Every finding on record at Nixa Nursing & Rehab

Based on interview and record review, the facility failed to ensure each resident's choice of to receive Cardiopulmonary Resuscitation (CPR - an emergency treatment that's done when someone's breathing or heartbeat has stopped) or not was consistently and clearly documented when staff documented conflicting CPR choice information for 10 residents (Resident #11, #12, #17,#23, #26, #30, #40, #41, #46 and #58) out of a sample of 16 residents. The facility census was 65. Review of the facility's policy and procedure titled, Advanced Directives from the Nursing Guidelines Manual, undated, showed the following: -The facility will respect advance directives in accordance with state law; -Upon admission of a resident to the facility, the Social Services Designee (SSD) will provide written information to the resident concerning his/her right to make decisions concerning medical care, including the right to accept or refuse medical or surgical treatment, and the right to formulate an advance directive; -Upon admission of a resident, the social services designee will inquire of the resident, and/or his/her family members, about the existence of any written advance directives; -Information about whether or not the resident has executed an advance directive shall be displayed prominently in the medical record under the advance directive tab; -Advance directives include, but are not limited to, living will (a document that specifies a resident's preferences about measures that are used to prolong life when there is a terminal prognosis) and do not resuscitate (DNR - indicates that, in case of respiratory or cardiac failure, the resident, legal guardian, healthcare proxy or representative has directed no CPR or other life saving methods are to be used; -Inquiries concerning advance directives should be referred to the SSD. 1. Review of Resident #11's face sheet (a document that gives a resident's information at a quick glance) showed the following information: -admitted [DATE]; -The resident's code status was full code (wished to receive CPR). Review of the resident's [DATE] Physician Order Sheet (POS) showed and order, dated [DATE], for DNR status Review of the resident's care plan, dated [DATE] and reviewed on [DATE], showed the resident chose to be a DNR. Review of the facility's Code Status Book located at the nurses' desk showed the following: -The resident's admission face sheet showed the resident was a full code; -Behind the resident's admission face sheet was purple DNR sheet, dated [DATE], which directed staff to not provide CPR. 2. Review of Resident #12's face sheet showed the following information: -admitted [DATE]; -The resident's code status was full code. Review of the resident's [DATE] POS showed an order, dated [DATE], for DNR status. Review of the resident's care plan, dated [DATE] and reviewed on [DATE], showed the resident chose to be a DNR. Review of the facility's Code Status Book located at the nurses' desk showed the following: -Resident's admission face sheet showed the resident was a full code; -Behind the resident's admission face sheet was a purple DNR sheet, dated [DATE], which directed staff to not complete CPR. 3. Review of Resident #17's face sheet showed the following information: -admitted [DATE]; -The resident's code status was full code. Review of the resident's [DATE] POS showed an order, dated [DATE], for DNR status for the resident. Review of the resident's care plan, dated [DATE] and reviewed on [DATE], showed the resident chose to be a DNR. Review of the facility's Code Status Book located at the nurses' desk showed the following: -The resident's admission face sheet showed the resident was a full code; -Behind the resident's admission face sheet was a purple (DNR) sheet, dated [DATE], which directed staff to not provide CPR. 4. Review of Resident #23's face sheet showed the following information: -admitted [DATE]; -The resident's code status was full code. Review of the resident's [DATE] POS showed an order, dated [DATE], for full code status . Review of the resident's care plan, dated [DATE] and reviewed on [DATE], showed the resident chose to be a DNR. Review of the facility's Code Status Book located at the nurses' desk showed the following: -The resident admission face sheet showed the resident was a full code; -Behind the resident's admission face sheet was a purple DNR sheet, dated [DATE], that directed staff to not provide CPR. 5. Review of Resident #26's face sheet showed the following information: -admitted [DATE]; -The resident's code status was full code. Review of the resident [DATE] POS showed an order, dated [DATE], for DNR status for the resident. Review of the resident's care plan, dated [DATE] and reviewed on [DATE], showed the resident chose to be a DNR. Review of the facility's Code Status Book located at the nurses' desk showed the following: -The resident's admission face sheet showed the resident was a full code; -Behind the resident's admission face sheet was a purple DNR sheet, dated [DATE], which directed staff to not provide CPR. 6. Review of Resident #30's face sheet showed the following information: -admitted [DATE]; -The resident's code status was full code. Review of the resident's [DATE] POS showed an order, dated [DATE], for DNR status. Review of the resident's care plan, dated [DATE] and reviewed on [DATE], showed the resident chose to be a DNR. Review of the facility's Code Status Book located at the nurses' desk showed the following: -The resident's admission face sheet showed the resident was a full code; -Behind the resident's admission face sheet was a purple DNR sheet, dated [DATE], that directed staff to not perform CPR. 7. Review of Resident #40's face sheet showed the following information: -admitted [DATE]; -The resident's code status was full code. Review of the resident's [DATE] POS showed an order, dated [DATE], for DNR code status. Review of the resident's care plan, dated [DATE] and reviewed on [DATE], showed the resident chose to be a DNR code status. Review of the facility's Code Status Book located at the nurses' desk showed the following: -The resident's admission face sheet showed the resident was a full code; -Behind this resident's admission face sheet was a purple DNR sheet, dated [DATE], which directed staff to not perform CPR. 8. Review of Resident #41's face sheet showed the following information: -admitted [DATE]; -The resident's code status was full code. Review of the resident's [DATE] POS showed an order, dated [DATE], for DNR status. Review of the resident's care plan, dated [DATE] and reviewed on [DATE], showed the resident chose to be a DNR code status. Review of the facility's Code Status Book located at the nurses' desk showed the following: -The resident's admission face sheet showed the resident was a full code; -Behind the resident's admission face sheet was a purple (DNR) sheet, dated [DATE], which directed staff to not perform CPR. 9. Review of Resident #46's face sheet showed the following information: -admitted [DATE]; -The resident's code status was full code. Review of the resident's [DATE] POS showed an order, dated [DATE], for DNR code status. Review of the resident's care plan, dated [DATE] and reviewed on [DATE], showed the resident chose to be a DNR code status. Review of the facility's Code Status Book located at the nurses' desk showed the following: -The resident's admission face sheet showed the resident was a full code; -Behind the resident's admission face sheet was a purple DNR sheet, dated [DATE], which directed staff to not perform CPR. 10. Review of Resident #58's face sheet showed the following information: -admitted [DATE]; -The resident's code status was full code. Review of the [DATE] POS showed an order, dated [DATE] for DNR code status. Review of the resident's care plan, dated [DATE] and reviewed on [DATE], showed the resident chose to be a DNR code status. Review of the facility's Code Status Book located at the nurses' desk showed the following: -The resident's admission face sheet showed the resident was a full code; -Behind the resident's admission face sheet was a purple DNR sheet, dated [DATE], which directed staff to not perform CPR. 11. During an interview on [DATE], at 3:00 P.M., the SSD said she was responsible for keeping each resident's code status up to date. She kept three binders with residents from A Hall, B Hall, and C Hall at the nurses' station with all residents from each of those halls code status, to include DNR or a full code status. The resident's face sheet and the purple advanced health directive sheet were placed in the book in alphabetical order. The book was up to date. The book was where the nurses would go to in case of an emergency to find code status. All residents' face sheets, POS, care plans, and purple sheets should be the same code status, either full code or DNR. During an interview on [DATE], at 3:25 P.M., Licensed Practical Nurse (LPN) E said the residents' advanced health care directive and code status were on the computer, on the residents' face sheets, and on the residents' physicians orders. The face sheet, the care plan, the POS, and the purple sheet should all match with either DNR or full code status. There is a book at the nurses' station that has hard copies of the residents' face sheets and DNR purple sheets which tells the nurses each resident's code status. They should match to be a full code or a DNR. He/she would look on the resident's door for a green (CPR) or red dot (DNR) or in the code status book in an emergency. During an interview on [DATE], at 3:40 P.M., the Administrator and Director of Nursing (DON) both said code status on the residents' face sheets and DNR purple sheets should match to either a full code or a DNR status. The SSD is responsible for keeping the code status books up to date. The DON and Administrator were not aware the books were not updated. Nobody was monitoring the SSD to ensure the code status books were up to date for all residents.

