer closet door knob with his/her bare hand, and disposed of the trash bag in a biohazard box; - CNA E removed gloves, did not perform hand hygiene, and exited the room. During an interview on 06/15/26 at 1:45 P.M., CNA E said he/she would normally wear a gown during wound care but was distracted. He/She should have changed gloves before applying a clean brief and should have performed hand hygiene after removing gloves and leaving the room. During an interview on 06/16/26 at 1:47 P.M., RN D said he/she would normally remove the gown and perform hand hygiene before leaving the room. During an interview on 06/11/26 at 12:05 P.M., the Director of Nursing (DON) said she would expect all staff performing wound care to be wearing gowns and gloves. Staff should wash hands and remove PPE before exiting the room. During an interview on 06/11/26 at 12:18 P.M., the Administrator said she would expect all staff performing wound care to put on EBP before providing care and remove it before leaving the room as well as performing hand hygiene.

Based on observation, interview, and record review, the facility failed to ensure an environment free from accident hazards. Staff failed to secure access to soiled laundry and chemicals in an unlocked soiled linen laundry room. The room contained a sink basin of bleach water and an open container of multipurpose cleaner solution. The unlocked, unlatched soiled linen room presented a potential hazard to all residents who were able to move freely around the facility with 14 residents at increased risk due to their mental capacity from a diagnosis of dementia (a group of thinking and social symptoms that interferes with daily functioning) or Alzheimer's disease (a progressive disease that destroys memory and other important mental functions). The facility census was 61. Review of the facility policy titled, Chemical Storage, undated, showed: - Keep chemicals locked up away from patients when not in use. Review of the Product Specification Document titled, Rapid Multi-Surface Disinfectant Cleaner, dated 10/19/23, showed: - Keep out of reach of children; - Precautions: Concentrate is corrosive. Causes irreversible eye damage and skin burns. Diluted solution causes moderate eye irritation; - Physical and Chemical Hazards: Do not mix with anything but water. Observations of the soiled linen room in the laundry rooms showed: - On 02/06/25 at 10:30 A.M. - 10:32 A.M., 10:38 A.M. - 10:42 A.M., 10:47 A.M. - 10:49 A.M., 11:00 A.M. - 11:02 A.M., the soiled linen room door in the laundry rooms was unlocked and unlatched with a sink basin filled with bleach water with one towel and an open container of multipurpose cleaner solution with a toilet brush sitting in the solution inside the right sink basin, a large bin of soiled items, and a large bin of trash items. No staff were present inside the laundry rooms. Multiple residents and staff walked by the unlocked and unlatched room door. Three residents sat in chairs in the common area approximately 20 feet from the soiled linen room; - On 02/07/25 at 7:50 A.M. - 7:54 A.M., 7:58 A.M. - 8:03 A.M., and 8:05 A.M. - 8:08 A.M., the soiled linen room door in the laundry rooms was unlocked and unlatched with a sink basin filled with bleach water and an open container of multipurpose cleaner solution with a toilet brush sitting in the solution inside the right sink basin, a large bin of soiled items, and a large bin of trash items. No staff were present inside the laundry rooms. Multiple residents and staff walked by the unlocked and unlatched room door. Two residents sat in chairs and one resident sat in a wheelchair in the common area approximately 20 feet from the soiled linen room. During an interview on 02/06/25 at 11:05 A.M., Laundry/Housekeeping E said the soiled linen door was left unlocked when staff were out rounding the halls to pick up soiled barrels. The door was locked when the task was complete. During an interview on 02/07/25 at 8:15 A.M., Housekeeper G said the soiled linen door in the laundry was not locked or latched when he/she pushed the door open to check the trash bin. The door was locked at times and a code must be entered to open the door. During an interview on 02/07/25 at 1:10 P.M., Laundry/Housekeeping Staff E and Laundry/Housekeeping F said the doors to the laundry, including the soiled linen, should be kept latched and always locked. During an interview on 02/07/25 at 1:30 P.M., the Director of Nursing (DON) said the laundry room doors should be latched and locked when unattended.