Based on interview and record review, the facility failed to ensure all allegations of possible misappropriation were reported to the State Survey Agency (Department of Health and Senior Services, DHSS) within the required 24-hour time frame when staff failed to report an allegation of misappropriation of property made by one resident (Resident #122). The facility census was 65. Review of the facility's policy titled Reporting - Abuse Policy, undated, showed the following: -It is the policy of the facility that each resident will be free from abuse. Abuse can include verbal, mental, sexual, or physical abuse, misappropriation of resident property and exploitation, corporal punishment, or involuntary seclusion. The facility will strive to educate staff and other applicable individuals in techniques to protect all parties; -Any nursing home employee or volunteer who becomes aware of abuse, mistreatment, neglect, exploitation or misappropriation shall immediately report to the nursing home administrator; -The nursing some administrator or designee will report abuse to the state agency per State and Federal requirements. 1. Review of Resident #122's face sheet (resident's information at a quick glance) showed the following information: -admitted [DATE] with readmitted [DATE]; -Diagnoses included sarcopenia (musculoskeletal disease in which muscle mass, strength, and performance are significantly compromised with age) and hyperlipidemia (high levels of fat in blood). Review of the resident's significant change Minimum Data Set (MDS - federally mandated assessment tool completed by facility staff), dated 04/30/24, showed the resident was cognitively intact. During an interview on 07/15/24, at 10:07 A.M., the resident said the following: -He/she did not want to answer any questions because he/she was upset; -An aide took his/her embroidery scissors from him/her a couple of weeks ago; -The scissors were taken by an aide that worked the night shift and the resident did not know the aides name; -The resident spoke with the Administrator and Social Service Director (SSD) this morning and they were not aware that the resident's scissors had been taken by an aide; -He/she likes to crochet and used the scissors to cut yarn; -The scissors had a yellow, plastic handle and the blades were very small and short; -The scissors were a gift from his/her family that had visited from out of state; -He/she had not been told he/she could not have scissors. During an interview on 07/16/24, at 10:30 A.M., the resident said the following: -He/she does not participate in activities and prefers to stay in his/her room and crochet; -No one has followed up with him/her about his/her scissors; -The resident had no scissors to cut his/her yarn. Review of the facility's July 2024 Grievance Log showed no grievances had been filed for the month of July 2024. During an interview on 07/16/24, at 11:40 A.M., the SSD said the resident came to the SSD on 07/15/24 stating that an aide had taken his/her embroidery scissors. The SSD asked the resident if he/she wanted to file a formal grievance and the resident said no. During an interview on 07/18/24, at 1:20 P.M., the Housekeeping Supervisor said the following: -The staff were told in morning meeting that the resident's scissors had been taken by an aide; -The residents aren't allowed to have regular scissors, but can have safety scissors; -The Housekeeping Supervisor gave the resident his pair of safety scissors until administration finds which aide took the resident's scissors. During an interview on 07/18/24, at 1:24 P.M., the Activities Director said the following: -The resident does not participate in group activities; -The resident crochets in his/her room; -The staff were told in morning meeting that the resident's scissors had been taken by an aide; -There was no risk associated with the resident having scissors. Review of the resident's record showed staff did not document reporting the allegation of misappropriation. Review of DHSS records showed the home did not self-report the allegation of misappropriation. During an interview on 07/23/24, at 2:00 P.M., Certified Nurse Aide (CNA) A said the following: -Misappropriation is a form of abuse and should be reported to administration; -If misappropriation was reported to CNA A, he/she reported it to the charge nurse and the chain of command; -The state required allegations of abuse, neglect, and misappropriation be reported to the state within two hours. During an interview on 07/23/24, at 2:15 P.M., Certified Medical Technician (CMT) B said the following: -If a resident reported abuse, neglect, or misappropriation to him/her, CMT B would tell the charge nurse immediately; -The state required allegations of abuse, neglect, or misappropriation to be reported to the state within two hours. During an interview on 07/23/24, at 2:11 P.M., SSD said the following: -If a resident reported abuse, neglect, or misappropriation to him/her, SSD would report it to the Administrator; -The Administrator and Director of Nursing (DON) investigate allegations; -The state required allegations of misappropriation be reported to the state within 24 hours; -There have not been any allegations of misappropriation; -The resident did report to her on 07/15/24, that an aide took his/her scissors; -He/she ask the resident if he/she wanted to file a formal grievance and the resident said no; -Staff were looking for the resident's scissors; -She did not report the misappropriation allegation to the state. During an interview on 07/23/24, at 3:45 P.M., the DON said the following: -The resident had been at the home for over a year; -The resident had scissors to use for crocheting; -There was no risk associated with the resident having scissors; -The SSD should document the allegations made by the resident; -The allegation of misappropriation should have been reported to the stated within 24 hours. During an interview on 07/23/24, at 3:52 P.M., the Administrator said the following: -During his morning rounds on 07/15/24, he was told by the resident that an aide had taken his/her scissors; -He referred the resident to the SSD to file a grievance; -Staff was made aware of the missing scissors in a morning meeting; -Staff would look for the scissors; -Reports of items taken by staff would be considered misappropriation and should be reported to the state within 24 hours.

Based on interview and record review, the facility failed to complete investigations of all allegations of misappropriation when staff failed to investigate one resident's (Resident #122) allegation of misappropriation. The facility census was 65. Review of the facility's policy titled Investigation, undated, showed the following: -It is the policy of this facility that reports of abuse (mistreatment, neglect, or abuse, including injuries of unknown source, exploitation, and misappropriation of property) are promptly and thoroughly investigated; -The investigation is the process used to try to determine what happened. The designated facility personnel will begin the investigation immediately. A root cause investigation and analysis will be completed; -The facility staff will complete an active search for missing item(s) including documentation of investigation; -The investigation will consist of at least the following: a review of the completed complaint report; an interview with the person or persons reporting the incident; interviews with any witnesses to the incident; a review of the resident medical record if indicated; a search of resident room (with resident permission); an interview with staff members having contact with the resident during the relevant periods or shifts of the alleged incident;, and interviews with the resident's roommate, family members and visitors. 1. Review of Resident #122's face sheet (resident's information at a quick glance) showed the following information: -admitted [DATE] and readmitted [DATE]; -Diagnoses included sarcopenia (musculoskeletal disease in which muscle mass, strength, and performance are significantly compromised with age) and hyperlipidemia (high levels of fat in blood). Review of the resident's significant change Minimum Data Set (MDS - federally mandated assessment tool completed by facility staff), dated 04/30/24, showed the resident was cognitively intact. During an interview on 07/15/24, at 10:07 A.M., the resident said the following: -He/she did not want to answer any questions because he/she was upset; -An aide took his/her embroidery scissors from him/her a couple of weeks ago; -The scissors were taken by an aide that worked the night shift and the resident did not know the aides name; -The resident spoke with the Administrator and Social Service Director (SSD) this morning and they were not aware that the resident's scissors had been taken by an aide; -He/she likes to crochet and used the scissors to cut yarn; -The scissors had a yellow, plastic handle and the blades were very small and short; -The scissors were a gift from his/her family that had visited from out of state; -He/she had not been told he/she could not have scissors. During an interview on 07/16/24, at 10:30 A.M., the resident said the following: -He/she does not participate in activities and prefers to stay in his/her room and crochet; -No one has followed up with him/her about his/her scissors; -The resident had no scissors to cut his/her yarn. Review of the resident's record showed staff did not document investigating the allegation of misappropriation of the resident's scissors. During an interview on 07/16/24, at 11:40 A.M., the SSD said the resident came to the SSD on 07/15/24 stating that an aide had taken his/her embroidery scissors. The SSD asked the resident if he/she wanted to file a formal grievance and the resident said no. During an interview on 07/18/24, at 1:24 P.M., the Activities Director said the following: -The resident does not participate in group activities; -The resident crochets in his/her room; -The staff were told in morning meeting that the resident's scissors had been taken by an aide; -There was no risk associated with the resident having scissors. Review of the facility's July 2024 Grievance Log showed no grievances had been filed for the month of July 2024. Review of the facility records showed the facility did not provide a timely written investigation of the resident's allegation of misappropriation. During an interview on 07/23/24, at 2:00 P.M., Certified Nurse Aide (CNA) A said administration is responsible for investigating allegations of misappropriation. During an interview on 07/19/23, at 1:42 P.M., Certified Medication Tech (CMT) C said the Director of Nursing (DON) investigated allegations of misappropriation and the state would send someone to investigate. During an interview on 07/23/24, at 2:11 P.M., SSD said the administrator and Director of Nursing (DON) investigate allegations of abuse, neglect, and misappropriation. There had not been any allegations of misappropriation. The resident did report to her on 07/15/24, that an aide took his/her scissors. During an interview on 07/23/24, at 3:45 P.M., the DON said she and the Administrator were responsible for completion of investigations of abuse, neglect, exploitation, and misappropriation. The resident had been at the home for over a year and had scissors to use for crocheting. There was no risk associated with the resident having scissors. The SSD should document the allegations made by the resident. During an interview on 07/23/24, at 3:52 P.M., the Administrator said the following: -The Administrator said that during his morning rounds on 07/15/24, he was told by the resident that an aide had taken his/her scissors; -The Administrator said reports of items taken by staff were considered misappropriation.

Based on observation, record review, and interview, the facility failed to ensure a medication error rate of less than 5% when the facility staff made three errors out of 26 opportunities resulting in an error rate of 11.53% when staff failed to prime the insulin pens for three residents (Resident #1, #2, and # 3), failed to follow manufacturer recommendations to ensure the full dose of insulin was administered for three resident(Resident #1, #2, and #3), and staff failed to ensure one resident (Resident #3) had meal intake within 30 minutes of insulin administration during two medication pass observations. The facility census was 62. Record review of a facility document titled Medication, Administration Guidelines, dated March 2015, showed the following: -It is the purpose of this facility that residents receive their medication on a timely basis and in accordance with establish policies; -The complete act of administration entails removing an individual dose from a previously dispensed, properly labeled container, verifying it with the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] -Medications are given to benefit a resident's health as ordered by the physician. Record review of the facility's policy, titled Specific Medication Administration Procedures: Insulin Pen Administration Procedures, dated July 2021, showed the following: -Gather supplies needed for insulin injection; -Check 5 rights as medication is checked against the order; -Right resident, right time, right medication, right dose, and right route; -Check expiration date of the insulin pen; -Remove cap from insulin pen and check for air bubbles, particulate matter, clumps, or cloudiness; -Wash hands and put on gloves; -Clean rubber seal with an alcohol swab; -Attach pen needle to insulin pen and removed cover if not a safety needle; -Prime insulin pen prior to use; -Dial pen to 2 units; -Hold pen upright and push the button on the end of the pen so a small drop of insulin appears; -Dial insulin to the desired insulin dose to be administered to the resident; -Check 5 rights again before medication is administered; -Choose an injection site on the abdomen or thigh. Record review of the [MEDICATION(S)] KwikPen (name brand for insulin [MEDICATION(S)] injection - fast action insulin)manufacturer's website, dated April 2020, is a man-made fast-acting insulin used to control high blood sugar in adults and children with diabetes mellitus, it is absorbed quickly and starts working in about 15 minutes after injection to lower blood sugar after meals. Instruction for use included the following: -Pull the pen cap straight off. Wipe the rubber stopper with an alcohol swab; -Check the liquid in the pen, it should look clear and colorless; -Attach a new needle, push the capped needle straight onto the pen and twist the needle on until it is tight; -Priming the pen means removing air from the needle and cartridge that may collect during normal use and ensure the pen is working correction. If the pen is not primed before each injection, too much or too little insulin may be given; -To prime the pen, turn the dose knob to select 2 units; -Hold the pen with the needle pointing up. Tap the cartridge holder gently to collect air bubbles at the top; -Continue holding the pen with needle pointing up. Push the dose knob in until it stops, and 0 is seen in the dose window. Hold the dose knob in and count to 5 slowly. A drop of insulin should be seen at the tip of the needle. If you do not see insulin, repeat priming; -Turn the dose knob to select the number of units to inject. The dose indicator should like up with the dose to be administered; -Choose the injection site, wipe the skin with an alcohol swab and let the skin dry before injection; -Insert the needle into the skin. Push the dose knob all the way in. Continue to hold the dose knob in and slowly count to 5 before removing the needle; -Pull the needle out of the skin, carefully unscrew the capped needle and dispose of needle; -Replace the pen cap and store at room temperature. Record review of the [MEDICATION(S)] [MEDICATION(S)] (name brand for insulin [MEDICATION(S)] - fast acting insulin) manufacturer's website, dated October 2021, showed the product prescription is fast-acting insulin that starts to work about 15 minutes after injection, peaks in about one hour, and keeps working for two to four hours. [MEDICATION(S)] [MEDICATION(S)] is used to improve blood sugar control in adults and children with diabetes mellitus. Instructions for use included the following: -Remove the pen cap with clean hands; -Wipe the rubber stopper with an alcohol swab; -Remove the protective tab from the new needle, screw the needle lightly onto the [MEDICATION(S)]. It is important that the needle is put on straight; -Pull off the big outer needle cap; -Pull off the inner needle cap and throw it away; -To avoid injecting air and to ensure proper dosing turn the dose selector to 2 units; -Hold the [MEDICATION(S)] with the needle pointing up. Tape the cartridge gently a few time to make any air bubbles collect at the top of the cartridge; -Keep the needle pointing upwards, press the push-button all the way in, the dose selector returns to 0, a drop of insulin should appear at the needle tip, if not change the needle and complete the process again; -Turn the dose selector to the number of units to be injected. The pointer should line up with the dose; -Insert the needle into the skin. Inject by pressing the push-button all the way in until the 0 lines up with the pointer; -Keep the needle in the skin for at least 6 seconds, and keep the push-button pressed all the way in until the needle has been pulled out from the skin. This will make sure that the full dose has been given; -Carefully remove the needle and place it in a disposal container; -Put the cap back on the [MEDICATION(S)] and store at room temperature. 1. Record review of Resident #1's face sheet (brief resident information sheet) showed the following information: -admitted [DATE]; -diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the resident's current physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] -An order, dated 8/29/2022, for [MEDICATION(S)] KwikPen Insulin 100 units/milliliter (ml) Pen, administer subcutaneous (under the skin) per sliding scale before meals per sliding scale of; -If blood sugar is less than 70 milligrams/deciliter (mg/dL) call the physician; -If blood sugar is 140 to 175 mg/dL, administer one unit of insulin; -If blood sugar is 176 to 200 mg/dL, administer two units of insulin; -If blood sugar is 201 to 250 mg/dL, administer three units of insulin; -If blood sugar is 251 to 299 mg/dL, administer five units of insulin; -If blood sugar is 300 to 350 mg/dL, administer seven units of insulin; -If blood sugar is greater than 350 mg/dL, call the physician. During an observation on 9/15/2022, at 11:25 A.M., Licensed Practical Nurse (LPN) A put on gloves, removed the cap from the [MEDICATION(S)] KwikPen, wiped the stopper with an alcohol wipe, and put on a new needle. Without priming the pen, the LPN turned the dial to the 1 indicator mark (one unit of insulin for blood sugar of 147 mg/dL). He/she entered the resident's room and used an alcohol wipe to clean the resident's abdomen. The LPN injected 1 unit of [MEDICATION(S)] in the resident's abdomen. He/she did not wait any length of time after injecting the medication before removing the needle from the resident's abdomen. He/she returned to the medication cart, removed the needle, and entered the required information into the resident's medication administration record. During observation on 9/15/2022, at 12:04 P.M., the resident received his/her meal tray in his/her room (39 minutes after insulin administration). 2. Record review of Resident #2's face sheet showed the following information: -admitted [DATE]; -diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the resident's current physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] -An order, dated 8/16/2022, for [MEDICATION(S)] KwikPen Insulin 100 unit/ml administer subcutaneous per sliding scale before meals and at bedtime per a sliding scale of: -If blood sugar less than 60 mg/dL, call physician; -If blood sugar is 0 to 139 mg/dL, administer 0 units of insulin; -If blood sugar is 140 to 199 mg/dL, administer 2 units of insulin; -If blood sugar is 200 to 249 mg/dL, administer 4 units of insulin; -If blood sugar is 250 to 299 mg/dL, administer 6 units of insulin; -If blood sugar is 300 to 349 mg/dL, administer 8 units of insulin; -If blood sugar is greater than 349 mg/dL, administer 10 units of insulin; -If blood sugar is greater than 400 mg/dL, call the physician. During an observation on 9/15/2022, at 11:35 A.M., LPN A put on gloves, removed the cap from the [MEDICATION(S)] KwikPen, wiped the stopper with an alcohol wipe, and put on a new needle. Without priming the pen, the LPN turned the dial to the 8 indicator mark (8 units for blood sugar of 326 mg/dL). He/she entered the resident's room and used an alcohol wipe to clean the resident's abdomen. The LPN injected 8 units of [MEDICATION(S)] in the resident's abdomen. He/she did not wait any length of time after injecting the medication before removing the needle from the resident's abdomen. He/she returned to the medication cart, removed the needle, and entered the required information into the resident's medication administration record. During observation on 9/15/2022, at 12:10 P.M., the resident received his/her meal tray in his/her room (35 minutes after insulin administration). 3. Record review of Resident #3's face sheet showed the following information: -admitted [DATE]; -diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the resident's current physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] -An order, dated 7/12/2022, for [MEDICATION(S)] [MEDICATION(S)] insulin 100 units/ml, administer 10 units subcutaneous three times per day; -An order, dated 7/12/2022, for [MEDICATION(S)] [MEDICATION(S)] insulin 100 unit, administer subcutaneous per sliding scale before meals and at bedtime per a sliding scale of: -If blood sugar is 140 to 199 mg/dL, administer 2 units of insulin; -If blood sugar is 200 to 249 mg/dL, administer 4 units of insulin; -If blood sugar is 250 to 299 mg/dL, administer 6 units of insulin; -If blood sugar is 300 to 349 mg/dL, administer 8 units of insulin; -If blood sugar is greater than 349 mg/dL, administer 10 units of insulin. During an observation on 9/15/2022, at 11:45 A.M., LPN A put on gloves, removed the cap from the [MEDICATION(S)] [MEDICATION(S)], wiped the stopper with an alcohol wipe, and put on a new needle. Without priming the pen, the LPN turned the dial to the 12 indicator mark (scheduled 10 units plus 2 units for blood sugar of 174 mg/dL). He/she entered the resident's room and used an alcohol wipe to clean the resident's abdomen. The LPN injected 12 units of [MEDICATION(S)] in the resident's abdomen. He/she did not wait any length of time after injecting the medication before removing the needle from the resident's abdomen. He/she returned to the medication cart, removed the needle, and entered the required information into the resident's medication administration record. During observation on 9/15/2022, at 12:45 P.M., the resident received his/her meal tray in the main dining room (one hour after insulin administration). Staff did not offer or provide a snack before the resident received his/her meal. During observation on 9/16/2022, at 11:27 A.M., LPN B prepared insulin for the resident, primed the pen, dialed the insulin and administered 12 units of [MEDICATION(S)] for blood sugar of 169 mg/dL. During observation on 9/16/2022, at 1:00 P.M., the resident received his/her meal tray in the main dining room (one hour and thirty-three minutes after insulin administration). Staff did not offer or provide a snack before the resident received his/her meal. 4. During an interview on 9/15/2022, at 11:48 A.M., LPN A said that he/she normally had insulin administration completed by 11:30 A.M. so that he/she could go to lunch and get back to help residents in the dining room. 5. During an interview on 9/16/2022, at 8:40 A.M., LPN C said that he/she administers resident lunch time insulin between 11:00 A.M. and 11:30 A.M., so he/she can be back to help staff in the dining room. 6. During an interview on 9/16/2022, at 2:00 P.M., LPN B said that the process to use an insulin pen included: -Staff should verify the resident and the medication and the dose; -Clean the rubber stopper with alcohol wipe, apply pen needle; -Prime pen to 2 units and then dial up the amount after verify with orders; -When administering insulin, hold in resident skin for up to 10 seconds. -Staff prime the pen to ensure there is no air in the needle otherwise the dose would not be accurate. 7. During an interview on 9/16/2022, at 2:10 P.M., LPN C and LPN D said the proper process to administer insulin given by pen was to remove the cap, wipe the rubber stopper with alcohol, apply a new needle, prime the pen with 2 units, then dial the pen to the ordered dose and administer to the patient skin. They said that staff should hold the pen in resident skin for approximately 10 seconds to ensure the resident receives the full dose. 8. During an interview on 9/16/2022, at 2:24 P.M., LPN E said that staff should always prime the insulin pens with 2 units to ensure proper dosing. He/she said that if resident was to receive 1 unit of insulin and the pen was not primed the resident probably did not receive any insulin. 9. During an interview on 9/16/2022, at 2:53 P.M., the Director of Nursing (DON) said the following: -For insulin administration by insulin pens, the staff should clean the stopper with the alcohol, prime the pen with 2 units, and then dial the dose due to resident. She said that this is required because there will be air in the needle if not primed. Staff would not know if a resident received the appropriate dose if the needle is not primed.; -Residents should have their meal within 30 minutes of an insulin injection, if it would be longer than 30 minutes the resident should be provided a snack; -Staff hold the insulin pen in the place for 10 seconds to ensure the proper dose was received before removing from skin. 10. During an interview on 9/16/2022, at 2:53 P.M., the Administrator agreed with the DON instructions for the staff providing insulin.