Based on observation, interview, and record review, the facility failed to maintain proper infection control practices during incontinent care for two residents (Residents #5 and #16) out of four sampled residents, catheter (a tube inserted into the bladder to drain urine) care for one resident (Resident #21) out of one sampled resident, and wound care for two residents (Residents #5 and #58) out of two sampled residents. The facility failed to ensure proper infection control measures during administration of insulin for one resident (Resident #37) out of one sampled resident and touched medications with bare hands for one resident (Resident #118) out of five sampled residents. The facility also failed to ensure proper infection control measures during laundry services. The facility census was 61. Review of the facility's policy titled, Safety and Sanitation Best Practice Guidelines, dated 11/2017, showed: - Glove use should never take the place of the first and primary barrier against germs, proper handwashing; - Gloves should be changed often, before moving from one task to another, or if contaminated; - Always wash hands using correct hand washing procedures before putting on gloves, putting on gloves with contaminated hands will contaminate the outside of the glove; - Change gloves after any action that might contaminate foods; - Remove gloves, then wash hands; - Dry hands and arms with disposable paper towel or other sanitary means, such as an air-drying device. Do not use a cloth towel for a continuous towel system that has been used by others. Review of the facility's policy titled, Peri Care Check List Female/Male, undated, showed: - Gather supplies, perform hand hygiene, put on gloves, clean the peri area using a clean portion of the washcloth each time, assist the resident to turn, hand hygiene and change gloves, cleanse the buttocks, remove gloves, hand hygiene, dispose of soiled linen. Review of the facility's policy titled, Specific Medication Administration, Injectable Medication, dated 01/01/19, showed: - Wash hands with soap and water; - Prepare medication; - Sanitize hands, put on gloves; - Expose area to be injected, clean with alcohol wipe; - For subcutaneous (injection under the skin) pinch the skin up between the thumb and forefinger; - Inject the medication, remove the needle, apply adhesive bandage or apply gentle pressure to the site; - Dispose of the syringe in a sharps container; - Remove and discard gloves, clean hands by washing or sanitizing. Review of the facility's policy titled, Specific Medication Administration, Oral Medication Administration, dated 01/01/19, showed: - Wash hands when beginning medication pass or when contact with resident is expected or has occurred; - Pour correct number of tablets or capsules into the medication cup, taking care to avoid touching the tablet or capsule, unless wearing gloves. Review of the facility's policy titled, Linen and Laundry Management, undated, showed: - Always wear gloves before handling soiled linen; - Never carry soiled linen against the body; - Have handwashing facilities; - If there is risk of splashing, staff should always wear gowns or aprons and face protection; - Transport laundry from patient rooms to laundry chute or area. Avoid leaning into cart when gathering laundry to prevent direct contact of skin and clothes with dirty linens. The facility referenced Centers of Medicare and Medicaid Services (CMS) Memo QSO-24-08-NH as their policy for Enhanced Barrier Precautions (EBP) in Nursing Homes to Prevent Spread of Multidrug-Resistant Organisms (MDROs), dated 03/20/24, showed: - EBP recommendations now include the use of EBP for residents with chronic wounds or indwelling medical devices during high-contact resident care activities regardless of their MDRO status; - EBP refer to an infection control intervention designed to reduce transmission of MDROs that employs targeted gown and glove use during high contact resident care activities; - EBP is for residents with chronic wounds and indwelling medical devices (examples include urinary catheters); - High contact resident care activities include (dressing, bathing/showering, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, device care or use, wound care. 1. Observation of incontinent and catheter care on 02/04/25 at 11:02 A.M., for Resident #16 showed: - EBP signage for the resident; - Registered Nurse (RN) A did not perform hand hygiene, put on gloves and a gown, removed the split gauze dressing soiled with a brown substance from the suprapubic catheter (a thin tube that drains urine from the bladder through a small incision in the lower abdomen) site; - Certified Nurse Assistant (CNA)/Certified Medication Technician (CMT) H did not perform hand hygiene, put on gloves and a gown, opened a zip lock bag with gauze and DermaKlenz (a wound cleanser); - RN A did not change gloves, did not perform hand hygiene, removed the clean gauze from the zip lock bag, touched the DermaKlenz bottle, sprayed the DermaKlenz to the skin around the suprapubic catheter site, used the gauze to wipe the skin around the catheter site multiple times, and wiped the catheter with a twisting motion down the tube with the same gauze, and placed the soiled gauze into the zip lock bag; - RN A did not change gloves, did not perform hand hygiene, placed a clean split gauze to the catheter site, secured with tape, placed the DermaKlenz bottle into the zip lock bag with the soiled gauze, removed the DermaKlenz bottle, closed the zip lock bag, changed gloves, did not perform hand hygiene, and touched the resident's pillow; - CNA/CMT H retrieved the resident's clean clothes from the dresser and closet. RN A and CNA/CMT H assisted the resident with putting on his/her socks and pants; - RN A removed a previously used catheter leg bag stored in a trash bag, did not perform hand hygiene, did not change gloves, unattached the catheter from the large drainage bag, attached the leg strap to the resident's right thigh area, did not perform hand hygiene, did not change gloves, attached the leg catheter drainage bag to the catheter, and secured to the right thigh leg strap; - RN A exited the room, removed the gloves, did not perform hand hygiene, did not remove the gown, walked down the hall to the closet, touched the door knob, retrieved a zip lock bag and wash cloths, pumped soap into the zip lock bag with the washcloths, entered the resident's room with the same gown, put on gloves, went to the bathroom and added water to the zip lock bag with the wash cloths and soap; - RN A did not change gloves, did not perform hand hygiene, removed two wash cloths from the zip lock bag, cleaned the resident's buttocks soiled with fecal material, and placed the wash cloths soiled with fecal material back into the zip lock bag; - RN A did not change gloves, did not perform hand hygiene, touched the wipe package, removed the wipes, cleaned the resident's buttocks, did not remove all of the fecal material from between the anus to the perineal area, picked up the Nystatin (a medication used to treat fungal or yeast infections of the skin) tube, applied the Nystatin to the resident's buttocks, removed the gloves, did not perform hand hygiene, exited the room, retrieved more gloves, entered the room, did not perform hand hygiene, and put on gloves; - RN A put slippers on the resident's feet and transferred the resident to an electric wheelchair via a Hoyer lift (a mechanical device used to move or transfer a person); - RN A and CNA/CMT H removed the gowns and gloves, and did not perform hand hygiene; - CNA/CMT H took the zip lock bags of soiled items and trash to the soiled utility closet, went to another resident's room, and did not perform hand hygiene; - RN A did not perform hand hygiene, exited the room with the DermaKlenz bottle in his/her bare hand, did not perform hand hygiene, entered into another resident's room with the bottle in his/her bare hand, did not perform hand hygiene, exited the resident's room, did not perform hand hygiene, entered the central supply closet on A hall, touched the doorknob, opened the drawer of of the treatment cart, placed the DermaKlenz bottle in the drawer, exited the room, went into the medication room, and performed hand hygiene. 2. Observation on 02/04/25 at 1:48 P.M., of Resident #58's wound care showed: - EBP signage for the resident; - Licensed Practical Nurse (LPN) J gathered supplies on a paper plate, performed hand hygiene, put on a gown, entered the resident's room, and sat the plate on the resident's bedside table; - LPN J opened the gauze roll package with the scissors from the plate, put on gloves, removed the dressing soiled with a brown substance and the packing strip from the left elbow wound; - LPN J did not perform hand hygiene, did not change gloves, used a cotton swab to apply lidocaine solution (a local anesthetic used to ease pain) to the skin around the elbow wound, removed the gloves, performed hand hygiene, put on gloves, removed the sock and Tubi grip (an elastic tubular support bandage used for light/moderate compression) from the resident's left lower extremity, did not sanitize the scissors and cut the gauze dressing from the left heel wound, and removed the dressings; - LPN J did not perform hand hygiene; did not change gloves; opened a container of Aquaphor (an ointment which protects the skin to enhance the natural healing process and help prevent external irritants from reaching the wound) ointment; sat the Aquaphor container on the floor; did not perform hand hygiene; did not change gloves; dipped his/her fingers into the Aquaphor container; applied the Aquaphor ointment to the resident's left lower leg, foot and toes; did not perform hand hygiene; did not change gloves; dipped his/her fingers into the Aquaphor container; and applied the Aquaphor ointment to the left lower leg, foot, and toes; - LPN J did not perform hand hygiene, did not change gloves, removed the bordered foam dressing from the package, placed it on the left heel, wrapped with a gauze roll, did not sanitize the scissors and cut the gauze wrap, removed the gloves, and performed hand hygiene; - LPN J removed the sock from the right foot, performed hand hygiene, put on gloves, removed the ace wrap from right lower leg and foot, removed the dressings from the right heel, did not perform hand hygiene, did not change gloves, retrieved a gauze pad and normal saline from the plate, cleaned the right heel, did not perform hand hygiene, did not change gloves, did not sanitize scissors and cut a piece of Polymem max silver (a wound care treatment made for wounds with heavier drainage), placed the Polymem max silver on the right heel wound, secured with a bordered foam dressing, did not perform hand hygiene, did not change gloves, dipped his/her fingers into the Aquaphor ointment container, and applied to the right foot; - LPN J did not perform hand hygiene, did not change gloves, wrapped the right heel with a gauze roll, did not sanitize the scissors and cut the gauze wrap, secured the dressing with tape, wrapped the right foot and lower leg with an ace wrap, removed the gloves, performed hand hygiene, and put on gloves; - LPN J cleaned the left elbow wound with a gauze pad and normal saline, did not perform hand hygiene, did not change gloves, packed the wound with dry packing tape with a cotton swab, did not sanitize the scissors and cut the packing tape, opened and applied the bordered foam, did not perform hand hygiene, did not change gloves, wrapped the elbow with gauze wrap, did not sanitize the scissors and cut the gauze wrap, removed the gloves, did not perform hand hygiene, exited the room with the gown on, retrieved gloves, entered the room, performed hand hygiene, did not change gowns, put on gloves, cleaned the right elbow wound with normal saline and gauze, did not perform hand hygiene, did not change gloves, did not sanitize the scissors and cut a small piece of Polyman max silver to cover the wound on the right elbow, did not perform hand hygiene, did not change gloves, secured with a gauze roll, secured with tape, removed the gloves, did not perform hand hygiene, picked up trash from the area, placed the Tubi grip to the left lower leg, placed non-slip socks to both feet, removed the gown, and performed hand hygiene; - LPN J did not sanitize the Aquaphor ointment container, the lidocaine solution, and the bottle of hand sanitizer, and placed them back into treatment cart; - LPN J entered the resident's room, did not perform hand hygiene, put on gloves, retrieved a trash bag, did not perform hand hygiene, did not remove gloves, exited the resident's room, took the trash to the soiled closet, removed gloves, and sanitized hands. During a phone interview on 02/17/25 at 11:45 A.M., LPN J said the scissors should be cleaned before and after each wound. Before using on a new wound area, the scissors should be cleaned with alcohol. Gloves should be changed and hand hygiene should be performed between dirty and clean tasks. Staff should perform hand hygiene, take off a gown and gloves when leaving a room and put on new gown and gloves and perform hand hygiene when re-entering. If a treatment item was reusable, the container should be cleaned with a disinfecting cloth before putting it back into the treatment cart. 3. Observation on 02/04/25 at 2:21 P.M., of Resident #5's incontinent and wound care showed: - EBP signage for the resident; - CNA /CMT H did not perform hand hygiene, put on gloves, grabbed a bag of wash cloths and squirted soap in it from the hall closet; - CNA/CMT H did not perform hand hygiene, did not put on a gown, did not change gloves, entered the resident's room and added water to the bag of washcloths from the resident's bathroom; - CNA/CMT H did not perform hand hygiene, did not change gloves, cleaned the resident's peri area with the same side/area of the wash cloth multiple times; - CNA/CMT H put the dirty wash cloths in a bag, did not remove gloves, did not perform hand hygiene, and exited the resident's room with the bag of dirty wash cloths; - CNA/CMT H put the bag of dirty wash cloths in the closet, removed the gloves, touched the door to the closet twice, and did not perform hand hygiene; - Registered Nurse (RN) A entered the resident's room, performed hand hygiene, put on gloves, did not put on a gown, and removed strips of the wick silver (a dressing that [NAME] sweat and has microbial factors) from the resident's right groin area and the right abdominal fold; - RN A did not perform hand hygiene, did not change gloves, cleaned and dried the groin area and the abdominal fold to the resident's right side; - RN A did not perform hand hygiene, did not change gloves, applied a new wick silver to the resident's right groin area and the right abdominal fold; - RN A did not perform hand hygiene, did not change gloves, removed the old wick silver and the soiled with blood calcium alginate (dressings absorb wound exudate, forming a gel that keeps the wound moist and promotes healing) from the left groin area and the left abdominal fold; - RN A did not perform hand hygiene, did not change gloves, cleaned the left groin area and the left abdominal fold; - RN A did not perform hand hygiene, did not change gloves, applied a new calcium alginate over the open bleeding area and new wick silver into the left abdominal fold; - CNA/CMT H entered the resident's room, did not perform hand hygiene, put on gloves, and assisted with a Hoyer lift transfer, and touched the resident, the hoyer lift sling, the resident's shirt, and the Hoyer lift; - RN A changed gloves, did not perform hand hygiene, and CNA/CMT H assisted with the Hoyer lift transfer. During an interview on 02/04/25 at 2:30 P.M., CNA/CMT H said hands should be washed and gloves changed before providing incontinent care, when going from dirty to clean care, and when leaving a resident's room. During an interview on 02/04/25 at 2:45 P.M., RN A said hands and gloves should be changed at the start of wound care, when going from dirty to clean care, a new wound site, and at the end of the wound care. 4. Observation on 02/06/25 at 10:20 A.M., of Resident #21's catheter care showed: - EBP sign hung on the door; - CNA B performed hand hygiene, put on gloves, and did not put on a gown; - CNA B cleaned the resident's thighs with a soapy cloth, rinsed the soap off with a wet cloth, and dropped the cloths onto the floor; - CNA B cleaned the resident's abdominal folds with a soapy cloth, rinsed the soap off with a wet cloth, and dropped the cloths onto the floor; - CNA B cleaned the resident's peri area with a soapy cloth, with the same cloth he/she cleaned the catheter up toward the insertion point in a back and forth motion, and dropped the cloth onto the floor; - CNA B did not perform hand hygiene or change gloves; - CNA B rinsed the peri area with a clean cloth, with the same cloth he/she rinsed the catheter up toward the insertion point, and dropped the cloth onto the floor; - CNA B dried the resident's front peri area with a dry towel and dropped the towel onto the floor; - CNA B did not perform hand hygiene or change gloves, and rolled the resident to the right side; - CNA B cleaned the resident's back thighs and buttocks with a soapy cloth and dropped the cloth onto the floor; - CNA B cleaned fecal material from the resident's buttocks with a soapy cloth and dropped the cloth onto the floor; - CNA B rinsed the resident's back peri area with a wet cloth and dropped the cloth onto the floor; - CNA B did not perform hand hygiene or change gloves; - CNA B removed the brief soiled with fecal material from the resident, did not perform hand hygiene, did not change gloves, and placed a new brief under the resident; - CNA B did not perform hand hygiene, did not change gloves, rolled the resident, fastened the brief, and touched the blanket, the call light, and the bedside table; - CNA B picked up the wet cloths from the floor and placed them into a trash bag; - CNA B removed gloves and performed hand hygiene. During an interview on 02/06/24 at 10:30 P.M. CNA B said Resident #21 was usually a two person assist for care and so he/she normally didn't have to change gloves or wash hands. He/She couldn't find the trash bag once care was started so he/she just threw the cloths on the floor. CNA B said he/she should clean from the insertion point of the catheter down with a new side of the cloth each time when cleaning. During an interview on 02/07/25 at 1:00 P.M., RN A said hand hygiene should be performed between the residents, and gown and gloves should be worn during care of a resident on EBP. Perform hand hygiene and put on gloves before providing care to a resident, performing incontinent care, or catheter care. Perform hand hygiene and change gloves when moving from dirty to clean tasks during care, and when performing catheter care. Catheter care should start at the entry point, and move down the catheter away from the body, and should use a new area of the cloth with each wipe, do not clean up and down the catheter or in a twisting motion. 5. Observation on 02/06/25 at 10:42 A.M., the laundry showed: - Laundry Staff (LS) E entered the soiled linen room of the laundry area with barrels of dirty laundry. With a glove on his/her right hand, LS E opened the soiled linen room door with his/her bare left hand, rolled the soiled linen barrels inside the room, did not perform hand hygiene, put on a glove on the left hand, did not put on a gown, opened the lid of the barrel, and leaned into the barrel to retrieve the linen and bags with his/her jacket and shirt touching the inside lip of the barrel; - LS E did not perform hand hygiene, did change gloves, removed the lid from the second barrel, removed the unbagged linens soiled with urine in the barrel, leaned into the barrel to retrieve the items from the bottom of the barrel with his/her jacket and shirt touching the outside and the inside of the barrel; - LS E removed the gloves, washed his/her hands in the second sink basin with a container of cleaning solution and a toilet brush inside of it, dried his/her hands on a large white towel that hung on the wall of the clean linen side of the laundry, and put on gloves; - LS E retrieved the toilet brush from the container of cleaning solution from the second sink basin, brushed the cleaning solution around the inside walls and the bottom of the barrel, and dipped the toilet brush back into the cleaning solution three times; - LS E removed the gloves, did not perform hand hygiene, put on a glove onto the right hand, placed the lids on barrels with the right gloved hand, opened the laundry room door to the hall with the ungloved left hand, placed the empty barrels outside the door into the hall, did not remove the glove from the right hand, and did not perform hand hygiene; - LS E entered the spa/shower room near the C hall, touched the door handle with the ungloved left hand, retrieved the barrel, and pushed it to the soiled utility room; - LS E did not put on a gown, removed the lid of the barrel with the gloved right hand, placed the lid upside down on the soiled linen bin, leaned into the barrel to retrieve the dirty items from the barrel; - LS E did not change the glove to the right hand, did not perform hand hygiene, replaced the lid on the linen barrel with the gloved right hand, put on a glove to the left hand, rolled the barrel with the soiled items to the clean side of the laundry area, placed the soiled linen into the washer, including one green dining napkin to the same washer, placed the unsprayed wash cloths soiled with fecal material into the same washer; - LS E rolled the barrel back to the soiled linen room of the laundry area, removed the gloves, washed hands, dried hands on the same white towel that hung on the wall in the clean linen side of the laundry; - LS E put on gloves, rolled the lined barrel of residents' personal linens and clothing to the clean side of the laundry, placed the items into a second washer, retrieved trash from the clean side of the laundry, placed the trash in an empty barrel, rolled the barrel to the soiled side of the laundry, removed the liner from the barrel and placed it in a large trash bin, removed the gloves, washed hands, dried on the same white towel that hung on the wall in the clean linen side of the laundry; - LS E put on a glove to the right hand, cleaned the inside of the barrel with the toilet brush from toilet brush from the container of cleaning solution from the second sink basin, sprayed Lysol into the lined barrel, removed the right glove, did not perform hand hygiene, put on a glove to the right hand, transferred the empty barrels to the hall outside the door, transferred the empty lined barrel back to the spa/shower room, removed the right glove, and sanitized hands. During an interview on 02/06/25 at 11:05 A.M., LS E said the process for the laundry was to take a cleaned laundry barrel to the hall with one gloved hand to retrieve the dirty barrel from the hall soiled utility closet, transfer it to the soiled linen side of the laundry, sort the items with the same gloved hand to the appropriate bin, remove the glove, wash hands, wear a glove on one hand and transfer the barrels to and from the other halls with the same process. When taking items to the clean side of the laundry, staff kept on the same one glove used to sort the laundry, open the cut through door with their foot, use the non-gloved (clean) hand to open the washer, transfer the items into the washer with the gloved hand, shut the washer door with the non-gloved hand, transfer the barrel back to the soiled side of the laundry room, remove the glove, wash hands, dry on the hanging towel on the clean side, and fold clothes if needed. The door to the soiled linen side of the laundry was left unlocked and unlatched during the process of picking up barrels from the halls and sorting laundry, then the room was locked when the task was completed. When the barrels were cleaned or sprayed, they were placed into the hall outside the laundry room with no more than three empty barrels were to be left in the hall outside the laundry room at a time. This allowed other staff to grab a barrel if an empty one was needed. When sorting and washing laundry, the residents' personal items were washed separate from the facility linens, and dining room linens were washed separate from all other linens. The white towel hanging on the clean side of the laundry room was used throughout the day by staff. It was changed at least every shift, or if it was used a lot and was damp. 6. Observation on 02/07/25 at 7:53 A.M., of Resident #37's insulin administration showed: - RN A primed two insulin pens, performed hand hygiene, did not put on gloves, cleaned the resident's abdomen with an alcohol pad, did not perform hand hygiene, did not put on gloves, administered one insulin, did not perform hand hygiene, did not put on gloves, administered the second insulin, and performed hand hygiene. During an interview on 02/07/25 at 11:00 A.M., RN A said gloves should be worn during administration of insulins. 7. Observation on 02/07/25 at 8:40 A.M., of Resident #118's medication administration showed: - RN A performed hand hygiene, did not put on gloves, removed two medications from the medication bubble packs, and the two medications fell on the plate under the medication cup; - RN A picked up the two medications from the plate with his/her bare hands and placed them into the medication cup; - RN A administered the medications in the medication cup to the resident. During an interview on 02/07/25 at 11:00 A.M., RN A said medications shouldn't ever be touched with his/her bare hands. 8. Observation of the laundry on 02/07/25 at 7:54 A.M., showed: - LS F entered the soiled linen room of the laundry area with a barrel of soiled linen and with one large dishwashing glove on the right hand; - LS F put another large dishwashing glove on the left hand, did not put on gown, and sorted the items from the barrel; - LS F did not change gloves, did not perform hand hygiene, touched the inside door knob of the soiled linen room, opened the door, and exited the room; - LS F did not change gloves, did not perform hand hygiene, took one barrel from the hall outside the door, removed one glove, sat the glove on the lid of the barrel, did not perform hand hygiene, and touched the door knob of the A Hall soiled closet; - LS F swapped the barrels with the gloved hand, pushed open the soiled linen side door of the laundry room with the his/her bare hand, did not put on a gown, emptied the items from the barrel with the gloved hand, leaned into the barrel, and the front of LS F's clothing touched the side and lip of the soiled linen barrel; - LS F did not change gloves, did not perform hand hygiene, exited the room with the same barrel to transport soiled linen down B Hall, touched the door knob and the latch chain of the soiled utility closet with his/her bare hand, and pulled the latch chain with his/her bare hand, touched the outside of the door with his/her gloved hand to close the door; - LS F did not change gloves, did not perform hand hygiene, went to the B Hall shower room, opened the shower room door with his/her bare hand, checked the laundry, exited the shower room, removed the glove from the one hand, did not perform hand hygiene, did not put on gloves, and lay his/her bare hand on top of the transport barrel; - LS F did not perform hand hygiene, retrieved keys from his/her pocket, unlocked the salon door, entered and checked the linen, and the exited room; - LS F did not perform hand hygiene, put on one glove, entered the other shower room near C Hall with the transport barrel, opened the door with his/her bare hand, transferred the soiled linen from the shower room barrel to the transport barrel with the one gloved hand, and took the transport barrel to the soiled linen room; - LS F did not perform hand hygiene, put on one glove to his/her bare hand, did not put on a gown, transferred the soiled linen from the barrel to the bins, leaned into the barrel, and the front of LS F's clothing touched the side and inside of the soiled linen barrel; - LS F did not perform hand hygiene, did not change gloves, exited the soiled laundry room with the same gloves, touched the door, retrieved another full barrel from the hall, did not put on a gown, leaned into the barrel, and the front of LS F's clothing touched the soiled linen barrel; - LS F removed one glove, did not perform hand hygiene, went down D Hall with a barrel, touched the soiled utility closet with his/her bare hand, swapped barrels, returned to the soiled linen room of the laundry with another full soiled linen barrel; - LS F did not perform hand hygiene, did not change gloves, did not put on gown, put on a glove to his/her bare hand, leaned into barrel, and the front of LS F's clothing touched the soiled barrel; - LS F did not perform hand hygiene, did not change gloves, rolled the soiled empty barrel to the clean side of the laundry, loaded the washer with the soiled linens, did not perform hand hygiene, did not change gloves, pushed the barrel back to the soiled side of the laundry. LS F removed the gloves, washed hands, dried hands on the same white towel that hung on the wall in clean linen side of the laundry; - LS F did not put on a gown, folded the clean linens with the clean linens touching the front of LS F's contaminated clothing, and placed the clean linens on the clean linen carts. During an interview on 02/07/25 at 1:35 P.M., the Director of Nursing (DON) said hands should be sanitized and gloves changed before any care was started, when going from dirty to clean care, a new site or task, and at the end. Catheters should be cleaned from the insertion point down with a new side of a wash cloth for each wipe. Gloves should be worn during insulin administration and medications should not be touched with bare hands. Laundry was expected to not cross contaminate themselves or other items. During an interview on 02/07/25 at 1:40 P.M., the Administrator said she would expect staff to follow infection control guidelines when providing care to residents. 47445

Based on observation, interview, and record review, the facility failed to ensure a urinary indwelling catheter (a tube inserted into the bladder to drain urine) drainage bag was kept off the floor for one resident (Resident #61) out of three sampled residents. The facility census was 61. Review of the facility's policy titled, Catheter Care, undated, showed: - The policy didn't address catheter tubing or drainage bags not touching the floor. 1. Review of Resident #61's medical record showed: - admitted on [DATE]; - Diagnosis of urine retention. Review of the resident's Physician Order Sheet (POS), dated February 2025, showed: -An order to change the indwelling/suprapubic (catheter inserted through the abdomen into the bladder for urine drainage) catheter every 30 days. Insert the catheter size 16 French (Fr- the measurement used to measure sizes of urinary catheters) and bulb size 5-10 cubic centimeter (cc) on the 1st of the month, during day 6:00 AM - 06:00 PM. Diagnosis of urinary retention, dated, 01/23/25; - An order for an indwelling catheter/suprapubic catheter care every shift dated, 01/14/25. Review of the resident's Care Plan, dated 01/21/25, showed: - Resident had an indwelling catheter related to retention of urine, Size 16 Fr with 10 cc bulb. Maintain the drainage bag in privacy cover or fig leaf bag (a urinary drain bag that preserves the dignity of the patient by hiding the fluid from view with a built in cover). Review of the resident's admission Minimum Data Set (MDS - a federally mandated process for clinical assessment of all residents in certified nursing homes), dated 01/08/25, showed: - The resident had an indwelling catheter. Observations on 02/04/25 at 11:45 A.M., and 12:09 P.M., showed the resident sat in a wheelchair and propelled him/herself down the hallway with six inches of the catheter tubing dragging the floor. Observation on 02/05/25 at 8:45 A.M., showed the resident transferred by two staff from the bed into the wheelchair. Certified Nursing Assistant (CNA) B sat the catheter drainage bag on the floor, opened the privacy bag under the wheelchair, and stuffed the catheter drainage bag inside. During an interview on 02/07/25 at 10:30 A.M., Licensed Practical Nurse (LPN) A said the catheter bag and tubing should never touch the floor. During an interview on 02/07/25 at 10:45 A.M., LPN D said catheter bags and tubing should not touch the floor. During an interview on 02/07/25 at 1:50 P.M., the Director of Nursing (DON) said a catheter, including the drainage bag and tubing, should not touch the bag. During an interview on 02/07/25 at 1:55 P.M., the Administrator said catheters should not touch the floor.