Based on observation, record review, and interview, the facility failed to ensure residents were free of significant medication errors when staff failed to prime the insulin pens for three residents (Resident #1, #2, and # 3) during one medication pass observation and failed to follow manufacturer recommendations to ensure the full dose of insulin was administered for three residents during two mediation pass observations (Resident #1, #2, and #3).The facility census was 62. Record review of a facility document titled Medication, Administration Guidelines, dated March 2015, showed the following: -It is the purpose of this facility that residents receive their medication on a timely basis and in accordance with establish policies; -The complete act of administration entails removing an individual dose from a previously dispensed, properly labeled container, verifying it with the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] -Medications are given to benefit a resident's health as ordered by the physician. Record review of the facility's policy, titled Specific Medication Administration Procedures: Insulin Pen Administration Procedures, dated July 2021, showed the following: -Gather supplies needed for insulin injection; -Check 5 rights as medication is checked against the order; -Right resident, right time, right medication, right dose, and right route; -Check expiration date of the insulin pen; -Remove cap from insulin pen and check for air bubbles, particulate matter, clumps, or cloudiness; -Wash hands and put on gloves; -Clean rubber seal with an alcohol swab; -Attach pen needle to insulin pen and removed cover if not a safety needle; -Prime insulin pen prior to use; -Dial pen to 2 units; -Hold pen upright and push the button on the end of the pen so a small drop of insulin appears; -Dial insulin to the desired insulin dose to be administered to the resident; -Check 5 rights again before medication is administered; -Choose an injection site on the abdomen or thigh. Record review of the [MEDICATION(S)] KwikPen (name brand for insulin [MEDICATION(S)] injection - fast action insulin)manufacturer's website, dated April 2020, is a man-made fast-acting insulin used to control high blood sugar in adults and children with diabetes mellitus, it is absorbed quickly and starts working in about 15 minutes after injection to lower blood sugar after meals. Instruction for use included the following: -Pull the pen cap straight off. Wipe the rubber stopper with an alcohol swab; -Check the liquid in the pen, it should look clear and colorless; -Attach a new needle, push the capped needle straight onto the pen and twist the needle on until it is tight; -Priming the pen means removing air from the needle and cartridge that may collect during normal use and ensure the pen is working correction. If the pen is not primed before each injection, too much or too little insulin may be given; -To prime the pen, turn the dose knob to select 2 units; -Hold the pen with the needle pointing up. Tap the cartridge holder gently to collect air bubbles at the top; -Continue holding the pen with needle pointing up. Push the dose knob in until it stops, and 0 is seen in the dose window. Hold the dose knob in and count to 5 slowly. A drop of insulin should be seen at the tip of the needle. If you do not see insulin, repeat priming; -Turn the dose knob to select the number of units to inject. The dose indicator should like up with the dose to be administered; -Choose the injection site, wipe the skin with an alcohol swab and let the skin dry before injection; -Insert the needle into the skin. Push the dose knob all the way in. Continue to hold the dose knob in and slowly count to 5 before removing the needle; -Pull the needle out of the skin, carefully unscrew the capped needle and dispose of needle; -Replace the pen cap and store at room temperature. Record review of the [MEDICATION(S)] [MEDICATION(S)] (name brand for insulin [MEDICATION(S)] - fast acting insulin) manufacturer's website, dated October 2021, showed the product prescription is fast-acting insulin that starts to work about 15 minutes after injection, peaks in about one hour, and keeps working for two to four hours. [MEDICATION(S)] [MEDICATION(S)] is used to improve blood sugar control in adults and children with diabetes mellitus. Instructions for use included the following: -Remove the pen cap with clean hands; -Wipe the rubber stopper with an alcohol swab; -Remove the protective tab from the new needle, screw the needle lightly onto the [MEDICATION(S)]. It is important that the needle is put on straight; -Pull off the big outer needle cap; -Pull off the inner needle cap and throw it away; -To avoid injecting air and to ensure proper dosing turn the dose selector to 2 units; -Hold the [MEDICATION(S)] with the needle pointing up. Tape the cartridge gently a few time to make any air bubbles collect at the top of the cartridge; -Keep the needle pointing upwards, press the push-button all the way in, the dose selector returns to 0, a drop of insulin should appear at the needle tip, if not change the needle and complete the process again; -Turn the dose selector to the number of units to be injected. The pointer should line up with the dose; -Insert the needle into the skin. Inject by pressing the push-button all the way in until the 0 lines up with the pointer; -Keep the needle in the skin for at least 6 seconds, and keep the push-button pressed all the way in until the needle has been pulled out from the skin. This will make sure that the full dose has been given; -Carefully remove the needle and place it in a disposal container; -Put the cap back on the [MEDICATION(S)] and store at room temperature. 1. Record review of Resident #1's face sheet (brief resident information sheet) showed the following information: -admitted [DATE]; -diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the resident's current physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] -An order, dated 8/29/2022, for [MEDICATION(S)] KwikPen Insulin 100 units/milliliter (ml) Pen, administer subcutaneous (under the skin) per sliding scale before meals per sliding scale of; -If blood sugar is less than 70 milligrams/deciliter (mg/dL) call the physician; -If blood sugar is 140 to 175 mg/dL, administer one unit of insulin; -If blood sugar is 176 to 200 mg/dL, administer two units of insulin; -If blood sugar is 201 to 250 mg/dL, administer three units of insulin; -If blood sugar is 251 to 299 mg/dL, administer five units of insulin; -If blood sugar is 300 to 350 mg/dL, administer seven units of insulin; -If blood sugar is greater than 350 mg/dL, call the physician. During an observation on 9/15/2022, at 11:25 A.M., Licensed Practical Nurse (LPN) A put on gloves, removed the cap from the [MEDICATION(S)] KwikPen, wiped the stopper with an alcohol wipe, and put on a new needle. Without priming the pen, the LPN turned the dial to the 1 indicator mark (one unit of insulin for blood sugar of 147 mg/dL). He/she entered the resident's room and used an alcohol wipe to clean the resident's abdomen. The LPN injected 1 unit of [MEDICATION(S)] in the resident's abdomen. He/she did not wait any length of time after injecting the medication before removing the needle from the resident's abdomen. He/she returned to the medication cart, removed the needle, and entered the required information into the resident's medication administration record. 2. Record review of Resident #2's face sheet showed the following information: -admitted [DATE]; -diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the resident's current physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] -An order, dated 8/16/2022, for [MEDICATION(S)] KwikPen Insulin 100 unit/ml administer subcutaneous per sliding scale before meals and at bedtime per a sliding scale of: -If blood sugar less than 60 mg/dL, call physician; -If blood sugar is 0 to 139 mg/dL, administer 0 units of insulin; -If blood sugar is 140 to 199 mg/dL, administer 2 units of insulin; -If blood sugar is 200 to 249 mg/dL, administer 4 units of insulin; -If blood sugar is 250 to 299 mg/dL, administer 6 units of insulin; -If blood sugar is 300 to 349 mg/dL, administer 8 units of insulin; -If blood sugar is greater than 349 mg/dL, administer 10 units of insulin; -If blood sugar is greater than 400 mg/dL, call the physician. During an observation on 9/15/2022, at 11:35 A.M., LPN A put on gloves, removed the cap from the [MEDICATION(S)] KwikPen, wiped the stopper with an alcohol wipe, and put on a new needle. Without priming the pen, the LPN turned the dial to the 8 indicator mark (8 units for blood sugar of 326 mg/dL). He/she entered the resident's room and used an alcohol wipe to clean the resident's abdomen. The LPN injected 8 units of [MEDICATION(S)] in the resident's abdomen. He/she did not wait any length of time after injecting the medication before removing the needle from the resident's abdomen. He/she returned to the medication cart, removed the needle, and entered the required information into the resident's medication administration record. 3. Record review of Resident #3's face sheet showed the following information: -admitted [DATE]; -diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the resident's current physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] -An order, dated 7/12/2022, for [MEDICATION(S)] [MEDICATION(S)] insulin 100 units/ml, administer 10 units subcutaneous three times per day; -An order, dated 7/12/2022, for [MEDICATION(S)] [MEDICATION(S)] insulin 100 unit, administer subcutaneous per sliding scale before meals and at bedtime per a sliding scale of: -If blood sugar is 140 to 199 mg/dL, administer 2 units of insulin; -If blood sugar is 200 to 249 mg/dL, administer 4 units of insulin; -If blood sugar is 250 to 299 mg/dL, administer 6 units of insulin; -If blood sugar is 300 to 349 mg/dL, administer 8 units of insulin; -If blood sugar is greater than 349 mg/dL, administer 10 units of insulin. During an observation on 9/15/2022, at 11:45 A.M., LPN A put on gloves, removed the cap from the [MEDICATION(S)] [MEDICATION(S)], wiped the stopper with an alcohol wipe, and put on a new needle. Without priming the pen, the LPN turned the dial to the 12 indicator mark (scheduled 10 units plus 2 units for blood sugar of 174 mg/dL). He/she entered the resident's room and used an alcohol wipe to clean the resident's abdomen. The LPN injected 12 units of [MEDICATION(S)] in the resident's abdomen. He/she did not wait any length of time after injecting the medication before removing the needle from the resident's abdomen. He/she returned to the medication cart, removed the needle, and entered the required information into the resident's medication administration record. 4. During an interview on 9/16/2022, at 2:00 P.M., LPN B said that the process to use an insulin pen included: -Staff should verify the resident and the medication and the dose; -Clean the rubber stopper with alcohol wipe, apply pen needle; -Prime pen to 2 units and then dial up the amount after verify with orders; -When administering insulin, hold in resident skin for up to 10 seconds. -Staff prime the pen to ensure there is no air in the needle otherwise the dose would not be accurate. 5. During an interview on 9/16/2022, at 2:10 P.M., LPN C and LPN D said the proper process to administer insulin given by pen was to remove the cap, wipe the rubber stopper with alcohol, apply a new needle, prime the pen with 2 units, then dial the pen to the ordered dose and administer to the patient skin. They said that staff should hold the pen in resident skin for approximately 10 seconds to ensure the resident receives the full dose. 6. During an interview on 9/16/2022, at 2:24 P.M., LPN E said that staff should always prime the insulin pens with 2 units to ensure proper dosing. He/she said that if resident was to receive 1 unit of insulin and the pen was not primed the resident probably did not receive any insulin. 7. During an interview on 9/16/2022, at 2:53 P.M., the Director of Nursing (DON) said the following: -For insulin administration by insulin pens, the staff should clean the stopper with the alcohol, prime the pen with 2 units, and then dial the dose due to resident. She said that this is required because there will be air in the needle if not primed. Staff would not know if a resident received the appropriate dose if the needle is not primed.; -Staff hold the insulin pen in the place for 10 seconds to ensure the proper dose was received before removing from skin. 8. During an interview on 9/16/2022, at 2:53 P.M., the Administrator agreed with the DON instructions for the staff providing insulin.