Based on interview and record review, the facility failed to provide documentation of ongoing assessments, monitoring, and communication between the facility and the dialysis (a process for removing waste and excess water from the blood) center for one resident (Resident #264) out of one sampled resident. The facility census was 61. Review of the facility's policy titled, Care of a Hemodialysis Patient, undated, showed: - Will communicate concerns with dialysis center of any pertinent information/changes with communication observation sent with resident; - The hemodialysis access site will be observed every shift to ensure the dialysis dressing is intact and if there are any signs and symptoms of infection. Should signs and symptoms of infection be noted, the physician will be contacted; - The hemodialysis access site will be palpated (to feel or exam the body with hands or fingers) for the presence of a thrill (a vibration caused by blood flow) or auscultated (use a stethoscope to listen to the sounds inside of your body) for a bruit (a whooshing sound as blood flows through a narrowed vessel) each shift if indicated. The physician will be contacted if there is no thrill or bruit at the access site; - Should the access site have major bleeding, pressure will be applied and emergency services will be contacted; - Pre and post dialysis weights may be obtained at the dialysis center or at the facility. This should be communicated between the dialysis clinic and the facility; - Nurse should assess/monitor and document: shunt (a connection between a vein and artery that helps your body create the flow of blood it needs for dialysis to work) site for bleeding and infection, weights as ordered. 1. Review of Resident #246's Physician Order Sheet (POS), dated February 2025, showed: - admitted on [DATE]; - Diagnoses of end stage renal disease (the kidneys are no longer able to work at a level needed for day-to-day life) and dependence on renal dialysis; - An order for dialysis on Monday, Wednesday, and Friday, once a day, dated 12/04/24; - An order to complete the dialysis communication observation pre-dialysis with special instructions: do prior to dialysis, once a day on Monday, Wednesday, and Friday, dated 01/31/2025; - An order to remove pressure dressing the evening of dialysis, once a day on Monday, Wednesday, and Friday at 7:00 P.M., dated 12/04/24; - An order for monthly weights with special Instructions: change to correct day of the month resident to be weighed, once a day on the first of the month, dated 12/04/24; - An order for weekly weights, once a day on Wednesday, dated 12/18/24; - No order to assess/monitor and document the dialysis shunt location and status before and after dialysis treatments. Review of the resident's Care Plan, last reviewed 11/07/24, showed: - Hemodialysis addressed with interventions of observe the shunt site for the thrill/bruit present at the shunt site. Observe for emergency bleeding at the shunt site. If found, apply pressure to site and call the primary care provider. Observe skin around the dressing for signs/symptoms of infection. Make sure the dressing is intact. Review of the facility's Dialysis Communication Worksheets, dated 01/01/25 - 02/04/25, showed: - No Dialysis Communication Worksheets completed for 01/01/25, 01/20/25, and 01/27/25, with three out of 14 opportunities missed; - The pre-dialysis weights were not documented by the facility and the post-dialysis weights and other information/responses were not documented by the dialysis center for the completed Dialysis Communication Worksheets; - On 01/03/25, 01/17/25, and 01/29/25, the dialysis site assessment was not documented. Review of the Dialysis Communication Reports provided by the dialysis center, dated 12/01/24 - 02/06/25, showed: - No documentation of the Dialysis Communication Reports for 12/02/24, 12/04/24, 12/09/24, 12/11/24, 12/13/24, 12/16/24, 12/18/24, 12/20/24, 12/25/24, 12/27/24, and 12/30/24, with 11 out of 13 opportunities missed; - No documentation of the Dialysis Communication Reports for 01/01/25, 01/03/25, 01/06/25, 01/08/25, 01/13/25, 01/17/25, 01/22/25, 01/24/25, 01/29/25, and 01/31/25, with 10 out 14 opportunities missed; - No documentation of the Dialysis Communication Reports for 02/03/25, and 02/05/25, with two out of two opportunities missed. Review of the resident's Progress Notes, dated 12/01/24 - 02/05/25, showed: - No documentation of the resident assessments completed after dialysis treatments; - No documentation of the resident assessments of the dialysis site. During an interview on 02/04/25 at 2:14 P.M., the resident said he/she went to dialysis on Monday, Wednesday, and Friday. He/She had a fistula (a surgical connection made between an artery and a vein for dialysis access) in the left upper arm. Staff did not look at it, feel of it, or check the bandage when he/she returned from dialysis. He/She removed the dressing him/herself after he/she returned from dialysis. Observations and interviews of the resident showed: - On 02/05/25 at 12:35 P.M., the resident with an undated gauze bandage taped on his/her left upper extremity (LUE) that covered the dialysis site. The resident said no one looked at the dressing when he/she returned from dialysis; - On 02/06/25 at 9:15 A.M., the resident sat in a recliner in his/her room with an undated gauze bandage taped on his/her LUE that covered the dialysis site. The resident said it was the same dressing that was on 02/05/25, and no one had looked at it or done anything to it. During an interview on 02/07/25 at 10:44 A.M., Registered Nurse (RN) K said night shift completed the dialysis communication form and printed it to be sent with the resident when he/she left the facility for dialysis. When the resident returned, the resident had the dialysis communication paper if the dialysis center sent it. The form was sent from the dialysis center to the facility was not the same form that was sent with the resident from the facility. The communication form usually showed pre and post dialysis weights, and the amount of fluid pulled off during dialysis. Staff had to ask the resident for the paperwork, but he/she usually didn't have it. If the resident didn't have it, the RN would call over to the dialysis center and they faxed the paperwork over to the Assistant Director of Nursing (ADON), the Director of Nursing (DON), or the dialysis center might send it back with the resident on the next dialysis appointment. The weights on the paperwork were entered into the resident's electronic medical record (EMR) at the facility. RN K didn't do anything with the resident when he/she returned from dialysis and he/she was unsure where the resident's dialysis access site was located. The resident had a port (a medical device placed under the skin in the chest, arm or abdomen that allows for easy access to a vein for receiving treatments) and RN K believed it was in the resident's left arm. RN K did not do anything with the access site when the resident returned from dialysis and did not assess the site daily. During an interview on 02/07/25 at 10:55 A.M., the DON said there was a communication sheet in the resident's EMR. The nurses filled it out and sent it with the resident when he/she went to the dialysis center. All questions on the communication sheet should be answered. She expected the resident to be weighed per the physician's orders. If the resident returned from the dialysis center without the communication paper from the dialysis center, it should be followed up on by calling the dialysis center and having it faxed/sent to the facility. Resident #245 was transported to and from the dialysis center by an outside transport company so the resident should have the paperwork if it was sent. The nurse should check the access site bandage upon return, and check it daily for signs of infection. If there was a fistula , the nurse should check for the bruit every shift and before dialysis.

Based on observation, interview, and record review, the facility failed to ensure the medication cart was locked while unattended and failed to ensure a safe medication system when leaving medications unattended and unsupervised for one resident (Resident #16) out of ? sampled residents during a medication pass. This had the potential to affect all residents. The facility census was 61. Review of the facility policy titled, Specific Medication Administration Procedures, dated 01/01/19, showed: - All medication storage areas (carts) are locked at all times unless in use and under direct observation of the medication nurse/technician. Review of the facility policy titled, Medication Storage in the Facility, dated 01/01/19, showed: - Medication rooms, carts, and medication supplies are locked when not attended by persons with authorized access; - Schedule II medications are stored in an affixed, double locked compartment separate from all other non-controlled medications; - Bedside medication storage is permitted for residents who wish to self-administer medications, upon the written order of the prescriber and once self-administration skills have been assessed and deemed appropriate in the judgement of the facility's interdisciplinary resident assessment team; - All nurses and aides are required to report to the charge nurse on duty any medications found at the bedside not authorized for bedside storage. Review of the facility's policy titled, Specific Medication Administration, Oral Medications, dated 01/01/19, showed: - Do not leave medication at bedside unless specifically ordered by the prescriber. 1. Review of Resident #16's Physician Order Sheet (POS), dated February 2025, showed: - An order for Benefiber Sugar Free powder (a prebiotic fiber supplement) 3 gram (gm)/4 gm 15 gm by mouth once a day and mix in at least 8 ounces (oz) of water, dated 01/06/25; - An order for Celexa (an antidepressant medication) 20 milligrams (mg) by mouth daily for major depressive disorder, dated 10/13/21; - An order for cholecalciferol (Vitamin D3 - a supplement) over the counter (OTC) 1,000 unit three tablets by mouth every day for vitamin D3 deficiency, dated 01/09/19; - An order for cranberry (supplement) OTC 450 mg administer 2 tab by mouth every day, dated 06/21/2017; - An order for Daily-Vite with folic acid (a multivitamin) 400 microgram (mcg) by mouth for Vitamin B deficiency, dated 10/30/24; - An order for lisinopril (a blood pressure medication) 20 mg by mouth twice a day for hypertension (HTN - high blood pressure), dated 11/13/21; - An order for Metformin (an antihyperglycemic medication) tablet extended release 24 hour 500 mg once a day for diabetes, dated 01/17/24; - An order for methenamine (an antibiotic) 1 gm by mouth daily for retention of urine. Special instructions: take with Vitamin C, this will be a long-term medication for urinary tract infection (UTI) suppression due to urinary retention, dated 11/13/21; - An order for metoprolol succinate (a blood pressure medication) tablet extended release 24 hour 50 mg by mouth once a day for HTN, dated 03/24/22; - An order for Vitamin C OTC 500 mg by mouth twice a day, for retention of urine. Special instructions: take with methenamine), dated 01/09/19; - An order for Wellbutrin XL (an antidepressant medication) extended release 24 hour 150 mg by mouth once a day for major depressive disorder, dated 10/14/21; - No order to keep medications at bedside; - No order for the resident to self administer medications. Review of the resident's medical record showed: - No assessment for the resident to have medications at the bedside; - No assessment for the resident to self-administer medications. Review of the resident's comprehensive care plan, last reviewed 01/21/25, showed: - Did not address self-administration of medications; - Did not address medications to be left in the room for resident to take at his/her discretion. Observations of the resident showed: - On 02/04/25 at 10:45 A.M., 11 pills in a medication cup on the resident's bedside table and one plastic cup of Benefiber mixed in water. The resident took the pills and the Benefiber himself/herself at 10:55 A.M.; - On 02/05/25 at 8:34 A.M., 11 pills in a medication cup on the resident's bedside table and one plastic cup of Benefiber mixed in water. The resident took the pills and the Benefiber himself/herself at 8:52 A.M.; - On 02/06/25 at 8:14 A.M., 11 pills in a medication cup on the resident's bedside table and one plastic cup of Benefiber mixed in water. The resident took the pills and the Benefiber himself/herself at 8:52 A.M. During an interview on 02/04/25 at 10:45 A.M., Resident #16 said his/her medications were left on the bedside table every morning because the staff trust him/her to take the medications. He/She wanted to eat breakfast and drink coffee first. The pills were his/her morning medication. 2. Observation on 02/06/25 at 3:20 P.M. - 3:29 P.M., of the medication cart on the locked memory care unit showed: - At 3:20 P.M., the medication cart was unlocked in the dining room beside the nurse station and faced the dining room; - Four residents sat in the dining room, two residents sat in the TV room within view of the medication cart; - Certified Nursing Assistant (CNA) in resident rooms and Licensed Practical Nurse (LPN) A exited the unit; - At 3:29 P.M., LPN A entered the unit, walked to the unlocked cart, opened it, and put in supplies. 3. Observation on 02/07/25 at 7:40 A.M. - 7:48 A.M., of Hall A medication cart showed: - At 7:40 A.M., the unlocked medication cart sat against the wall beside the central supply closet facing the hall. A resident sat in a wheelchair in the hall and Certified Medication Technician (CMT) C stood in the hall with another resident. CMT C was not in direct view of the unlocked medication cart; - At 7:42 A.M., CMT C walked down the hall to a different resident and pushed the resident into a room; - At 7:44 A.M., staff walked past the unlocked cart; - At 7:46 A.M., CMT C walked past the unlocked medication cart to the kitchen; - At 7:48 A.M., LPN D walked up to the unlocked medication cart, opened it, took out a medication, and locked the cart. During an interview on 02/07/25 at 10:30 A.M., LPN A said medication carts should be locked at all times when not in use, especially if the responsible staff members were not with them. Medication should not be left unattended in resident rooms and residents shouldn't be allowed to self-administer them without an order to do so. During an interview on 02/07/25 at 10:45 A.M., LPN D said medication carts should always be locked when not in use. Medication shouldn't be left unattended in resident rooms and self-administered. During an interview on 02/07/25 at 1:00 P.M., Registered Nurse (RN) A said medications should not be left unattended in a resident's room and self-administered. Resident #16 took the medications later, not when given. He/She believed it was care planned. During an interview on 02/07/25 at 1:30 P.M., the Director of Nursing (DON) said medication carts should be locked when unattended. Medication shouldn't be left unattended in resident rooms and self-administered without an order to do so, assessment, and care planned. During an interview on 02/07/25 at 1:35 P.M., the Administrator said medication carts should always be locked when left unattended. The policy for medications being left unattended in resident rooms and self-administered should be followed. In general, medications shouldn't be left unattended.

Based on record review and interview, the facility failed to ensure all residents were treated with respect and dignity when one staff (Certified Nurse Aide (CNA) A) spoke to one resident (Resident #1) in a rude manner while using profane language. The facility census was 62. Record review of the facility's policy on Privacy, Dignity, and Respect, updated 11/19/19, showed the following: -Dignity is concerned with how people feel, think, and behave in relation to the worth or value of themselves and others; -To treat someone with dignity is to treat them as being of worth, in a way that is respectful of them as valued individuals, being of equal value and worth, in a way that is respectful of them as valued individuals; -Respect is positive regard shown to a person as a human being as an individual, by others, and demonstrated as courtesy, good communication, taking time and equal access; -Privacy, dignity and respect are of high priorities for healthcare users and healthcare providers; -Satisfaction with care is inextricably linked with privacy, dignity, and respect; -Staff should deal sensitively with the various circumstances in which privacy, dignity, and respect may be infringed; -As healthcare workers all staff should display values and behaviors which promote privacy, dignity, and respect to each other and through the organization. 1. Record review of Resident #'1's face sheet showed the following: -Readmitted [DATE]; -diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff), dated 7/14/22, showed the following: -Cognition severally impaired; -Limited assist, one person with bed mobility, transfer, dressing and toilet use; -Substantial assistance with toileting hygiene; -Occasionally incontinent of the bladder; -Always continent of the bowels. Record review of the resident's care plan, revised on 7/20/22, showed the following information: -Resident needs assistance in performing, improving, and maintaining some of his ADLs (activities of daily living - dressing, grooming, bathing, eating, and toileting) including assistance with combing hair and shaving, requiring assist of one with bed mobility, and providing perineal care following incontinent episodes ; -The resident is hard of hearing and uses a sound amplification device with microphone pick up in a box attached to ear buds. Record review of a witness statement from Registered Nurse (RN) H, dated on 7/22/22 at 2:30 A.M., showed the following: -RN H was in the hallway giving resident medications across hallway. Upon exiting the room, RN H overheard CNA A saying, I wish you would stop pissing in this trash can, I'm getting sick of cleaning this[OBSCENITY]up. The resident started grumbling something and RN H went into room and by the curtain and CNA A pointed with his/her hands to the urinal stating it is right there it is right paused a second and then said there. The resident went to talking about having his/her job (per norm) and CNA A stated I'm not wasting my [OBSCENITY] ing breathe on you, grabbed the dirty linens, and walked out of the room. Record review of CNA A's written statement, completed on 7/22/22, showed the following: -He/she was doing a bed change for the resident. He/she was notified that the resident's trash can was loaded with urine. He/she yelled at the resident to stop peeing in the damn trash bag, your urinal is right in front of you. The resident told CNA A that he/she wasn't and that he/her urinal could only hold so much. The resident told CNA A that he/she never wanted to do anything to help anyone around here. CNA A walked out of the room, telling the resident, I'm not dealing with this today, And he/she walked to RN H after saying, I'm not wasting my [OBSCENITY] ing breath on you. During a phone interview on 7/22/22, at 2:05 P.M., CNA A said the following: -He/she was doing a bed change for the resident. The resident's bed was soaked and the trashcan was full of urine. He/she yelled at the resident to stop peeing in the trash can, the urinal was in front of him/her. The resident said CNA A doesn't do anything and is just there for the money. CNA A said he/she was not dealing with this tonight, and he/she walked out of the resident's room; -He/she agreed that what he/she said to the resident was in appropriate; -He/she said there have been no past incidents of yelling or cursing at other residents. During an interview on 7/22/22, at 1:40 P.M., Licensed Practical Nurse (LPN) D said the following: -Speaking rudely to residents or cursing at residents would be inappropriate. During interviews on 7/22/22, at 1:45 P.M. and 2: 37 P.M., RN E said the following: -It would not be appropriate to curse at, or say I'm not wasting my time to a resident, this could be considered not treating residents in a dignified and respectful manner. During an interview on 7/22/22, at 2:45 P.M., LPN F said the following: - It would not be appropriate to curse or say I'm not wasting my time to a resident. During an interview on 7/22/22, at 2:48 P.M., CNA G said the following: -It's never appropriate to curse or say I'm not wasting my time to a resident, this would be disrespectful; -He/she would report to DON and administrator. During an interview on 7/22/22, at 3:02 P.M., the Administrator and Director of Nursing, said the following: -It is never appropriate for staff to curse or say to a resident they're wasting staff's time. MO 342

Based on observation, interview, and record review, the facility failed to keep food safe from potential contamination when staff did not air dry dishes and stacked dishes while still wet which could potentially contaminate any food prepared for residents. The facility census was 61. Record review of the facility's policy, titled Safety and Sanitation Best Practice Guidelines, dated 2003 and revised 11/2017, showed the following information: -Air-dry all items; -Towels may contaminate items; -Make sure all items are completely dry before stacking to prevent wet-nesting (when dishes are stacked wet and promote bacterial contamination). Record review of the 2013 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 of the kitchen on 2/14/2022, at 10:42 A.M., showed the following in the dish washing room area: -Six water glasses, stacked upside down on a tray wet; -Eleven juice glasses, stacked upside down on tray wet; -Thirteen medium clear plastic drinking cups, stacked upside down wet; -Thirty-six plastic juice cups, stacked upside down wet. Observation of the kitchen on 2/14/2022, at 10:42 A.M., showed the following in the food serving room: -Twenty-five plastic bowls, stacked upside down on a tray wet; -Eighteen clear plastic bowls, stacked upside down on a tray wet. Observation of the kitchen on 2/17/2022, at 8:50 A.M., showed the following in the dish washing room area: -Twelve water glasses, stacked upside down on a tray wet; -Twelve juice glasses, stacked upside down on tray wet; -Nine medium clear plastic drinking cups, stacked upside down on a tray wet; -Twenty-eight plastic juice cups, stacked upside down on a tray wet. Observation of the kitchen on 2/17/2022, at 8:50 A.M., showed the following in the food serving room; -Twenty-two plastic bowls, stacked upside down on a tray wet; -Seventeen clear plastic bowls, stacked upside down on a tray wet. During an interview on 2/17/2022, at 9:00 A.M., Dietary Aide I said the following: -Dishes are to be set out to dry; -Dishes should not be stacked when they are wet; -He/she sets them out on the counter to dry and allows a fan to blow on them; -Dishes shouldn't be stacked because they could grow bacteria or harm someone. During an interview on 2/17/2022, at 9:10 A.M., Dietary Aide J said the following: -He/she knows that dishes cannot be stacked wet; -He/she didn't realize the dishes were still wet when they were stacked up. During an interview and observation on 2/17/2022, at 9:00 A.M., Dietary Aide K said the following: -He/she will help with dishes once in a while, although he/she usually cooks; -Dishes should not ever be stacked because that's how bacteria begins to grow; -He/she did not know why any dishes were stacked up wet. During an interview on 2/17/2022, at 9:00 A.M., the Food Services Manager said the following: -He/she knows dishes cannot be stacked upside down wet; -He/she knows staff should all know this too. During an interview on 2/18/2022, at 9:59 A.M., the Director of Nursing (DON) said the following: -He/she did not realize staff did not leave the dishes on a drying station long enough to air dry; -Wet, dark, humid areas are the prime place for bacteria to grow.

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 a hospital, including the reasons for the transfer, for five residents (Residents #10, #43, #57, #59, and #210). The facility census was 61. Record review of a facility's policy entitled Transfer/Discharge, revised 2/2021, showed the following: -A resident may be transferred or discharged to another health care institution or discharged home upon the written order of the attending physician; -Sufficient information will be provided to the patient to assure continuity of care, regardless of the destination of the patient or the reason for the transfer. (The policy did not give information pertaining to a written notification to the resident and/or resident's representative of a transfer to a hospital.) 1. Record review of Resident #10's nurses' progress notes showed the following information: -On 11/9/2021, staff reported critical laboratory results to the physician and followed orders to send him/her to the hospital for further evaluation and treatment. Resident contacted spouse per his/her request. A copy of paperwork was placed under the Assistant Director of Nursing (ADON)'s door. Record review of the resident's electronic medical record (EMR) showed no copy of written notice provided to the resident or resident representative regarding the transfer on 11/9/2021. 2. Record review of Resident #43's resident's nurses' notes showed the following information: -On 12/17/2021, the resident was sent to the hospital related to an episode of grand mal [CONDITION(S)] (causes a loss of consciousness and violent muscle contractions). Record review of the resident's EMR showed no copy of written notice provided to the resident or resident representative regarding the transfer on 12/17/2021. 3. Record review of #57's face sheet (a brief summary) showed the following: -discharged to hospital on 11/8/2021; -discharged to hospital on 1/10/2022. Record review of the resident's admission Minimum Data Set (MDS - a federally required assessment complete by facility staff), dated 1/25/2022, showed the following information; -Mild cognitive impairment; -Extensive assistance of two staff person required for bed mobility, transfers, toileting, personal hygiene. Record review of the resident's nurses' progress notes showed the following information: -On 11/8/2021, at 10:45 A.M., staff documented that the resident left the facility via stretcher with Emergency Medical Services (EMS); -On 1/10/2022, at 2:00 P.M., staff documented notification to the physician of x-ray and abnormal labs, along with resident's continued increased confusion. New order received to send the resident to the hospital for evaluation and treatment. Record review of the resident's medical record showed no copy of a written notice of transfer sent to the resident or resident's responsible party regarding the transfers on 11/8/2021 or 1/10/2022. 4. Record review of Resident #59's face sheet showed the following: -discharged to the hospital on 1/21/2022; -discharged to the hospital on 1/28/2022. Record review of the resident's nurses' progress notes showed the following information: -On 1/21/2022, at 8:24 A.M., staff documented of staff report that the resident was upside down in his/her wheelchair at the front lobby. The transport aide tried to get the resident on the lift and the chair turned over. Staff assisted with Hoyer lift (a mechanical device with a sling attached to lift and transfer a non ambulatory resident) after resident was assessed and got back into wheelchair. The resident was complaining of side pain and the physician ordered the resident be sent to the hospital for evaluation and treatment; -On 1/21/2022, at 8:34 A.M., staff documented the resident left via ambulance. Record review of the resident's medical record showed no written notice sent to the resident or resident's responsible party regarding the transfer on 01/21/2022. Record review of the resident's nurses' progress notes showed the following information: -On 1/28/2022, at 10:30 A.M., staff documented the resident left facility via stretcher; -On 1/28/2022, at 12:24 P.M., staff documented family notified of transfer to hospital via telephone call. Record review of the resident's medical record showed no written notice sent to the resident or resident's responsible party regarding the transfer on 1/28/2022. 5. Record review of Resident #210's face sheet showed the following: -discharged to the hospital on 2/3/2022. Record review of the resident's nurses' progress notes showed the following information: -On 2/3/2022, at 8:00 A.M., staff documented the resident had pulled out the peg tube (percutaneous endoscopic gastrostomy - which a tube is passed into a patient's stomach, most commonly to provide a means of feeding when oral intake is not adequate). Staff received a new order to send the resident to the emergency room for new peg tube placement. Staff attempted to call resident's family with no answer. Record review of the resident's medical record showed no written notice sent to the resident or resident's responsible party regarding the transfer on 2/3/2022. 6. During an interview on 2/17/2022, at 9:42 A.M., the Social Services Director (SSD) said he/she had no involvement in completing or sending transfer notices. He/she said nurses handle the notices, and he/she sends a monthly log to the Ombudsman. 7. During an interview on 2/17/2022, at 2:18 P.M., Licensed Practical Nurse (LPN) E said when a resident is transferred out to the hospital, the nurse fills out transfer paperwork to send with the Emergency Medical Technician (EMT). LPN E was not aware of a written notice being sent to the responsible party. 8. During an interview on 2/18/2022, at 11:02 A.M., the Director of Nursing (DON) said that when a resident is transferred to the hospital they are sent with a transfer form.

Based on interview and record review, the facility failed to give written information to the resident and/or resident's representative of the facility's bed hold policy for three residents (Residents #10, #43, and #57) who were transferred out to the hospital. The facility census was 61. Record review of a facility's policy entitled Transfer/Discharge, revised 2/2021, showed the following: -A patient may be transferred or discharged to another health care institution or discharged home upon the written order of the attending physician; -Sufficient information will be provided to the patient to assure continuity of care, regardless of the destination of the patient or the reason for the transfer. (The policy did not address staff providing a written notification of the facility's bed hold policy to the resident and/or resident's representative upon transfer to a hospital.) 1. Record review of Resident #10's nurses' progress notes showed the following information: -On 11/9/2021, staff reported critical laboratory results to the physician and followed orders to send him/her to the hospital for further evaluation and treatment. The resident contacted spouse per his/her request. A copy of paperwork was placed under the Assistant Director of Nursing (ADON)'s door. Record review of the resident's electronic medical record (EMR) showed no copy of a written notice pertaining to the bed hold policy provided to the resident or resident representative regarding a transfer on 11/9/2021. 2. Record review of Resident #43's resident's nurses' notes showed the following information: -On 12/17/2021, the resident was sent to the hospital related to an episode of grand mal [CONDITION(S)] (causes a loss of consciousness and violent muscle contractions). Record review of the resident's EMR showed no copy of a written notice pertaining to the bed hold policy provided to the resident or resident representative regarding the transfer on 12/17/2021. 3. Record review of Resident #57's face sheet (a brief summary) showed the following: -discharged to hospital on 1/10/22. Record review of the resident's nurses' progress notes showed the following information: -On 1/10/2022, at 2:00 P.M., staff documented notification to the physician of x-ray and abnormal labs, along with resident's continued increased confusion. New order received to send the resident to the hospital for evaluation and treatment; -On 1/10/2022, at 2:37 P.M., staff documented phone call with resident's representative regarding sending the resident to the hospital. Record review of the resident's medical record showed no written notice of the facility's bed hold policy sent to the resident or resident's responsible party regarding the transfer on 1/10/2022. 4. During an interview on 2/17/2022, at 2:18 P.M., Licensed Practical Nurse (LPN) E said when a resident is transferred out to the hospital, the nurse fills out the Bed Hold Policy using the EMR program, prints it out, and has it signed by the resident if they are able; otherwise two staff witness inability to sign. A copy is kept to be scanned into the file, and they send the original with resident. 5. During an interview on 2/18/2022, at 11:02 A.M., Director of Nursing (DON) said that when a resident is transferred to the hospital they are send with a bed hold policy. If a resident was not alert and oriented maybe would mail the bed hold to the family, but otherwise only send the information with the resident. 6. During an interview on 2/18/2022, at 11:23 A.M., the Administrator said that the bed policy is sent with residents when there are sent to the hospital, but she did not know if it was mailed to the family.