Based on observation and interview, the facility failed to post daily nurse staffing information, in a clear and readable format, in a prominent place readily accessible to residents and visitors. The facility census was 62. 1. Observation on 9/12/2022, at 1:25 P.M., showed the nurse staffing information not posted at the nurses' station, the front desk, or any other common areas. Observation on 9/13/2022, at 10:53 A.M., showed the nurse staffing information not posted at the nurses' station, the front desk, or any other common areas. Observation on 9/14/2022, at 11:39 A.M., showed the nurse staffing information not posted at the nurses' station, the front desk, or any other common areas. Observation on 9/15/2022, at 2:22 P.M., showed the nurse staffing information not posted at the nurses' station, the front desk, or any other common areas. Observation on 9/16/2022, at 10:39 A.M., showed the nurse staffing information on a clipboard at the nurses' station and behind the daily staff schedule. Information included the facility name, date, census, and staffing hours worked. This information was not available for public review without requesting from staff. During an interview on 9/16/2022, at 2:27 P.M., Licensed Practical Nurse (LPN) C said that the daily schedule is on a clipboard at the nurses' desk. The staff add the census hours daily by using the daily schedule. The schedule and form are not posted anywhere for residents and visitors to view. During an interview on 9/15/2022, at 2:36 P.M., the Director of Nursing (DON) said that the nurse staffing schedule is at the nurses' desk and was not posted on any wall. The night shift prepares the form and the staff updated the hours with each shift. The residents and visitors can ask to see the schedule. During an interview on 9/16/2022, at 3:15 P.M., the Administrator said that the nurse staffing posting had been taken down during remodeling and had been placed on a clipboard at the nurses' desk.

Based on interview and record review, the facility failed to inform residents and families/legal representatives of the facility bed hold protocol at the time of transfer to the hospital for two residents (Resident #19 and #48). A sample of 16 residents selected for review. The facility census was 47. Record review of the facility's undated policy titled, Bed Hold Guidelines, showed the following information: -The facility will notify all residents and/or their representative of the bed hold guidelines. This information shall be given on admission to the facility, at the time of transfer to the hospital, and at the time of non-covered therapeutic leave; -The facility guidelines for bed holds are as follows: -Medicare Part A-Medicare does not pay for any type of bed hold. If the resident is discharged to the hospital, or goes out for over-night leave of absence, the bed may be held by paying the current room rate for the bed being reserved; -Medicaid-Medicaid will pay for 12 over-night leaves of absence during the six month period of (MONTH) 1 through (MONTH) 30, and 12 over-night leaves of absence during the six month period of (MONTH) 1 through (MONTH) 31. If the resident exceeds the allowable number of over-night leaves of absence, the bed may be held by paying the current Medicaid rate for each non-covered day; -Private pay-Private pay residents discharged to the hospital or going on over-night leave of absence may reserve their bed by paying the current rate for the bed being reserved; -If the resident or resident representative wants to hold the bed, a signed authorization must be obtained with each discharge. Signed authorization must be received within 24 hours of the discharge if it occurs during the week. Signed authorization must be received by the first business day following the discharge if it occurs on the weekend or holiday; -If the resident or resident representative does not choose to hold the bed, the bed will be released and any personal belongings must be picked up within three days; -Bed holds are strictly voluntary. If the bed is not held and is not available when the resident wants to be readmitted , the resident's name will be placed on a waiting list for the next available bed; -If the resident or resident representative doses not choose to hold the bed and pay the room rate to hold the bed, the resident or resident representative will have released the bed and any personal belongings must be picked up within three days; -If the resident or resident representative want to hold the bed, a signed authorization of the Bed Hold Selection Notice must be obtained with each physician approved hospitalization or therapeutic leave of absence. Signed authorization must be received within 48 hours of transfer or leave. Record review of the facility policy titled, Discharge/Transfer of Resident, dated (MONTH) (YEAR), showed the following information: -Obtain physician order for [REDACTED].>-Explain transfer and reason to the resident and/or representative and give copy of signed transfer or discharge notice to the resident and/or representative or person responsible for care. NOTE: If emergency transfer, transfer or discharge notice form may be completed later, but as soon as possible; -Explain and give copy of bed hold form to resident and/or representative; -Complete transfer form, copy any portion of the medical record necessary for the care of the resident; -Send original of transfer form and portions of medical record that was copied with the resident; -Notify business office/ administration of discharge; -Notify dietary department of discharge. 1. Record review of Resident #19's nurses' notes showed the following information: -On 5/28/19, at 5:40 P.M., staff notified the nurse the resident had been lethargic (appear to have little or no energy, drowsy or sluggish) and had moderate amount of nasal drainage and could not be woke up. Staff completed the resident's vital signs, including a temperature of 103.6, pulse 86, respirations 21, blood pressure 110/66. Staff called the physician and informed him/her of the resident's symptoms and to report the chest x-ray results. The physician gave an order to send the resident to the hospital for evaluation and treatment. -At 5:45 P.M., staff called the paramedics; -At 6:05 P.M., staff loaded the resident into the ambulance and transported the resident to the hospital; -At 6:10 P.M., staff called and left a message for the resident's family member regarding the resident; -On 5/31/19, at 2:00 P.M., the resident returned to the facility by transport in a wheelchair. Staff notified the physician of the resident's return admission to the facility; -On 6/1/19, at 10:14 [NAME]M., staff called and left a message for the resident's family member of the readmission to the facility and antibiotic orders. Record review of the resident's medical record did not show any bed hold notice given to the resident or resident's responsible party during the transfer on 5/28/19. 2. Record review of Resident #48's nurses' notes showed the following information: -On 6/26/19, at 2:06 [NAME]M., staff notified the nurse practitioner (NP) of oxygen (O2) saturations (measurement of blood oxygen level) at 75% on 4 liters (L) of oxygen. The resident's vital signs included temperature 96.9, pulse 88, respirations 22-24, and blood pressure 104/58. Staff administered a [MEDICATION NAME] treatment (a combination of medications used to treat symptoms such as wheezing and shortness of breath) to the resident at 1:30 [NAME]M. The NP said to call the resident's family member to see if they wanted him/her treated at the facility or at the hospital. Staff contacted the family member about the resident's condition. The family member stated he/she would come out and see the resident, and make the decision at that time; -At 2:25 [NAME]M., the family member saw the resident and requested treatment at the hospital; -At 2:35 [NAME]M., staff called and requested ambulance service; -At 2:51 [NAME]M., staff gave the resident's paperwork to the ambulance personnel. The family member followed behind the ambulance to the emergency room . Record review of the resident's medical record did not show any bed hold notice given to the resident or resident's responsible party regarding the transfer on 6/26/19. 3. During an interview on 9/26/19, at 10:20 [NAME]M., the Director of Nursing (DON) said the nurses complete the discharge or transfer paperwork, including the bed hold notice, and give a copy to the resident and put a copy in the social service's box. 4. During an interview on 9/26/19, at 10:35 [NAME]M., the Social Services Director (SSD) said the nurses give a copy of the transfer notice, including the bed hold notice, to the resident when being sent to the hospital and place a copy in the SSD box. He/she keeps these copies on file in the SSD office. He/she did not receive a copy of the transfer notice for Resident #19 in (MONTH) or Resident #48 in June. The SSD said sometimes the notice gets filed in the resident medical record and would go check. At 10:56 [NAME]M., the SSD said he/she did not locate a copy of the hospital notice in either resident's medical record.