Based on observation, interview, and record review, the facility failed to complete a a risk/benefit review and document alternatives attempted prior to side rail use for two residents (Resident #43 and #58); failed to obtain informed consent for the use of side rails for four residents (Resident #43, #57 #58 210); and failed to complete a side rail safety check to include measurements of the bed frame and all bed rails for risk of entrapment for four residents (Residents #6, #26, #57, and #210). The facility failed to care plan the use of the side rails for four residents (Resident #6, #26, #43, and #210). The facility census was 61. Record review of a facility policy statement entitled Bed Safety, revised December 2007, showed the following information: -The facility shall strive to provide a safe sleeping environment for the resident; -The resident's sleeping environment shall be assessed by the interdisciplinary team, considering the resident's safety, medical conditions, comfort, and freedom of movement, as well as input from the resident and family regarding previous sleeping habits and bed environment; -To try to prevent deaths/injuries from the beds and related equipment (including the frame, mattress, side rails, headboard, footboard, and bed accessories), the facility shall promote the following approaches: a) Inspection by maintenance staff of all beds and related equipment as part of our regular bed safety program to identify risks and problems including potential entrapment risks; b) Review that gaps within the bed system are within the dimensions established by the FDA (Food and Drug Administration); c) Ensure that when bed system components are worn and need to be replaced, components meet manufacturer's specifications; d) Ensure that bed side rails are properly installed using the manufacturer's instructions and other pertinent safety guidance to ensure proper fit (e.g., avoid bowing, ensure proper distance from the headboard and footboard, etc.); and e) Identify additional safety measures for residents who have been identified as having a higher than usual risk for injury including entrapment (e.g., altered mental status, restlessness, etc.); -If side rails are used, there shall be an interdisciplinary assessment of the resident, consultation with the Attending Physician, and input from the resident and/or legal representative; -The staff shall obtain consent for the use of side rails from the resident or resident's legal representative prior to their use; -Before using side rails for any reason, the staff shall inform the resident and family about the benefits and potential hazards associated with side rails; -Before using side rails for any reason, the staff shall take measures to reduce related risks; -Side rails shall not be used as protective restraints. Should a protective restraint be used, the facility's protocol for the use of restraints shall be followed. Record review of a document attached to the facility Bed Safety policy, entitled Restraints: Bed Rail Safety Check showed drawings of the seven areas in the bed system that have a potential for entrapment. The zones included within rail; under rail; between rail supports or next single rail support; between rail and mattress; under rail, at ends of rail; between end of rail and side edge of head or foot board; and between head or foot board and mattress end. Each zone was duplicated for each side of the bed, with recommended parameters listed for certain zones. 1. Record review of Resident #43's significant change Minimum Data Set (MDS - a federally mandated comprehensive assessment tool completed by facility staff), dated 1/11/2022 , showed the following: -admitted [DATE]; -diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] -Moderately impaired cognition. Record review of the resident's physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Observations on 2/15/2022, at 8:20 A.M., showed the resident lay in bed. The bed was in a lowered position and a fall mat was placed on the floor next to the bed. Side rails were attached to both sides of the bed in the raised position and were approximately 1/2 the length of the mattress. The resident's call light was attached to the rail of the resident's left side. Observations on 2/18/2022, at 10:30 A.M., showed the resident lay in bed. Side rails were in the raised position on both sides of the bed. He/she briefly grasped the left rail to reposition him/herself. Record review of the resident's current care plan, last updated 1/11/2022, showed staff did not care plan the use of side rails. Record review of the resident's electronic medical record (EMR) showed the following: -Safety gap measurements were documented on 9/29/2021; -Staff did not document regarding completion of a pre-use risk evaluation, alternatives attempted prior to use, or risk education to the resident and/or resident's representative with informed consent to use bed rails at the initial time of use. 2. Record review of Resident #58's annual MDS, dated [DATE], showed the following: -admitted [DATE]; -diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] -Cognitively intact. Record review of the resident's POS, current as of 2/18/2022, showed an order that resident may have 1/4 side rails for positioning and mobility. Record review of the resident's current care plan, last reviewed/revised 2/2/2022, showed the resident used 1/4 side rails to help with positioning. Observation made on 2/17/2022, at 8:36 A.M., showed the resident sat in a wheelchair beside the right side of his/her bed. A side rail was in the raised position on the resident's left side of the bed. The side rail attached to the right side of the bed was not raised. Record review of the resident's EMR showed the following: -Safety gap measurements were documented on 9/29/2021; -Staff did not document alternatives attempted prior to use or risk education to the resident and/or resident's representative with informed consent to use bed rails at the initial time of use. 3. Record review of Resident #6's quarterly MDS, dated [DATE], showed the following: -admitted [DATE]; -diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] -Severely impaired cognition. Record review of the resident's current POS showed an order, dated 5/30/2019, that resident may have 1/4 side rails for positioning and mobility. Observations on 2/15/2022, at 8:20 A.M., showed the resident lay in bed with his/her eyes closed. Side rails were in the raised position on both sides of the bed and approximately 1/2 the length of the bed. Observations on 2/15/2022, at 4:31 P.M., showed the resident lay in bed with his/her eyes closed. Side rails were in the raised position on both sides of the bed and approximately 1/2 the length of the bed. During an interview on 2/16/2022, at 10:30 A.M., Certified Medication Technician (CMT) A said the resident can use the side rails to help with turning and repositioning during care. Record review of the resident's current care plan, last updated 2/8/2022, showed staff did not care plan the use of bed rails. Record review of the resident's electronic medical record (EMR) showed the following: -Safety gap measurements were documented for the left side rail on 9/29/2021 with no measurements were shown for the right side rail. 4. Record review of Resident #26's significant change MDS, dated [DATE], showed the following: -admitted [DATE]; -diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] -Severely impaired cognition. Record review of the resident's POS, current as of 2/18/2022, showed an order dated 5/26/2020 for resident to have 1/4 side rails for positioning and mobility. Observations made on 2/15/2022, at 8:16 A.M., showed the resident lay in bed. Side rails were attached to both sides of the bed and were in the raised position. Observation made on 2/17/2022, at 9:30 A.M., showed the resident lay in bed with his/her eyes closed. Side rails were attached to both sides of the bed and were in the raised position. Record review of the resident's current care plan, last updated 12/15/2021, showed staff did not care plan the use of side rails. Record review of the resident's EMR showed the following: -Safety gap measurements were documented for the left side rail on 9/29/2021. No measurements were documented for the right side rail. 5. Record review of Resident #57's face sheet (basic information sheet) showed the following information: -admitted [DATE]; -diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the resident's admission MDS, dated [DATE], showed the following: -Cognitively intact; -Totally dependent on staff for activities of daily living (ADL - dressing, grooming, bathing, eating, and toileting); -Two person assist to complete activities of daily living such as bathing, grooming, repositioning, transfers. Record review of the resident's POS, dated 12/21/2021, showed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the resident's care plan, last updated 12/24/2021, showed the following information: -Resident required extensive staff assistance for transfers and bed mobility; -Used ¼ side rails on bed to help with mobility and to help staff when rolled in bed. Observations on 2/14/2022, at 2:49 P.M., showed the resident in bed calling out to staff with bilateral side rails, approximately ½ the length of the bed, in the upright position. Observation and interview on 2/15/2022, at 11:17 A.M., showed the resident in bed with television on with bilateral side rails in the upright position. The resident said that he/she used the side rails to hold onto when staff help him/her roll during personal cares. Record review of the resident's medical record showed staff did not document an informed consent for risks and benefits of the bed rails with consent given by the resident or responsible party and no documentation of side rail gap measurements. During an interview on 2/18/2022, at 12:39 P.M., Maintenance Director said that he did not have any side rail measurements available for the resident. 6. Record review of Resident #210's face sheet showed the following: -admitted [DATE]; -diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the resident's admission MDS, dated [DATE], showed the following information: -Mild cognitive impairment; -Extensive assistance of one staff person required for transfer, bed mobility, toileting, locomotion, and personal hygiene. Record review of the resident's POS showed an order, dated 1/27/2022, for ¼ side rails for positioning and bed mobility. Observations and interview on 2/14/2022, at 11:54 A.M., showed the resident was seated in recliner with a family member in the room. The bed had bilateral side rails approximately ½ the length of the bed in the upright position. The resident's family member did not remember if risk and benefits were discussed. He/she said that the resident used the side rails to assist with repositioning in bed. Observations on 2/16/2022, at 10:25 A.M., showed the resident in bed with eyes closed with bilateral side rails in the upright position. Record review of the resident's care plan, dated 1/28/2022, showed staff did not care plan the use of side rails. Record review of the resident's medical record showed staff did not document an informed consent for risks and benefits of the bed rails with consent given by the resident or responsible party and no documentation of side rail gap measurements. During an interview on 2/18/2022, at 12:39 P.M., the Maintenance Director said that he had no side rail measurements available for the resident. 7. During an interview on 2/17/2022, at 2:18 P.M., Licensed Practical Nurse (LPN) E said on admission the nurse asks the resident and/or resident's representative about the use of side rails and educate resident/family on the risks. The LPN was not aware of anything that had to be signed regarding bed rails. Nursing tells the Director of Nursing (DON) or Assistant Director of Nursing (ADON) if side rails are needed or requested. The DON gets a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Maintenance staff installs the bed rails and does the safety measurements. 8. During an interview on 2/18/22, at 11:23 .M., the Administrator said that side rails are discussed with the resident and family at admission and there is a graphic visual that even shows entrapment risk, but the home does not have a side rail risk/benefit consent form. 9. During an interview on 2/18/2022, at 12:45 P.M., the Director of Nursing (DON) said education is given to the resident and/or representative either during the admission process or when side rails are requested, regarding the risks of using side rails on a bed. Consent is obtained and documented prior to utilizing the rails. When physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . MDS checks all rooms routinely and keeps a list of all residents using side rails; he/she gives a copy of the list to maintenance for use in doing routine safety checks. 10. During an interview on 2/18/2022, at 12:53 P.M., the MDS coordinator said that there is a list of residents with side rails. He/she said that the use of side rails should be in the resident's care plan. He/she said that the standing physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . He/she said if the bed rail went past the head of the bed it would be considered 1/2 or 3/4 rail.

Based on observation, record review, and interview, the facility failed to ensure a medication error rate of less then 5% when staff made five errors out of 27 opportunities resulting in an 18.51% error rate. Staff failed to correctly dilute intravenous (administered into a vein) antibiotic and start the antibiotic infusion at the correct time for one resident (Resident #57), failed to prime insulin pens for two residents (Residents #1 and #46), and administered insulin outside of accepted time parameters for two residents (Residents #19 and #20), during random medication pass observations. The facility had a census of 61. 1. Record review of the facility provided policy titled Medication Administration-General Guidelines, dated 2006, showed the following information: -Personnel authorized to administer medications should do so only after they have familiarized themselves with the medication; -Prior to administration, the medication and dosage schedule on the resident's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] -Medications are administered with 60 minutes of scheduled time. (The policy did not address intravenous administration.) Record review of Resident #57's face sheet showed the following: -admitted [DATE]; -diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the resident's February 2022 Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] -An order, dated 1/25/22, for [MEDICATION(S)] (bacterial antibiotic used against resistant strains of infections) reconstitute solution, 1 gram, intravenous (IV), give with 0.9% sodium chloride (intravenous infusion is an [MEDICATION(S)] solution (solution that has the same salt concentration as cells and blood)) one time every other day due to [CONDITION(S)]. Staff to administer at 8:00 A.M. Record review of the resident's [MEDICATION(S)] vial showed the following information: -Reconstitute by adding 20 milliliter (ml) of sterile water for injection to the one gram vial of dry, sterile [MEDICATION(S)] powder; -Must be further diluted before use. Observation on 2/16/22, at 10:55 A.M., of Licensed Practical Nurse (LPN) B showed following: -The LPN prepared the supplies needed for IV infusion including [MEDICATION(S)] 1 gram, reconstitution solution and a 250 ml bag of 0.9% sodium chloride; -The LPN used a syringe to remove 3 ml of fluid from the 250 ml bag of 0.9% sodium chloride, inserted into the [MEDICATION(S)] vial, and lightly shook the vial of powder and fluid; -The removed an additional 2 ml of fluid from 0.9% sodium chloride bag and added to the [MEDICATION(S)] vial, and rolled and mixed the vial of powder and fluid (for a total of 5 ml of solution); -The LPN withdrew 3 ml of fluid from the vial and inserted into the 0.9% Sodium chloride bag, withdrew remaining fluid from the vial of approximately 2 ½ ml fluid and added to the sodium chloride bag, and lightly shook the 250 ml bag; -The LPN labeled and dated the bag and entered the resident room; -The LPN prepared the resident's peripherally inserted central catheter (PICC- thin, flexible tube that is inserted into a vein in the upper arm and guided (threaded) into a large vein above the right side of the heart called the superior vena cava) line access and started the intravenous infusion per order at 250 ml per hour. During an interview on 2/16/22, at 1:12 P.M., LPN B said the following: -He/she had to start the IV medications when he/she had time to get to it; -He/she had not received training on how to mix [MEDICATION(S)], he/she just knew that it had to be diluted somehow; -He/she was not aware the vial needed to be diluted with 20 ml of fluid. During an interview on 2/18/22, at 11:02 A.M., Director of Nursing (DON) said that IV medications have actual step-by-step instructions on the bag or the vial of medication. She did not know the amount required to dilute the [MEDICATION(S)] powder without looking at vial or pharmacy label. Staff should follow the directions on the medication label. During an interview on 2/18/22, at 11:23 A.M., the Administrator said that IV antibiotics come with the reconstitution powder attached to the bag. She did not know how much fluid was required for diluting the [MEDICATION(S)] without looking at the medication label. 2. Record review of the facility's undated policy, titled How to Use an Insulin Pen, included the following information: -Remove pen cover; -Get the needle ready and screw the needle onto insulin end of pen; -Prime the pen and clear air from the needle. This adjusts the pen and needle for good accuracy when it is time to measure the insulin dose. Turn the dose selector knob at end of the pen to one or two units; -Hold the pen with needle pointing upward, press knob up completely while watching for insulin drop or stream to appear. Repeat, if necessary, until insulin is seen at needle tip. The dial should be back at zero after completing the priming step; -Turn dose knob to dial in the insulin dose; -Select an injection site; -Inject insulin; -Press down on the dose knob until it stops and leave the needle in place for five to ten seconds to prevent insulin from leaking out of the injection spot; -Pull the needle straight out of the skin; -Throw away used needle in the sharps container and put the outer cover back on the pen. 3. Record review of the [MEDICATION(S)] (rapid-acting insulin used to lower blood glucose) patient instructions for use from the manufacturer, Novo Norodisk, dated March 2013, showed the following information: -Pull off the pen cap; -Wipe the rubber stopper with an alcohol swab; -Screw the needle tightly onto the [MEDICATION(S)] (pre-filled with insulin so you don't have to load it); -Before each injection small amounts of air may collect in the cartridge during normal use; -To avoid injecting air and to ensure proper dosing, turn the dose selector to two units; -Hold the [MEDICATION(S)] with the needle pointing up and tap the cartridge gently to make any air bubbles collect at the top of the cartridge; -Keep the needle pointing upwards, press the push-button all the way down, the dose selector returns to 0; -Check and make sure that the dose selector is at 0, then turn the dose selector to the number of units needed to inject; -Insert the needle into the skin, inject the dose by pressing the push-button all the way; -Keep the needle in the skin for at least six seconds and keep the push-button pressed all the way until the needle has been pulled out from the skin. This will make sure that the full dose has been given. -Remove the needle and put the pen cap on the [MEDICATION(S)]. 4. Record review of Resident #1's face sheet showed the following: -admitted to the facility on [DATE]; -diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the resident's February 2022 POS showed the following: -An order, dated 11/5/21, for [MEDICATION(S)] [MEDICATION(S)] U-100 insulin (Insulin [MEDICATION(S)]) solution, subcutaneous (administered under the skin), per sliding scale before meals due to type 2 diabetes mellitus; -If the resident's blood sugar is 150 milligram/deciliter (mg/dL) to 200 mg/dL, administer three units of insulin; -If the resident's blood sugar is 201 mg/dL to 250 mg/dL, administer five units of insulin; -If the resident's blood sugar is 251 mg/dL to 300 mg/dL, administer seven units of insulin; -If the resident's blood sugar is 301 mg/dL to 350 mg/dL, administer nine units of insulin; -If the resident's blood sugar is 351 mg/dL to 400 mg/dL, administer eleven units of insulin; -Call primary care physician if resident's blood sugar is less than 60 mg/dL or greater than 400 mg/dL and is symptomatic three consecutive time. Observation on 2/17/22, at 11:26 A.M., showed LPN C prepared the resident's [MEDICATION(S)] [MEDICATION(S)], dialed the pen to seven units due to blood glucose reading of 291 mg/dL, and administered the insulin to the resident. The LPN did not prime the pen before administration. The LPN did not hold the pen for any length of time after pressing the injector button. 5. Record review of Resident #46's face sheet showed the following: -admitted [DATE]; -diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Record review of the resident's February 2022 POS showed the following: -An order, dated 02/24/21, for [MEDICATION(S)] [MEDICATION(S)] U-100 insulin (Insulin [MEDICATION(S)]) insulin pen, five units subcutaneous before meals due to type 2 diabetes mellitus. Observation on 2/17/22, at 11:21 A.M., showed LPN C prepared the resident's [MEDICATION(S)] [MEDICATION(S)], dialed up five units, and administered the insulin to the resident. The LPN did not prime the pen before use. The LPN did not hold the pen for any length of time after pressing the injector button. 6. During an interview on 2/18/22, at 8:38 A.M., Registered Nurse (RN) D said that when using insulin pens, staff must prime the pen with two units prior to pulling up the ordered amount and staff should hold the pen with the button depressed for ten seconds before taking out of the patient's skin. 7. During an interview on 2/18/22, at 9:15 A.M., RN F said staff should gently shake the insulin pen, put on the needle, and prime with at least two units before preparing the ordered dose. 8. During an interview on 2/18/22, at 11:02 A.M., the DON said that staff should prime insulin pen with one to two units before administering the ordered insulin dose. Staff should administer the dose to the resident and do not have to hold for any length of time, just administer until all dose given. 9. During an interview on 2/18/22, at 11:23 A.M., the Administrator said that staff should prime insulin pen with each use. Staff should follow manufacturer directions for administration of insulin. 10. Record review of the [MEDICATION(S)] (rapid-acting insulin used to lower blood glucose) patient instructions for use from the manufacturer, Novo Norodisk, dated March 2013, showed the following information: -Because [MEDICATION(S)] has a more rapid onset and a shorter duration of activity than human regular insulin, it should be injected immediately (within 5-10 minutes) before a meal; after injecting, do not skip a meal or delay eating. 11. Record review of facility's documents showed meal times were scheduled to start as follows: -Breakfast at 6:30 A.M.; -Lunch at 11:30 A.M.; -Dinner at 4:30 P.M. 12. Record review of Resident #20's face sheet showed the following: -admitted [DATE]; -diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Record review of the resident's February 2022 POS showed the following: -An order, dated 10/20/2021, for fasting blood sugar checks before meals and at bedtime (5:00 A.M., 11:00 A.M., 4:00 P.M., and 8:00 P.M.); -An order, dated 11/5/2021, for [MEDICATION(S)] U-100 insulin [MEDICATION(S)] solution, 100 units/ml per sliding scale before meals (7:00 A.M., 11:00 A.M., 4:00 P.M.); -If resident's blood sugar is 150 mg/dL to 200 mg/dL, administer no units of insulin; -If resident's blood sugar is 201 mg/dL to 250 mg/dL, administer two units of insulin; -If resident's blood sugar is 251 mg/dL to 300 mg/dL, administer four units of insulin; -If resident's blood sugar is 301 mg/dL to 350 mg/dL, administer six units of insulin; -If resident's blood sugar is 351 mg/dL to 400 mg/dL, administer eight units of insulin; -If blood sugar is greater than 400 mg/dL, administer eight units of insulin subcutaneous; -Call physician if blood sugar is less than 60 mg/dL or greater than 400 mg/dL for three consecutive readings if symptomatic. Observation on 2/17/2022, at 3:17 P.M., showed Certified Medication Technician (CMT) A performed an AccuCheck (quick result blood test to determine glucose/sugar level) for the resident. CMT A said he/she could go ahead and administer two units of insulin at that time, because the sliding scale dose was scheduled as 3:30 P.M. on the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] .M. Observation on 2/17/2022, at 3:20 P.M., showed CMT A administered two units of [MEDICATION(S)] insulin to the resident. The CMT held the needle in the skin for less than four seconds (over one hour before scheduled meal service). Observation on 2/14/2022, at 4:05 P.M., showed service of the evening meal had not started and no residents had been served a meal at that time (45 minutes staff administered the insulin). 13. Record review of patient instructions for [MEDICATION(S)] insulin [MEDICATION(S)] showed the following: -[MEDICATION(S)] is a fast-acting insulin; -Give [MEDICATION(S)] insulin within 15 minutes before or right after eating. 14. Record review of Resident #19's face sheet showed the following: -admitted [DATE]; -diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the resident's February 2022 POS showed the following: -An order, dated 8/28/2020, for fasting blood sugar check before meals and at bedtime (5:00 A.M., 11:00 A.M., 4:00 P.M., and 8:00 P.M.); -An order, dated 11/5/2021, for [MEDICATION(S)] KwikPen insulin [MEDICATION(S)] pen, 100 units/ml per sliding scale before meals (7:00 A.M., 11:00 A.M., and 4:00 P.M.): -If resident's blood sugar is less than 70 mg/dL, call physician; -If resident's blood sugar is 150 mg/dL to 200 mg/dL, administer no units; -If resident's blood sugar is 201 mg/dL to 250 mg/dL; administer two units of insulin; -If resident's blood sugar is 251 mg/dL to 300 mg/dL, administer four units of insulin; -If resident's blood sugar is 301 mg/dL to 350 mg/dL, administer six units of insulin; -If resident's blood sugar is 351 mg/dL to 400 mg/dL, administer eight units of insulin; -If blood sugar is greater than 400 mg/dL, administer eight units of insulin, subcutaneous; -Call physician if blood sugar is high or low after three consecutive readings if symptomatic. Observation on 2/17/2022, at 3:30 P.M., showed CMT A performed an AccuCheck for the resident. Observation on 2/17/2022, at 3:33 P.M., showed CMT A administered eight units of [MEDICATION(S)] (quick-acting) insulin to the resident. The CMT held the needle in the skin for three seconds (one hour before scheduled meal service). Observation on 2/14/2022, at 4:05 P.M., showed service of the evening meal had not started and no residents had been served a meal at that time (30 minutes after staff administered the insulin). 15. During an interview on 2/18/22, at 9:15 A.M., RN F said that insulin should be administered about 15 to 30 minutes before each meal service. 16. During an interview on 2/18/22, at 11:23 A.M., the Administrator said that staff should follow the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] 17. During and interview on 2/18/2022, at 1:20 P.M., the DON said insulin should be given no longer than 30 minutes prior to meal, and, if indicated as with meal staff should give the insulin just before the resident eats. The DON said it would not be correct to administer insulin an hour prior to any scheduled meal service. She said dinner service did not start until 4:30 P.M. and 3:30 P.M. would be too early.