Based on observation, interview, and record review, the facility failed to properly disinfect glucometers (small hand-held devices that check blood glucose (sugar) levels for residents) while collecting blood glucose samples on residents with [DIAGNOSES REDACTED]. This practice involved three residents (Resident #46, Resident #3, and Resident #11) out of a sample of three. The facility census was 47. Record review of the Centers for Disease Control and Prevention (CDC) website showed the following information: -Blood glucometers approved for use for more than one person must be cleaned and disinfected. The CDC investigated multiple outbreaks of [MEDICAL CONDITIONS] (disease affecting the liver) among residents in long-term care (LTC) communities that were attributed to shared devices and other breaks in infection-control practices related to blood glucose monitoring devices. When blood glucose monitoring devices are shared between individuals, there is a risk of transmitting [MEDICAL CONDITIONS] other blood borne pathogens. Record review of the facility's diabetic infection control policy, dated (MONTH) (YEAR), showed the following information: -Purpose: To prevent the spread of infection; -Environmental surfaces, such as glucometers, will be decontaminated anytime contamination with blood or body fluids is suspected using an EPA (Environmental Protection Agency)-registered disinfectant; -Multiple resident-use glucometers will be cleaned and disinfected after each use using an EPA-registered disinfectant wipe according to the container label; -Annual training on diabetic infection control and glucometer use procedure will be completed. Record review of the cleaning and disinfecting procedures for the meter (Evencare G3 Meter (name brand) showed the following information: -The glucometer should be cleaned and disinfected between each resident. The following product, MEDLINE (name brand) Micro-Kill Bleach Germicidal Bleach Wipes, have been approved for cleaning and disinfecting the glucometer; -To disinfect the glucometer, clean the meter surface with one of the approved disinfecting wipes. -Allow the surface of the meter to remain wet at room temperature for the contact time listed on the wipe's directions for use; -Wipe meter dry or allow it to air dry. Record review of the Medline Microkill Germicidal Bleach wipes directions showed the following information: -A 30 second contact time is required to kill all of the bacteria [MEDICAL CONDITION] on the label except [MEDICAL CONDITION][MEDICATION NAME] (an opportunistic pathogenic (a pathogen (fungus is this case) that takes advantage of a weakened immune system) yeast that is a common member of the human gut flora. It can also survive outside the human body), which requires one minute. -[MEDICAL CONDITION] (D-Diff) (a bacteria that causes inflammation of the colon) requires three minutes. It can cause severe damage to the colon and can even be fatal. 1. Record review of Resident #3's face sheet (general resident information) showed the resident had a [DIAGNOSES REDACTED]. Record review of the resident's (MONTH) 2019 physician's orders [REDACTED]. -Dated 7/22/19: Humalog (name brand of insulin [MEDICATION NAME]) 100 units/milliliter (ml) per sliding scale. Administer subcutaneously (SC) (under the skin) three times a day before meals at 7:30 [NAME]M., 12:30 P.M., and 5:30 P.M. (Blood glucose checks would be performed in order to get blood glucose results during these scheduled times). Observation on 9/25/19, at 11:54 [NAME]M., showed Licensed Practical Nurse (LPN) A performed a blood glucose test on Resident #46 and carried the glucometer out of the room and placed it on a paper towel. LPN A wiped the glucometer off briefly with the 3-minute Microkill bleach wipe for approximately 3 seconds and replaced it on the paper towel. LPN A did not wrap the glucometer with the wipe and leave it wet for the recommended time frame. Observation on 9/25/19, at 12:00 P.M., showed LPN A performed the blood glucose test with the same improperly disinfected glucometer on Resident #3. LPN A carried the glucometer out of the resident's room and placed it on a paper towel on the medication cart. LPN A wiped the glucometer off with the three minute Microkill bleach wipe for approximately three seconds, and placed it on the paper towel on the medication cart. LPN A did not wrap the glucometer with the bleach wipe and leave it wet for the recommended time frame. Record review of Resident #11's face sheet showed the resident had a [DIAGNOSES REDACTED]. Record review of Resident #11's (MONTH) 2019 physician's orders [REDACTED]. -Dated 5/23/2019: [MEDICATION NAME] (name brand of insulin [MEDICATION NAME]) 100 units/ml per sliding scale. -Administer SC three times a day before meals at 7:30 [NAME]M., 12:30 P.M., and 5:30 P.M. Observation on 9/25/19, at 12:06 P.M., showed LPN A performed the blood glucose test with the same improperly disinfected glucometer on Resident #11. LPN A carried the glucometer out of the resident's room and placed it on a paper towel on the medication cart. LPN A wiped the glucometer off with the three minute Microkill bleach wipe for approximately three seconds, and placed it on the paper towel on the medication cart. LPN A placed the three minute Microkill bleach wipe over the glucometer in a tented position which did not make full contact with the glucometer to allow the surface to be left fully wet for the required time period. LPN A removed the wipe after approximately six minutes. During an interview on 9/26/19, at 11:04 [NAME]M., LPN B said the following: -He/she has worked at the facility for about [AGE] years. -The process for glucometer cleaning was to wipe them off first, then wrap them for two minutes. -LPN B doesn't know why, but that is just the process. LPN B was trained by the facility on the process. -Every so often, the facility updates staff on the process. The process is used to keep infection and germs away. -All nurses are responsible for glucometer cleaning. The facility uses the bleach wipes. -The glucometer is to be wrapped in order to keep it moist. -LPN B thinks the policy is kept in a book at the desk. During an interview on 9/26/19, at 11:09 [NAME]M., LPN A said he/she has worked at the facility for five years. For glucometer cleaning, the nurse completes the blood glucose testing, then wipes the glucometer off with the bleach wipe for two minutes, and then lets it air dry in case there is blood on it. The purpose is to kill all organisms for blood safety. He/she usually leaves the glucometer in the wipe and cleans it for two minutes, then lets it air dry. This is the protocol for two minutes to make sure the bleach kills germs on the glucometer. He/she thinks that is the facility policy now. He/she is pretty sure it says two minutes is required to kill everything on the container of wipes. He/she guesses they don't leave the glucometer wrapped for two minutes. It might be to air dry for two minutes. All nurses are responsible for glucometer cleaning. During an interview on 9/26/19, at 11:17 [NAME]M., the Director of Nursing said the following: -She expects nurses to use disinfectant wipes on the glucometers after use. -They go by what the container says. She believes it is two minutes. There is a red top one and a blue top one. -She believes they use the ones with bleach in them. -Nurses should wipe down the glucometer and wrap it afterwards. -The glucometer has to stay wet for the two minute time frame, then allow it to dry. -All nurses are responsible for glucometer cleaning, and in between uses. -If they don't go by the guidelines, the glucometers could be contaminated and spread infection.

Based on record review and interview, the facility failed to notify the resident and the resident's representative in writing of a transfer or discharge to the hospital, including the reason for the transfer for two residents (Resident #19 and Resident #48), and failed to provide the ombudsman (a resident advocate who provides support and assistance with problems and/or complaints regarding the facility) a copy of the notification for two residents (Resident #19 and Resident #48). A sample of 16 residents selected for review. The facility census was 47. Record review of the facility policy titled, Discharge/Transfer of Resident, dated (MONTH) (YEAR), showed the following information: -Obtain physician order for [REDACTED].>-Explain transfer and reason to the resident and/or representative and give copy of signed transfer or discharge notice to the resident and/or representative or person responsible for care. NOTE: If emergency transfer, transfer or discharge notice form may be completed later, but as soon as possible; -Explain and give a copy of bed hold form to resident and/or representative; -Complete transfer form, copy any portion of medical record necessary for care of resident; -Send original of transfer form and portions of medical record that was copied with resident; -Notify business office/ administration of discharge; -Notify dietary department of discharge. Record review of a blank Emergency Transfer Notice (provided by the facility when the facility policy for facility initiated emergency transfers to the hospital requested) showed the following information for staff to complete for emergency transfer to the hospital: -Date; -Resident name; -Responsible party/representative name and address; -This letter is to serve as your emergency notice of transfer to the hospital due to your need for urgent medical care which cannot be met in the facility. Federal regulation 42 CFR 483.15(c) (4)(i)(D) states in relevant part that Notice must be made as soon as practicable before transfer or discharge when an immediate transfer or discharge is required by the resident's urgent medical needs; -The effective date of transfer; -Ombudsman's information, telephone number, and email address; -Transfer location; -Administrator signature; -Ombudsman Jefferson City address and telephone number. Record review of a blank Transfer Notice Log (provided by the facility when the facility policy for facility initiated transfers requested) showed the following information for staff to complete for transfer notice to the ombudsman: -Regional Ombudsman Representative name, address; -Facility name; -Month of; -To be mailed/faxed to ombudsman monthly; -Date sent; -Resident name, transferred to, date of notice given, and notes. 1. Record review of Resident #19's nurses' notes showed the following information: -On 5/28/19, at 5:40 P.M., staff notified the nurse that the resident had been lethargic (appear to have little or no energy, drowsy or sluggish) and had moderate amount of nasal drainage and could not be woken up. Staff obtained the resident's vital signs, including temperature 103.6 degrees, pulse 86, respirations 21, and blood pressure 110/66. Staff contacted the physician to inform him/her of the resident's symptoms and reported the chest x-ray results. The physician gave an order to send the resident to the hospital for evaluation and treatment; -At 5:45 P.M., staff contacted the paramedics; -At 6:05 P.M., the paramedics loaded the resident into the ambulance and transported him/her to the hospital; -At 6:10 P.M., the staff called and left a message for the resident's family member regarding the resident; -On 5/31/19, at 2:00 P.M., the resident returned to the facility by transport in a wheelchair. He/she joked with the attendants. Staff checked the resident's vital signs and assessed the resident's blood pressure as 152/84, pulse 76, respirations 18, and temperature 98.4. Staff notified the physician of the resident's admission to the facility; -On 6/1/19, at 10:14 [NAME]M., staff called and left a message for the resident's family member regarding the readmission to the facility and antibiotic orders. Record review of the resident's medical record did not show any written notice sent to the resident or resident's responsible party or to the ombudsman regarding the transfer on 5/28/19. 2. Record review of Resident #48's nurses' notes showed the following information: -On 6/26/19, at 2:06 [NAME]M., staff notified the nurse practitioner (NP) of the resident's oxygen (O2) saturation (measurement of blood oxygen level) at 75% on 4 liters of oxygen. The resident's vital signs included: temperature 96.9, pulse 88, respirations 22-24, blood pressure 104/58. Staff administered a [MEDICATION NAME] treatment (a combination of medications used to treat symptoms such as wheezing and shortness of breath) at 1:30 [NAME]M. The NP stated to call the family member to see if he/she wanted the resident treated at the facility or at the hospital. Staff contacted the family member and notified him/her of the resident's condition. The family member said he/she would come to the facility and see the resident and make the decision at that time; -At 2:25 [NAME]M., the family member saw the resident and requested treatment at the hospital; -At 2:35 [NAME]M., staff called and requested ambulance service; -At 2:51 [NAME]M., staff gave the resident's paperwork to the ambulance personnel. The family member followed behind the ambulance to the emergency room . Record review of the resident's medical record did not show any written notice sent to the resident or resident's responsible party or to the ombudsman regarding the transfer on 6/26/19. 3. During an interview on 9/26/19, at 10:20 [NAME]M., the Director of Nursing (DON) said the nurses complete the discharge or transfer paperwork and give a copy to the resident and put a copy in the social service's box. The Ombudsman is sent a notice once a month of resident transfers and discharges. 4. During an interview on 9/26/19, at 10:35 [NAME]M., the Social Services Director (SSD) said the nurses give a copy of the transfer notice to the resident when being sent to the hospital and place a copy in the SSD box. He/she keeps these copies on file in the SSD office and sends a monthly notice to the Ombudsman. He/she did not receive a copy of the transfer notice for Resident #19 in (MONTH) or Resident #48 in June, therefore a notice was not sent to the Ombudsman. The SSD said sometimes the notice gets filed in the resident's chart and will go check. -At 10:56 [NAME]M., the SSD said he/she did not locate a copy of the hospital notice in either resident's chart.