Based on observation, interview, and record review, the facility failed to maintain an effective infection control program when the facility failed to ensure staff wore face coverings (masks) appropriately to prevent the potential spread of the coronavirus disease (COVID-19 -an infectious disease caused by the [CONDITION(S)]-CoV-2 virus); when the facility failed to properly clean and disinfect glucometers (digital machine used to test the glucose/sugar level in blood) after use for five residents (Resident #1, #19, #31, #46, and #59); when the facility staff continued to administer medications to three residents (Residents #7, #12 and #20) after the medications had fallen onto unclean surfaces; and when staff failed to administer and read [CONDITION(S)] (TB - potentially serious infectious disease that mainly affects the lungs) tests for three staff members (Housekeeping Aide M, Activity Director, and Laundry Aide N) at hire. The facility census was 61. 1. Record review of the CDC (Center for Disease Control and Prevention) guidance for Healthcare Workers, titled Facemask Do's and Don'ts, dated 06/02/2020, showed the following: -Do secure the bands around the ears; -Do secure the straps at the middle of the head and the base of the head; -Don't wear the facemask under the nose or mouth; -Don't wear the facemask around the neck. Record review of the CDC's Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, Implement Source Control Measures, updated 2/22/2022, showed the following: -Source control refers to use of respirators or well-fitting face masks or cloth masks to cover a person's mouth and nose to prevent spread of respiratory secretions when they are breathing, talking, sneezing, or coughing; -Source control and physical distancing (when physical distancing is feasible and will not interfere with provision of care) are recommended for everyone in a healthcare setting. This is particularly important for individuals, regardless of their vaccination status, who live or work in counties with substantial to high community transmission. Record review of the COVID Data Tracker, on the CDC website, showed the facility's county had a high transmission rate during the dates of the survey, 02/14/2022 to 02/18/2022. Observations on 2/16/2022 showed the following: -At 12:05 P.M., Licensed Practical Nurse (LPN) C entered Resident #59's room with the resident's lunch tray. The LPN's face mask was below his/her nose. The LPN put the tray on the bedside table and opened food covers, and cut up the resident's food with his/her face mask below nose. The resident did not have a face mask on; -The LPN left room and re-entered the same room with Resident #46's lunch tray. The LPN had his/her face mask below the nose. The resident requested an alternative meal. The LPN went to the kitchen window with his/her face mask below nose and put in the requested meal alternative. The resident did not have a face mask on; -At 12:12 P.M., the LPN entered Resident #46's room with the alternative meal option, with his/her face mask below the nose. He/she put the resident's meal on his/her bedside table and left the room. The resident did not have a face mask on. Observation on 2/17/2022 showed the following: -At 1:59 P.M., LPN C entered Resident #12's room with medications with his/her face mask below his/her upper lip and nose. The resident did not have a face mask on; -At 2:03 P.M., LPN C took liquid medication to the dining room for Resident #23, with his/her face mask below the nose. The LPN sat down next to the resident and assisted with the liquid medication. The resident did not have a face mask on. The dining room contained approximately 12 residents for an activity. Observation on 2/17/2022 at 3:35 P.M., showed Registered Nurse (RN) H was at the medication cart with his/her face mask below the nose. The RN went over to a resident seated at the dining table and provided iced tea with his/her face mask below the nose. The resident did not have a face mask on. Observation on 2/17/2022 at 11:17 A.M., LPN C entered Resident # 46's room with his/her face mask below the nose and obtained Resident #46's blood sugar and then gave the resident a pill. The resident did not have a face mask on. During an interview on 2/18/2022 at 9:15 A.M., RN F said said that face masks should be worn to cover the nose and mouth when working with residents. During an interview on 2/18/2022 at 9:45 A.M., LPN B said the face mask should completely cover a person's mouth and nose. During an interview on 2/18/2022 at 11:02 A.M., the Director of Nursing (DON) said staff should have masks above their nose and mouth, staff should not enter a resident room with their mask not covering their nose. During an interview on 2/18/22, at 11:23 A.M., the Administrator said she expected staff to wear their masks correctly while working in the facility. The mask should cover their mouth and nose. 2. Record review showed the facility did not provide a policy pertaining to glucometer use and cleaning. Record review of the facility's provided policy, titled Cleaning and Disinfection of Resident-Care Items and Equipment, dated October 2009, showed the following: -Resident-care equipment, including reusable items and durable medical equipment will be cleaned and disinfected according to current CDC recommendation for disinfection and the Occupational Safety and Health Administration (OSHA) Bloodborne Pathogens Standard; -Durable medical equipment must be cleaned and disinfected before reuse by another resident; -Reusable resident care equipment will be decontaminated and/or sterilized between residents according to manufacturers' instructions. Record review of the manufacturer's guidelines for Super Sani-Cloth Germicidal Disposable Wipes showed the following: -Unfold a clean wipe and thoroughly wet surface; -Allow treated surface to remain wet for a full two minutes; -Let air dry; -For visibly or heavily soiled surfaces, use a wipe to pre-clean prior to disinfecting; -Depending on air temperature, humidity, and air flow, a second wipe may be needed to maintain the contact time of 2 minutes. 3. Record review of Resident #46's face sheet (brief information about the resident), showed the following information: -diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #46's February 2022 physician order [MEDICAL RECORD OR PHYSICIAN ORDER] -A current order for [MEDICATION(S)] U-100 insulin [MEDICATION(S)] (a hormone that works by lowering levels of glucose (sugar) in the blood), per sliding scale before meals and at bedtime: -If resident's blood sugar is less than 70 milligrams/deciliter (mg/dL), call the physician; -If resident's blood sugar is 150 mg/dL to 200 mg/dL, administer three units of insulin; -If resident's blood sugar is 201 mg/dL to 250 mg/dL, administer five units of insulin; -If resident's blood sugar is 251 mg/dL to 300 mg/dL, administer seven units of insulin; -If resident's blood sugar is 301 mg/dL to 350 mg/dL, administer nine units of insulin; -If resident's blood sugar is 351 mg/dL to 400 mg/dL, administer 11 units of insulin; -If resident's blood sugar is greater than 400 mg/dL, administer 11 units of insulin and call the physician; 4. Record review of Resident #59's face sheet showed the following information: -diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] Record review of Resident #59's February 2022 POS showed the following: -A current order to check fasting blood sugar before meals and at bedtime; -A current order to administer [MEDICATION(S)] [MEDICATION(S)] U-100 insulin, per sliding scale: -If resident's blood sugar is 150 mg/dL to 200 mg/dL, administer four units of insulin; -If resident's blood sugar is 201 mg/dL to 250 mg/dL, administer six units of insulin; -If resident's blood sugar is 251 mg/dL to 300 mg/dL, administer ten units of insulin; -If resident's blood sugar is 301 mg/dL to 350 mg/dL, administer 12 units of insulin; -If resident's blood sugar is 351 mg/dL to 400 mg/dL, administer 15 units of insulin; -If blood sugar is greater than 400 mg/dL, administer 15 units of insulin and contact the physician. 5. Record review of Resident #1's face sheet showed the following: -diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Record review of Resident #1's February 2022 POS showed the following: -An order, dated 11/5/2021, for [MEDICATION(S)] [MEDICATION(S)] U-100 insulin (Insulin [MEDICATION(S)]) solution, subcutaneous (administered under the skin), per sliding scale before meals due to type 2 diabetes mellitus; -If the resident's blood sugar is 150 mg/dL to 200 mg/dL, administer three units of insulin; -If the resident's blood sugar is 201 mg/dL to 250 mg/dL, administer five units of insulin; -If the resident's blood sugar is 251 mg/dL to 300 mg/dL, administer seven units of insulin; -If the resident's blood sugar is 301 mg/dL to 350 mg/dL, administer nine units of insulin; -If the resident's blood sugar is 351 mg/dL to 400 mg/dL, administer eleven units of insulin; -Call primary care physician if resident's blood sugar is less than 60 mg/dL or greater than 400 mg/dL and is symptomatic three consecutive time. Observation on 2/17/2022 showed the following: -At 11:07 A.M., LPN C removed the glucometer from the top of the medication cart and entered Resident #59's room to obtain the resident's blood sugar. The LPN obtained a wet disinfecting (Sani-cloth) wipe and placed the glucometer into the wipe. The LPN did not wipe the full glucometer to ensure it was wet and remained wet for at least two minutes; -At 11:17 A.M., the LPN prepared a second glucometer; -At 11:19 A.M., the LPN obtained Resident #46's blood sugar; -At 11:20 A.M., the LPN left the room and placed the glucometer in a disinfecting wipe. The LPN did not wipe the full glucometer to ensure it was wet and remained wet for at least two minutes; -At 11:26 A.M., the LPN prepared a previously used glucometer and entered Resident #1's room. After leaving the room, he/she put the glucometer in a disinfecting wipe. The LPN did not wipe the full glucometer to ensure it was wet and remained wet for at least two minutes. 6. Record review of Resident #31's face sheet showed the following: -diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the resident's February 2022 POS showed the following: -An order, dated 9/4/2010, to perform a blood sugar level check before meals and at bedtime (7:00 A.M., 11:00 A.M., 4:00 P.M., and 8:00 P.M.). Observation on 2/17/2022 at 3:12 P.M., showed Certified Medication Technician (CMT) A performed an AccuCheck (blood sugar test) on the resident. CMT A returned to the medication cart, unlocked the cart and retrieved two lengths of Super SaniWipes (disinfectant). He/she did not clean the machine, but wrapped the wipes around the glucometer, placing it upright into a plastic drinking cup on top of the cart. 7. Record review of Resident #19's face sheet showed the following: -diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the resident's February 2022 POS showed the following: -An order, dated 8/28/2020, for fasting blood sugar check before meals and at bedtime (5:00 A.M., 11:00 A.M., 4:00 P.M., and 8:00 P.M.). Observation on 2/17/2022 at 3:30 P.M., showed CMT A unwrapped a glucometer, used the same wipe to wipe the face of the machine for one to two seconds, placed the glucometer on a paper plate with a test strip and an alcohol swab packet, entered the room of the resident. The CMT performed an Accucheck. The CMT returned to the cart, retrieved two lengths of wipes to wrap around the glucometer and placed it in a plastic cup on top of the cart. The CMT did not wipe/clean the machine with the wipe. CMT A unwrapped the first glucometer and placed it in the cart drawer. 8. During an interview on 2/18/2022 at 9:15 A.M., RN F said staff should wipe down the glucometer with the disinfecting wipe and soak it in the wet wipe for one to three minutes depending on the type of wipe. During an interview on 2/18/2022 at 11:02 A.M., the DON said staff should wipe the glucometer with a disinfecting wipe and then wrap it and let it set, most halls have two glucometers and can use the second one while the first one sets in a wet wipe. During an interview on 2/18/2022 at 11:23 A.M., the Administrator said staff should be wipe down the glucometer between each use with the disinfecting wipes. 9. Record review of Resident #7's face sheet showed the following: -diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . During interview and observation on 2/18/2022 at 8:38 A.M., showed RN D was looking on the floor around the medication cart and moving the medication cart around to look under the cart. The RN located two small white round pills on the floor about two feet from the medication cart. He/she said that the pills went flying when he/she opened the medication bag. He/she said the pills were the resident's [MEDICATION(S)] (diuretic) and [MEDICATION(S)] (antihistamine). The RN put on gloves and picked up to the two pills off the floor, took out a dry gauze pad, wiped off the two pills, and put the pills into the medication cup already prepared with other pills. He/she said did not have any extra pills to give to the resident. The RN entered the resident's room and handed the pill cup and drink of water to the resident. 10. Record review of Resident #12's face sheet showed the following: -diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the resident's February 2022 physician order [MEDICAL RECORD OR PHYSICIAN ORDER] -A current order for [MEDICATION(S)] (used to treat high blood pressure), 5 mg, one tab every morning; -A current order for aspirin, 325 mg, one tab every morning; -A current order for [MEDICATION(S)] (mood stabilizing medication), 10 mg, one tab every morning; -A current order for vitamin D, one tab 125 microgram (mcg) every morning; -A current order for [MEDICATION(S)] (anti-depressant) capsule, 30 mg, one cap every morning; -A current order for potassium chloride, 20 milliequivalents (meq), one tab every morning; -A current order for [MEDICATION(S)] (used to treat conditions such as GERD), 40 mg, one tab every morning; -A current order for multivitamin plus low iron tablet, one tab every morning. Observation on 2/18/2022 at 8:45 A.M., showed RN D prepared medications for the resident. The RN dropped one round tablet onto the medication cart. The RN D put on gloves, picked up the pill, wiped the pill with a dry gauze, and put the pill into the medication cup. The RN then took the medication cup to the resident's room. The RN did no clean the cart prior to beginning medication administration. 11. Record review of Resident #20's face sheet showed the following: -diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] .) Record review of the resident's POS for February 2022 showed the following orders: -A current order for [MEDICATION(S)] (used to treat high blood pressure), 0.3 mg, give by mouth three times daily for heart disease; -A current order for hydralizine (used to treat high blood pressure), 100 mg, give by mouth three times daily for heart disease. Observation and interview on 2/17/2022 at 12:09 P.M., showed CMT A tore open the pill pack and the two pills in it fell from the package toward a plastic medication cup. One pill fell outside the cup and onto the top of the cart. Without using hand sanitizer, CMT A donned a glove, picked up the pill, and placed it into the cup with the other scheduled pill. CMT A said if the pill had hit the floor, he/she would have had to throw it away and get a different one. The CMT went into a resident's room and handed him/her the medication cup. 12. During an interview on 2/18/2022 at 9:15 A.M., RN F said that if any medication was dropped on the floor the staff should dispose of the pill and pull new medication from the emergency kit (ekit). He/she said he/she would not wipe medication that fell on the floor with a gauze and administer to a resident. He/she said if a medication fell on to the top of the medication cart he/she might administer that pill because he/she sanitized the medication cart every time before he/she started each shift of work. During an interview on 2/18/2022 at 9:45 A.M., LPN B said that if a medication fell on the floor, he/she would discard the pill and get a new pill from the ekit. He/she would not wipe it off with gauze and administer it. He/she said if the medication fell on the medication cart, he/she would also throw away and get a new pill. During an interview on 2/18/2022 at 11:02 A.M., the DON said that if a medication falls onto the top of the medication cart it would be okay to administer, as staff should be sanitizing their carts with each shift. He/she said if a medication falls on the floor, the staff should throw it away and pull that medication from the next day's medication pack and notify the pharmacy for replacement medication. He/she said it would not be okay to pick up a pill from the floor and wipe with gauze and then administer to the resident. During an interview on 2/18/22, at 11:23 A.M., the Administrator said staff should not administer medication that has dropped onto the cart, especially if may have fallen on water, or other soiled item. The carts are cleaned every shift. He/she said that staff should not ever administer medication that has dropped on the floor. The staff should not wipe medication on the floor with gauze and then administer to the resident. They should dispose of the medication and either pull from the ekit or from the next days medication packs and notify the pharmacy of the needed medications. The pharmacy is really good about getting medication needed. 13. Record review of the facility's TB policy titled, TB Screening for Long Term Care Employees, Section 3, dated March 2014, showed the following information: -Employees/volunteers who work ten or more hours per week are required to obtain a Mantoux PPD two-step [MEDICATION(S)] test within one month prior to starting employment in the facility; -If initial test is zero to nine millimeters, the second test should be given as soon as possible within three weeks after employment; -Documentation may be provided showing a Mantoux PPD test in the past two years; -It is the responsibility of the facility to maintain a documentation of each employee's [MEDICATION(S)] status; -All skin test results are to be documented in millimeters (mm) of induration. 14. Record review of Housekeeping Aide M's personnel record showed the following information: -Hire/start date of 1/20/2022; -Staff administered the first step PPD to the housekeeping aide on 1/12/2022; -Staff did not document the results of the first step; -Staff administered the second step PPD to the housekeeping aide on 2/16/2022; -Staff did not document the results of the second step. 15. Record review of the Activity Director's (AD) personnel record showed the following information: -Hire/start date of 2/3/2022; -Staff did not have a copy of the first step PPD being administered to the AD on 8/3/2021; -Staff did not have a copy of the first step TB test being read on 8/5/2021; -Staff did not document a second step PPD being given or read. 16. Record review of Laundry Aide N's personnel record showed the following information: -Hire/start date of 2/22/2022; -Staff administered the first step PPD to the laundry aide on 1/25/2022; -Staff did not document the results of the first step; -Staff did not document a second step administered to the aide. 17. During an interview on 02/18/2022 at 9:12 A.M., the Housekeeping Supervisor said all employees should have a two-step test upon hire. During an interview on 02/18/2022 at 9:32 A.M., Licensed Practical Nurse (LPN) B said he/she has given new hires TB test. During an interview on 02/18/2022 at 9:47 A.M., Registered Nurse (RN) D said the following: -He/she will give TB shots sometimes on the weekends; -When he/she does give a TB shot on a weekend, he/she will place all the coordinating paperwork under the Assistant Director of Nursing's (ADON) door. During an interview on 02/18/2022 at 9:59 A.M., the Director of Nursing (DON) said the following: -He/she will sometimes give the TB shots, but usually one of the floor nurses does this; -It is an issue when the testing is done on the weekends because it doesn't always get back to the ADON or DON and then becomes lost in the shuffle and a second step ends up missed.