Based on observation, interview, and record review, the facility failed to report an injury of unknown origin for two residents (Resident #31 and #15), failed to report an allegation of employee to resident abuse within the two hour time frame for one resident (Resident #8), and failed to report incidents of resident to resident verbal or physical abuse involving two residents (Resident #32 and #35). A sample of 17 residents were selected for review in a facility with a census of 62. Record review of the facility's policy showed an attachment to the policy titled, Guidelines for Facility Self-Reporting, dated (MONTH) 28, (YEAR), included the following information: -The facility must 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 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours, if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including the State Survey Agency) in accordance with State law through established procedures. 1. Record review of Resident #32's face sheet showed the following information: -admission date of [DATE], with a readmission date of [DATE]; -[DIAGNOSES REDACTED]. Record review of Resident #32's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument, completed by facility staff, dated 5/30/18, showed the following information: -Moderately cognitively impaired; -Verbal behaviors including yelling, screaming, threatening; -One person assist with transfers, dressing, eating, hygiene, and bathing. Record review of Resident #32's care plan last updated, 6/6/18, showed the following information: -Redirect as needed when the resident is verbally aggressive or threatening; -Maintain a calm approach; -At risk for adverse consequences related to receiving an antipsychotic and antidepressant medications; -Monitor medications for side effects and mood response. Observation on 8/7/18, at 4:20 P.M., showed Resident #32 awake in bed, holding his/her stomach. Record review of Resident #35's face sheet showed the following information: -admission date of [DATE]; -[DIAGNOSES REDACTED]. Record review of Resident #35's quarterly MDS, dated [DATE], showed the following information: -Moderately cognitively impaired; -The resident had behaviors that did not affect others; -Independent with transfers, dressing, grooming, and eating. Record review of Resident #35's care plan, last updated 6/29/18, showed the following information: -The resident wanders, and may wander into other resident rooms; -Approach from the front before redirecting; -Remove resident from other resident rooms and unsafe situations. Record review of Resident #32's (MONTH) (YEAR) nurses notes showed the following: -On 6/2/18, at 10:07 A.M. a nurse documented that around 9:00 A.M., the resident was in the hall outside his/her room and told the nurse an old woman swiped in front of his/her face. No other resident was close. About five minutes later, a certified nursing assistant (CNA)/certified medication technician (CMT) reported Resident #32 said Resident #35 struck him/her in the face. The nurse asked Resident #32 about the incident, and the resident denied he/she was hit, but said he/she said Resident #35 took a swipe at Resident #32. The nurse notified the resident's family member and the physician; -On 6/4/18, at 10:14 A.M., the Director of Nurses (DON) documented she reviewed camera footage from 6/2/18 8:30 A.M. to 9:30 A.M. as the resident reported another resident swiped at him/her with a cane. This was not observed on the camera footage. Resident #35 passed Resident #32 in the hall several times, but no contact was made. One time, Resident #32 stopped Resident #35 in the hall to talk to him/her, and Resident #35 turned Resident #32's wheel chair around and went in Resident #32's room, and an aide took over. Record review of Resident #35's (MONTH) (YEAR) nurses notes showed the following information: -On 6/2/18, at 12:06 P.M., a nurse documented Resident #35 may have hit Resident #32 with his/her cane. The nurse spoke with the resident who stated he/she did not touch the resident, but did swipe the cane near his/her face; During an interview on 8/9/18, at 10:00 A.M., Resident #32 said he/she did not remember being hit or swiped at by another resident. 2. Record review of Resident #8's quarterly MDS, dated [DATE], showed the following information: -Severe cognitive impairment; -Continuous inattention and disorganized thinking; -Delusional; -[DIAGNOSES REDACTED]. -Uses wheelchair for mobility with limited assistance of staff. Record review of the resident's progress notes, dated 4/23/2018, at 4:55 P.M., showed the (former) activity director (AD) documented the following information: -AD passed the resident in the hallway and the resident stopped the AD and informed the AD the resident had been dragged out of (his/her) room by the blonde aide, and hit repeatedly in (his/her) left arm. -AD will report to nursing and administration for further investigation. Record review of the resident's progress note, dated 4/23/2018, at 4:56 P.M., the DON documented the following information: -Behavior: Resident observed in another resident's room going through the resident's items; -An aide (CNA) entered the room, told the resident he/she was in the wrong room, and needed to leave the other resident's belongings alone; -The aide assisted the resident to leave the room via wheelchair; -As the aide propelled the resident in her wheelchair through the doorway, the resident grabbed the doorway; -The aide asked the resident to put his/her arms inside the wheelchair boundary and assisted him/her to do so; -The resident became very agitated with the aide; -The aide attempted to redirect the resident from going into another resident's room and going through his/her belongings; -Will monitor. Observation on 08/09/18, at 3:47 P.M., showed the resident wandering down the hallway in his/her wheelchair. During an interview on 08/09/18, at 4:30 P.M., Licensed Practical Nurse (LPN) S said the following: -The nurse said she worked part-time on the evening shift; -The resident came to him/her in the hall and complained of his/her arm hurting; -The resident said someone was rough with him/her, but the resident could not tell him/her who it was; he/she believed this was in (MONTH) of (YEAR); -He/she documented the resident's complaint and asked the resident if he/she needed a pain pill; -The resident denied the need for a pain pill; -He/she might not have reported the resident's accusations to anyone since it was evening shift, but instead probably just documented it in the resident's medical record. During an interview on 08/09/18, at 4:50 P.M., Nursing Assistant (NA) A said the following: -Approximately two months ago, while providing cares for the resident, he/she reported a man tried to pick him/her up and hurt his/her arm; -The NA reported the accusation to a night charge nurse; -He/she believed the nurse said this incident was already documented; -The off going shift had also reported the resident's accusation to the NA, but he/she could not remember who the aides were; -The NA did not see any visible injuries to the resident's skin. During an interview on 08/09/18, at 5:39 P.M., the DON said the following: -She remembered CNA B said the resident became upset with him/her when he/she caught the resident going into another resident's room; -The CNA reported as he/she attempted to propel the resident in a wheelchair through the doorway of the other resident's room, he/she asked the resident to put his/her arms inside the wheelchair, and the resident started yelling; -The CNA did not report the resident made an allegation of abuse; - The DON said the AD did not report anything about the incident to the DON; -The DON said she later saw the resident in the hallway and he/she acted like he/she normally does; -The DON said one minute, the resident is very calm; and then the next minute, he/she is confused; -The ADON and DON review the resident progress notes daily, but the DON did not recall seeing a note from the AD about the resident's accusation; -The DON said she would have suspended the AD for not reporting, suspended the CNA involved, and conducted an investigation; -The DON said the previous AD resigned in (MONTH) (YEAR). Observation on 08/13/18, at 10:46 A.M., a staff member redirected the resident out of another resident's room without incident. During an interview on 8/13/18, at 4:45 P.M., the Director of Nursing (DON) said the following: -If the resident made an allegation of abuse, staff should report the information to the DON; -The DON said she did not know of the resident's allegation of abuse until this past week. 3. Record review of Resident #31's face sheet showed the following information; -admitted to the facility on [DATE]; -[DIAGNOSES REDACTED]. Record review of Resident #31's quarterly MDS, dated [DATE], showed the following information: -Severe cognitive impairment; -[DIAGNOSES REDACTED].>-Required extensive assistance of two staff with personal hygiene and bed mobility; -Total dependence on two staff for transfers and toileting. Record review of the resident's progress note, dated 5/08/18, showed LPN T documented the following information: -At 5:42 P.M., resident observed to have an approximate 3.75 centimeters (cm) by 2.0 cm sized bump with dark blue discoloration to the right side of his/her scalp. Staff asked the resident what happened and the resident said it happened in the morning. The resident said he/she hit it on the bed. No further injuries noted to the resident. The resident denied being hit by anyone. The resident's family member currently in the facility and aware. Staff will continue to monitor. -At 8:06 P.M., the resident's nurse practitioner notified of the bump on the resident's head. No new orders received. Staff will continue to monitor. -At 9:10 P.M., the resident's family member called, tearful and stated he/she was concerned regarding the bump on the resident's head and no one had reported it previously. This nurse informed the family member the resident had been laying on his/her left side and the view of the bump was obstructed. The resident's family member requested the resident's physician see the resident tomorrow (5/09/18). The resident's family member is concerned that the resident bumped his/her head on the bed and that he/she denied anyone else in the room at the time. The nurse again reassured the family member the resident would be monitored for 72 hours and would be placed on the physician's callboard. Record review of the resident's progress notes, dated 5/09/18, showed the DON documented the following information: -At 9:53 A.M., the DON spoke with the resident regarding his/her blue discoloration to the top right of his/her head. The resident said he/she, hit (his/her) head on that pipe. The DON asked the resident what pipe he/she was talking about and the resident said, on that machine. The DON asked if he/she meant the machine that gets him/her in and out of bed and the resident responded yes. The resident said he/she bumped his/her head on the pipe which would be the bar on the Hoyer lift. The DON asked the resident if it hurt and the resident said, It did when I did it, but doesn't now. The DON asked the resident if anyone hurt him/her and he/she said, Oh no. The resident takes [MEDICATION NAME] (an anticoagulant) which increases bruising risk. Staff reminded to watch the resident when in the Hoyer lift so he/she does not lean forward and bump his/her head on the bar. Will monitor. -At 10:25 A.M., the DON spoke with the resident's family member. The resident's family member wanted to know what happened with the resident's bruise to 'forehead'. The DON corrected that the injury was on the top of his/her head and discussed what the resident told this nurse earlier. The resident's family member wanted to know why staff did not report the injury and the DON explained the staff might not have noticed it as they were moving the resident and the machine also and it might not have been