Based on observation, interview, and record review, the facility failed to ensure staff treated all residents with dignity and respect when they did not provide a dignity bag for one resident's (Resident #57) catheter (sterile tube inserted into the bladder to drain urine) bag. The facility census was 61. Record review of the facility's policy titled Urinary Catheter Care, dated October 2010, showed the following information: -Purpose of the policy is to prevent catheter-associated urinary tract infections; -The policy did not address use of catheter bag privacy covers. Record review showed the facility did not provide a policy regarding dignity and respect. 1. Record review of Resident #57's face sheet (a brief resident profile sheet) showed the following: -admitted [DATE]; -diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the resident's care plan, dated 12/24/21, showed the following: -Resident needed assistance in performing and maintaining some of his/her activities of daily living (ADLs - dressing, grooming, bathing, eating, and toileting); -Resident had a urinary catheter and staff should complete catheter care every shift and as needed. (Staff did not care plan the use of a dignity bag for the catheter.) Record review of the resident's admission Minimum Data Set (MDS - a federally mandated assessment tool completed by facility staff), dated 1/25/22, showed the following: -Cognitively intact; -Totally dependent on staff for ADLs; -Two person assist to complete ADLs of daily living such as bathing, grooming, repositioning, transfers; -Indwelling catheter. Observations on 2/14/22 showed the following: -At 11:01 A.M., resident in his/her bed with catheter bag on the lower bed frame facing the door, with 150 milliliter (ml) yellow urine visible from the hallway. The catheter bag was visible to anyone passing the resident's room and was not in a dignity bag; -At 2:49 P.M., resident was in his/her bed with catheter bag on the lower bed frame facing the door with 400 ml yellow urine visible from the hallway. The catheter bag was visible to anyone passing the resident's room and was not in a dignity bag. Observation on 2/15/22 showed the following: -At 10:02 A.M., the resident was in his/her bed and the catheter bag was laying on the floor with yellow urine visible from the hallway. The catheter bag was visible to anyone passing the resident's room and was not in a dignity bag; -At 11:17 A.M., the resident was in his/her bed and the catheter bag was on the bed under the resident's right foot. The catheter bag was visible to anyone passing the resident's room and was not in a dignity bag. During an interview on 2/17/22, at 9:22 A.M., Registered Nurse (RN) F said that catheter bags should be in a privacy bag when visible in a resident room, when a resident is in a wheelchair, and when a resident was in the common areas. During an interview on 2/17/22, at 9:11 A.M., Certified Nurse Aide (CNA) G said that some catheter bags have a privacy cover on and some do not. He/she did not know if a catheter bag should be covered when in the resident room. It should be hooked on the bed frame on the lower portion of the bed. During an interview 2/18/22, at 9:45 AM, Licensed Practical Nurse (LPN) B said that catheter bags should be hooked on the lower part of the bed frame and in be placed in a privacy bag. Catheter bags should not be visible from doorway without being covered. During an interview on 2/18/22, at 11:02 A.M., the Director of Nursing (DON) said that catheter bags should be in a privacy bag when a resident is in the common areas of the facility. If the resident wants it in a privacy bag in the room then can have it covered there too, but it does not necessarily need to be covered in the resident room, it is okay if visible from door. During an interview on 2/18/22, at 11:23 A.M., the Administrator said that catheter bags should be in a privacy bag if the resident will be out of their room. The catheter bag does not necessarily need to be in a privacy bag if the resident is in their own room, even if visible from the door.

Based on observation, record review, and interview, the facility failed to ensure residents were free of significant medication errors when staff administered insulin (medication used to help control blood sugar levels) without priming the insulin pen prior to administration and without following manufacture recommendations to ensure the full dose of insulin was administered for two residents (Resident #1 and #46). The facility had a census of 61. Record review of the facility's undated policy, titled How to Use an Insulin Pen, included the following information: -Remove pen cover; -Get the needle ready and screw the needle onto insulin end of pen; -Prime the pen and clear air from the needle. This adjusts the pen and needle for good accuracy when it is time to measure the insulin dose. Turn the dose selector knob at end of the pen to one or two unit; -Hold the pen with needle pointing upward, press knob up completely while watching for insulin drop or stream to appear. Repeat, if necessary, until insulin is seen at needle tip. The dial should be back at zero after completing the priming step; -Turn dose knob to dial in your insulin dose; -Select an injection site; -Inject insulin; -Use thumb to press down on the dose knob until it stops. Leave the needle in place for five to ten seconds to prevent insulin from leaking out of the injection spot; -Pull the needle straight out of the skin; -Throw away used needle in sharps container and put the outer cover back on the pen. Record review of the [MEDICATION(S)] (rapid-acting insulin used to lower blood glucose) patient instructions for use from the manufacturer, Novo Norodisk, dated March 2013, showed the following information: -Pull of the pen cap; -Wipe the rubber stopper with an alcohol swab; -Screw the needle tightly onto the [MEDICATION(S)] (pre-filled with insulin); -Before each injection small amounts of air may collect in the cartridge during normal use; -To avoid injecting air and to ensure proper dosing, turn the dose selector to two units; -Hold the [MEDICATION(S)] with the needle pointing up and tap the cartridge gently to make any air bubbles collect at the top of the cartridge; -Keep the needle pointing upwards, press the push-button all the way down, the dose selector returns to zero; -Check and make sure that the dose selector is at zero, then turn the dose selector to the number of units needed to inject; -Insert the needle into the skin, inject the dose by pressing the push-button all the way; -Keep the needle in the skin for at least six seconds and keep the push-button pressed all the way until the needle has been pulled out from the skin. This will make sure that the full dose has been given; -Remove the needle and put the pen cap on the [MEDICATION(S)]. 1. Record review of Resident #1's face sheet showed the following: -admitted [DATE]; -diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the resident's February 2022 physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] -An order, dated 11/05/21, for [MEDICATION(S)] [MEDICATION(S)] U-100 insulin (Insulin [MEDICATION(S)]) solution, subcutaneous (administered under the skin), per sliding scale before meals due to type 2 diabetes mellitus; -If resident's blood sugar is 150 milligrams/deciliter (mg/dL) to 200 mg/dL, administer three unit of insulin; -If resident's blood sugar is 201 mg/dL to 250 mg/dL, administer five units of insulin; -If resident's blood sugar is 251 mg/dL to 300 mg/dL, administer seven units of insulin; -If resident's blood sugar is 301 mg/dL to 350 mg/dL, administer nine units of insulin; -If resident's blood sugar is 351 mg/dL to 400 mg/dL, administer eleven units of insulin;. -Call primary care physician if blood sugar is less then 60 mg/dL or greater than 400 mg/dL and is symptomatic three consecutive times. Observation on 2/17/22, at 11:26 A.M., showed Licensed Practical Nurse (LPN) C prepared the resident's [MEDICATION(S)] [MEDICATION(S)] and dialed the pen to seven units due to blood sugar reading of 291 mg/dL. The LPN administered the insulin to the resident. The LPN did not prime the pen before administration and did not hold the pen for any length of time after pressing the injector button. 2. Record review of Resident #46's face sheet showed the following: -admitted [DATE]; -diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] Record review of the resident's February 2022 physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] -An order, dated 2/24/21, for [MEDICATION(S)] [MEDICATION(S)] U-100 insulin (Insulin [MEDICATION(S)]) insulin pen, five units subcutaneous before meals due to type 2 diabetes mellitus. Observation on 2/17/22, at 11:21 A.M., LPN C prepared the resident's [MEDICATION(S)] [MEDICATION(S)] and dialed up to five units and administered the insulin to the resident. The LPN did not prime the pen before use or hold the pen for any length of time after pressing the injector button. 3. During an interview on 2/18/22, at 8:38 A.M., Registered Nurse (RN) D said that when using insulin pens, staff must prime the pen with two units prior to pulling up the ordered amount and staff should hold the pen with the button depressed for ten seconds before taking out of the patient's skin. 4. During an interview on 2/18/22, at 9:15 A.M., RN F said staff should gently shake the insulin pen, put on the needle, and prime with at least two units before preparing the ordered dose. He/she did not state if required to hold the pen for ten seconds. 5. During an interview on 2/18/22, at 11:02 A.M., Director of Nursing (DON) said that staff should prime insulin pen with one to two units before administering the ordered insulin dose. Staff should administer the dose to the resident and staff do not have to hold for any length of time, just administer until all dose given. 6. During an interview on 2/18/22, at 11:23 A.M., the Administrator said that staff should prime insulin pen with each use. Staff should follow manufacturer directions for administration of insulin.

Based on interview and record review, the facility failed to ensure all residents received treatment and care in accordance with professional standards when staff failed to reschedule and accompany one resident (Resident #1) to follow-up appointment after a right knee replacement with subsequent infection. The facility census was 59. Record review showed the facility did not provide a policy regarding transporting a resident to physician appointments. 1. Record review of Resident #1's face sheet (page to give personal information at a quick glance) showed the following: -admitted [DATE]; -diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of of the resident's quarterly Minimum Data Set (MDS-a federally mandated assessment instrument completed by facility staff), dated 8/4/21, showed the following: -Cognition intact; -Required extensive assistance of one staff for bed mobility and toilet use; -Did not transfer and did not walk in the room or the corridor; -Continent of bowel and bladder. Record review of the resident's care plan, dated 8/4/21, showed the following: -ADL (activities of daily living - dressing, grooming, bathing, eating, and toileting)/Rehabilitation potential; -The resident was to have the right knee hardware replaced, but found it had an infection in that knee joint; -The resident returned for antibiotic therapy to clear the infection and then will have the knee revision; -IV (intravenous-administered into the vein) antibiotics; -Anticipate comfort needs; -Continue therapy plan of care. Record review of the resident's progress notes, dated 8/12/21, showed the following: -At 8:43 A.M., a transport company transported the resident to the orthopedic physician's office. The resident returned at 1:44 P.M.; -Resident to return to orthopedic physician for an appointment on 9/13/21 at 2:00 P.M. During interview on 12/7/21, at 2:46 P.M., the Director of Nursing (DON) said the resident went to the hospital on 9/1/21 and had the right knee replacement surgery and returned to the facility on [DATE]. Record review of the resident's progress notes, dated 9/13/21, showed the resident had a physician's appointment and the transport did not show up. The facility transportation staff, Certified Medication Technician (CMT) A, called the transport company and was told the resident had canceled the transport ride on Saturday (9/11/21). The facility transporter called and re-scheduled the resident's appointment for 9/27/21 at 9:15 A.M. Record review of the resident's progress notes, dated 9/16/21, showed Registered Nurse (RN) B spoke to the nurse at the orthopedic clinic about the resident missing the 9/13/21 appointment for possible staple removal. The orthopedic physician gave orders for the staples to remain in the right knee until the follow up appointment scheduled on 9/27/21 (two weeks later from the 9/13/21 appointment). Record review of the resident's progress notes, dated 9/20/21, showed the resident began on antibiotic medication ([MEDICATION(S)] 500 milligrams (mg)) twice a day for three months due to prosthetic right knee infection. Record review of the resident's care plan, revised 9/20/21, showed the following: -Will have infection resolve with current treatment; -Administer antibiotic as ordered and notify physician if signs and symptoms of worsening infection occurs. Record review of the resident's After Visit Summary (orthopedic clinic), dated 9/30/21, showed the following: -Staples removed and steri-strips (small dressing strips to close wounds) applied to the right knee; -Remove steri-strips in one week; -Continue the oral antibiotic per the infectious disease physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] -Follow up with the orthopedic clinic in four weeks as scheduled on 10/28/21, at 1:30 P.M. (Staff did not document why the resident's appointment was completed on 09/30/21 instead of 09/27/21 as scheduled.) Record review of the resident's progress notes, dated 10/25/21, showed the resident was holding on to the bar on the wall to transfer while staff was getting the walker, when he/she turned to look at the staff member, the resident's knee gave out and he/she fell to the floor. The resident hit his/her right knee on the wall with noted bruising to the inner right knee cap area, two cuts on the right great toe and ball of right foot. Resident did not complain of pain at the knee and walked to bed from hallway without difficulty. Family and physician notified. Record review of the resident's medical record showed staff did not document the resident going to the scheduled appointment on 10/28/21. During interview on 12/2/21, at 11:15 A.M., CMT A said the following: -The resident had orthopedic appointments and a transportation company took the resident to the appointments since the appointments were outside the local town; -The resident went to a different city for the orthopedic surgery because the facility physician wanted the resident to go there to have knee surgery; -The resident could walk and the transport company was to take him/her to the other city; -The resident could not get into the van because his/her leg gave way and the resident sat down on the van's running board; -The resident thought the transport company was bringing a car to take him/her to the appointment so he/she walked outside and did not use the wheelchair; -Staff got the resident back into the facility and CMT A called and rescheduled the orthopedic appointment; -Staff will get the resident ready to transport; -If he/she needs to stay with the resident at the doctor's office, he/she will stay with them; -He/she did not have another staff member to go help him/her with a transport. During interview on 12/2/21, at 11:50 A.M., the resident said the following: -He/she had another right knee replacement (second one in same knee) in September and went to another city for this; -They put a metal rod in the knee, but it had an infection in the knee; -He/she sees an infection physician in the other city for this; -When he/she went back for a checkup at the orthopedic physician's office, they told him/her he/she could not see the physician anymore unless someone was with him/her at the appointment; -He/she used a transportation company to take him/her the long distance to the city; -The hospital refused him/her and said the physician said he wanted someone with him/her at the appointments; -The transport company take him/her to the appointment, but they do not help him/her out of the vehicle and he/she has a wheelchair; -CMT A asked about his/her family to go with him/her to the appointments, but they cannot go with him/her to the appointments; -The facility did not have enough staff to go with him/her to the appointment, but the physician says he wants someone from the nursing home to stay with him/her during the appointment; -The transport company was to bring a car and they were to send him/her with the wheelchair; -His/her last orthopedic appointment was canceled because he/she fell on the transport van when his/her knee gave out; -He/she can stand up for a little but cannot step up into a van. During interview on 12/2/21, at 2:15 P.M., the Social Service Director (SSD) said the following: -The orthopedic physician's office in the big city called and said they needed someone to come with the resident to be with him/her during the appointments; -The family member called and said he/she felt someone from the nursing home needed to go with the resident. During interview on 12/2/21, at 4:00 P.M., the DON said the following: -The resident was alert, oriented, and continent of bowel and bladder; -She told them the resident had his/her own mind and made his/her own decisions; -The facility does not send someone with a resident to a physician's appointment when the resident is able to speak for themselves and is independent; -He/she told the orthopedic clinic this and called the resident's family member to ask if he/she could take the resident to the appointment; -The family member said that he/she and his/her spouse could not take the resident to the appointment; -CMT A tried to get the appointment at the local orthopedic clinic and the local orthopedic clinic would not take the resident as a new patient at this time; -They called the orthopedic clinic back and asked them to call CMT A to make an appointment with CMT A to take the resident to the physician's appointment when CMT A could stay with the resident for this appointment; -CMT A knows he/she was to go with the resident and be with the resident during the appointment. During interview on 12/2/21, at 2:45 P.M., CMT A said the following: -The family member was to make the appointment for the resident's checkup and was to take the resident on his/her day off from work; -If the family member was unable to do this, he/she was to let CMT A know; -They do not have enough staff on the hall and he/she has to work the floor as a certified nurse aide (CNA) and he/she cannot go with the resident to his/her orthopedic appointment; -As soon as the orthopedic physician in the big city heard the resident lived in the nursing home, they said someone had to come with him/her and no other physician's office required this. During interview on 12/2/21, at 3:10 P.M., the DON said the following: -The facility made an appointment and the orthopedic physician's office canceled the 10/28/21 appointment; -The orthopedic physician's office will not do a telehealth (virtual) appointment with the resident; -The physician's office staff said the resident was in a nursing home for a reason; -They were to make the appointment with CMT A for him/her to go and stay with the resident during the appointment; -On 9/30/21, the resident's right knee gave out and he/she was assisted to the van. On 10/28/21, the transport company left the resident at the orthopedic physician's office. They turned the resident away and refused to see him/her; -The orthopedic physician wanted to see the resident before 12/20/21; -The resident's family member was supposed to make the appointment for going with the resident to his/her physician's appointment, but didn't know what was going on; -She told the clinic she called the family member who said he/she or spouse could not take the resident to the appointments; -No follow up appointment was made for the resident; -She would have expected CMT A to talk to her about all of this before now. MO 862

Based on interview and record review, the facility staff failed to report allegations of abuse involving one resident (Resident #1) and one staff member (Licensed Practical Nurse (LPN) D) immediately to facility management and within two hours to the State Survey Agency (Department of Health and Senior Services - DHSS). The facility census was 63. Record review of the facility's policy titled Policy for Allegations/Incidents of Abuse, Neglect, Misappropriation of Property and Exploitation, dated August 2001, and last revised on 12/11/17, showed the following: -The right to report a concern or incident is not limited to a formal, written grievance process, but includes any verbalized complaint to any center staff member; -All supervisory staff who receive reports of inappropriate behaviors will take immediate steps to correct such behaviors; -Any staff having either direct or indirect knowledge of any event that might constitute abuse, neglect, misappropriation of patient property or exploitation must report the event immediately, but not later than two hours after forming the suspicion if the events that cause the suspicion involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the suspicion do not result in abuse or serious bodily injury; -All allegations of possible abuse, neglect, misappropriation of patient property or exploitation will be immediately assessed to determine the appropriate direction of the investigation; -The facility will ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property are reported immediately, but not later than two hours after the allegation is made. 1. Record review of Resident #1's face sheet (a document that gives a resident's information at a quick glance) showed the following: -admitted d 3/4/19; -diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff), dated 5/12/21, and showed the following: -Adequate hearing and clear speech; -Makes self-understood; -Ability to understand others with clear comprehension; -Recalls staff names and faces; -Disorganized thinking not present; -No behaviors, hallucinations or delusions; -Total dependence on staff. Record review of the resident's care plan, updated on 5/26/21, showed direction for staff to do the following: -Assist with activities of daily living (ADL -dressing, grooming, bathing, eating, and toileting); -Listen to the resident concerns and validate requests; -Document and report immediately all attractions regarding behaviors; -Approach the residents calmly and listen attentively to concerns. Record review of the facility's Self-Report Investigation, dated 6/15/21, showed the following information: -On 6/15/21, at 2: 20 P.M., the Administrator was approached by the resident's family member regarding allegations of abuse that occurred on 5/27/2021. The family member said the resident told him/her that a nurse slapped the resident. The family member said the resident talked about the incident for two to three days after the resident was slapped. The family member said she thought it was strange, when LPN D called him/her and said nothing had occurred, the family believes that something happened and wanted the Administrator to look into it; -The resident said, The big lady (LPN D) came in and slapped him/her upside the head. The resident said the individual struck him/her with an open hand because he/she wanted him/her to shut up; -LPN D was interviewed and said the resident was upset because he/she was not given laxatives, as requested; -Certified Medication Technician (CMT) C said the resident called his/family member over the speaker phone. The resident said he/she had been struck on the head; -On 6/15/21, at 3:40 P.M., the Administrator reported the allegations to the Department pf Health and Senior Services, (DHSS) Region 1 Section of Licensing and Regulation. Observation and interview on 6/16/21, at 12:30 P.M., showed the resident sat in the wheelchair, tears rolling down his/her face, and said the following: -On 5/27/21, he/she was in pain and needed laxatives; -LPN D said, shut up and slapped him/her on the right cheek and across the ear. During an interview on 6/16/21, at 12:15 P.M., resident's family member said the following: -On 5/27/21, at approximately 12:30 P.M., he/she received a call from the resident; -The resident was crying and said LPN D slapped him/her on the face; -He/she called the resident's spouse; -It was very much unlike the resident to be crying over the phone. During an interview on 6/16/21, at 1:05 P.M., the resident's spouse said the following: -On 5/27/21, she received a phone call from LPN D; -LPN D said he/she did not slap the resident; -Prior to the incident, the resident had never accused staff of physically abuse; -He/she thought the incident was reported to the administrator; -On 6/15/21 she verified with the administrator; -The administrator said she was not aware of the incident. During an interview on 6/16/21, at 10:35 A.M., CMT C said the following: -On 5/27/21, while working the day shift, the resident asked for laxatives; -He/she notified LPN D; -LPN D went inside the resident room and closed the curtain; -Approximately ten minutes later the resident said LPN D slapped him/her on the head; -The resident used a mobile device and called his/her daughter; -The resident notified his/her daughter of the allegations; -The CMT said she reported the allegations to the Director of Nursing (DON); -All allegations should be reported immediately to the charge nurse and the DON immediately. During an interview on 6/16/21, at 10:55 A.M., LPN D said the following: -The resident is alert and oriented; - On 5/27/21, during the day shift, he/she went into the resident's room; -The resident was yelling for laxatives; -The LPN old the Resident he/she was not getting the laxatives due to having a bowel movement earlier; -Later, the resident told CMT C, he/she (LPN D) slapped the resident; -CMT C reported the allegations to the DON; -He/she understands all allegations of abuse should be reported to DHSS within two hours; -The LPN called the resident's spouse and discussed the allegations; -The LPN said he/she did not hit the resident; -The LPN did not document the incident in the resident's progress notes; -He/she was never suspended and an investigation was not done immediately; -He/she took care of the resident after the allegations were made. During an interview on 6/16/21, at 10:15 A.M., Certified Nurse Aide (CNA) A said the following: -All violations and allegations regarding abuse should be reported immediately to the charge nurse; -DHSS should be notified within two hours of the allegations being made. During an interview on 6/16/21, at 10:25 A.M., CMT B said the following: -The resident is easy to get along and is compliant; -When abuse allegations are made, the charge nurse and the Administrator should be notified immediately. During an interview on 6/16/21, at 1:40 P.M., Registered Nurse (RN) E said the following: -The resident communicates well and is alert and oriented; -On 6/15/21, he/she said LPN D slapped him/her on the face; -Noticed the resident was shading tears as he/she spoke; -All abuse allegations should be reported. During an interview on 6/16/21, at 2:10 P.M., RN F said staff are required to report all allegations of abuse immediately and to DHSS within 2 hours. During an interview on 6/16/21, at 3:40 P.M., the DON said the following: -On 5/27/21, CMT C said he/she overheard the resident and his/her family member talking over the speaker phone; -CMT C said the resident said staff slapped him/her; -She did not call the resident's spouse; -She did not investigate the allegations immediately; -There was miscommunication between her and CMT C; -All abuse violations are reported to DHSS within 2 hours. During an interview on 6/16/21, at 4:55 P.M., the Administrator said the following: -She expects all allegations of abuse to be called to the designated staff member immediately; -The allegations should have been reported to DHSS and investigated immediately; -All allegations of abuse are reported to DHSS no later than two hours after the allegation is made to facility staff. MO 755