an obvious bump to the bar. The resident's family member said he/she did not notice the injury at around 4:00 P.M., but noticed the injury at suppertime. The resident's family member said he/she was present for the Hoyer transfer to get out of bed for supper and did not notice anything out of the ordinary. Record review of the resident's physician visit, dated 5/09/18, showed the following information: -The resident seen today on a follow-up visit; -Recently, staff were trying to transfer the resident from the bed to the wheelchair using a Hoyer lift, unfortunately he/she hit his/her right frontal region. The resident has developed a hematoma. The resident does relate some pain. The resident has been undergoing routine neurological checks. The resident is having some discomfort over the right frontal and parietal region; -Demonstrates a small goose egg over the right frontal and parietal region. Area is mildly to moderately tender; -Resident to receive routine Tylenol twice daily for the next two days, staff to put an ice pack on the hematoma, and staff to continue the neurological checks. Observation on 08/07/18, at 11:03 A.M., the resident sat in his/her room in a high back wheelchair with elevated foot rests. The resident sat on a Hoyer lift pad. The resident had no obvious signs of injuries or distress. During an interview on 8/10/18, at 10:15 A.M., the resident's responsible party said he/she arrived at the facility on 5/08/18 to find the resident sitting in the dining room. The resident had a raised dark purple bruise to his/her head, the approximate size of a half dollar. The resident informed his/her family member the area really hurt. The family member said he/she was concerned because staff had not reported the injury to the family member. The resident said he/she hit his/her head on the headboard, but the family member did not see how that could have occurred. The family member said he/she spoke to the DON. The DON said she would write up the injury as the resident reported it, but the family member did not think the resident remembered what happened. The DON later said the resident hit his/her head on a Hoyer lift (a mechanical lift used to transfer residents from one location to another, such as bed to wheelchair), but the family member did not see how that could have occurred without staff being aware of the injury. The family member said the resident suffers from dementia and has memory problems. During an interview on 8/13/18, at 3:22 P.M., LPN T said the following: -The nurse said he/she remembered discussing the resident's head injury with the resident's family member, but did not remember the specifics of the conversation; -The resident did not know who injured him/her; -No staff reported the resident's head injury; -The facility could not determine which staff was involved; -The resident could have injured him/her self. During an interview on 8/13/18, at 4:45 P.M., the DON said the following: -On 5/08/18, one of the nurses on duty observed the resident had a bruise on his/her forehead at suppertime. The resident's family member was in the dining room at suppertime. The resident initially said he/she hit his/her head on a pipe, but after talking to him/her further, the DON said she figured out it was the Hoyer lift. Staff did not see the bruise to the resident's forehead because the resident was in bed with his/her face turned away prior to supper. No staff witnessed the cause of the resident's injuries, but staff are not watching his/her head during the Hoyer lift transfers. The DON said the facility did not report the incident to DHSS because the resident said the injuries were from the Hoyer lift. 4. Record review of Resident #15's face sheet showed the following information: -Resident admitted to the facility on [DATE]; -[DIAGNOSES REDACTED]. Record review of Resident #15's quarterly MDS, dated [DATE], showed the following information: -Severe cognitive impairment; -Unclear speech; -Required extensive assistance of one staff with bed mobility and transfers; -Required extensive assistance of two staff with dressing, toileting and personal hygiene. Record review of the resident's progress notes, dated 5/13/18, at 9:45 P.M., showed LPN F documented the following: -A CNA notified this nurse the resident had a discoloration on his/her right inner thigh. The nurse observed a discoloration approximately 3 centimeters (cm) wide by 9 cm long to the resident's right inner thigh. The color of the discoloration varied in multiple shades of purple to yellow. The nurse asked the resident what had happened, the resident denied any harm occurring to self, staff or family. The resident did not know when or how this discoloration happened. The nurse notified Registered Nurse (RN) supervisor H, about the discoloration. The LPN notified the oncoming nurse of the situation during change of shift report, The LPN told the night nurse to report to the day shift charge nurse, so he/she could notify the resident's family and physician in the morning. Record review of the resident's progress notes, dated 5/14/18, at 3:11 A.M., showed LPN E documented the following: -Discoloration noted to the resident's right inner thigh. The center of the discoloration is dark purple with yellow surrounding the outer edges. The resident denied pain or discomfort. Nurse will continue to monitor. Record review of the resident's progress note, dated 5/14/18, at 9:40 A.M., the DON documented the following information: -The DON, along with the charge nurse, spoke with the resident about the discoloration to his/her right inner thigh; -The discoloration is the location that staff hold the resident's leg to perform pericare; -The resident has right sided weakness from [MEDICAL CONDITION](stroke) and the muscle is tight which staff must hold firmly when performing care to keep leg abducted (to move away from the other leg); -The resident confirms this is the area they hold his/her legs when performing incontinent care; -The resident denied anyone hurting him/her; -The resident takes aspirin that can cause increased bruising risk; -The resident remained one assist of staff with transfers; -Staff encouraged to be gentle in holding the resident's leg; -Will monitor. Observation on 08/09/18, at 10:02 A.M., showed CNA Q assisted the resident to the bathroom in his/her wheelchair. The resident did not have any obvious bruising to his/her skin. The resident tolerated the assistance well and showed no signs of anxiety with cares. During an interview on 08/09/18, at 4:30 P.M., LPN S said the following: -The nurse remembered the resident having bruises on his/her inner thigh; -The nurse said he/she and the DON examined the resident's bruises together; -The nurse did not know if anyone figured out the cause of the resident's bruises; -The resident becomes upset very easily and is resistive to cares; -The resident gets upset with his/her self due to communication difficulties; -The nurse said he/she believed he/she notified the resident's family, but could not remember if he/she notified the resident's physician of the bruising. During an interview on 8/13/18, at 12:47 P.M., LPN F said the following: -CNAs came to the nurse at the end of the evening shift one night and reported the resident's inner thigh bruises; -The nurse said he/she notified the on call nurse, (RN H) of the bruising; -The nurse reported to the oncoming night nurse and informed him/her to pass the information onto the day shift the next day; -The nurse said the bruising was different shades of purple; -The nurse said the resident did not know what happened; -After the incident, the DON said the resident's bruising occurred when staff held the resident over on his/her side for cares; -The nurse said the facility could assume the resident's bruising came from staff holding the resident over onto his/her side; -The nurse said because of the time of night, he/she did not report the bruising to the physician or the resident's family, but instead passed it on for the day shift to do so the next day. During an interview on 8/13/18, at 1:27 P.M., RN H said the following: -The RN said he/she worked at the facility as a weekend supervisor and worked as the RN on-call for the facility one weekend per month; -The RN said he/she remembered getting a call from one of the nurses about the resident's inner thigh bruise; -The RN said the charge nurse thought maybe the bruise was from the resident's wheelchair armrest, but the cause was unknown; -The RN said he/she asked the charge nurse on duty if he/she asked the resident if anyone harmed him/her and the resident replied no. If the resident had said yes, the RN would have called the ADON or DON; -The bruise was oblong shaped to the resident's inner thigh; -The RN said the resident's bruise did not look like a hand print; -The RN said the bruise was an injury of unknown origin and he/she probably notified the ADON or DON. During an interview on 8/13/18, at 3:22 P.M., LPN T said the following: -The resident has communication difficulties, which frustrate the resident; -The resident does not always tell the truth; -The resident sometimes says yes, when she means no; -The nurse said he/she has heard the resident and a family member bicker, and the resident hits at the family member; During an interview on 8/13/18, at 4:45 P.M., the DON said the following: -An evening charge nurse, LPN F, documented in the nurses' progress notes that aides notified him/her of the resident's bruises; -The evening charge nurse reported the bruising to the RN supervisor on call; -The facility staff then notified the DON the next day on 5/14/18 about the resident's bruising; -The resident denied anyone abusing him/her; -The resident can answer questions appropriately and the facility trusts what the resident says; -The DON determined the resident was not abused based on her interview with the resident; -The resident is combative at times; -The DON determined the bruising to the inner thigh was caused by staff holding the resident's leg during personal cares; -The DON said the facility did not report the injuries to DHSS. 5. During an interview on 8/9/18, at 4:17 P.M., NA A said all incidents are reported to the charge nurse. 6. During an interview on 8/10/18, at 10:07 A.M., LPN E said incidents are reported to the DON or the RN on call. 7. During an interview on 8/10/18, at 1:41 P.M., LPN C said anything out of the ordinary is reported to the DON or RN on call. 8. During an interview on 8/10/18, at 1:50 P.M., CNA D said any incidents are reported to the charge nurse. 9. During an interview on 8/13/18, at 12:45 P.M., LPN F said any incidents are reported up the chain of command and to the hotline. 10. During an interview on 8/13/18, at 4:45 P.M., the DON said any abuse or injuries of unknown origin should be reported within 2 hours. The facility had been completing their investigation before calling, but now knew to report within two hours as the facility investigates. Any employee involved should be immediately suspended pending the investigation. 11. During an interview on 8/13/18, at 6:20 P.M., the administrator said all allegations of abuse and injuries on unknown origin should be reported within 2 hours. The facility is obligated to report, then begin an investigation. Any employees accused would be immediately suspended. Complaint# MO 841

Based on observation, interview, and record review, the facility failed to investigate an injury of unknown origin for two residents (Resident #31 and #15), failed to investigate an allegation of employee to resident abuse for one resident (Resident #8), and failed to investigate incidents of resident to resident verbal or physical abuse involving two residents (Resident #32 and #35). A sample of 17 residents were selected for review in a facility with a census of 62. Record review of the facility's policy showed an attachment to the policy titled, Guidelines for Facility Self-Reporting, dated (MONTH) 28, (YEAR), included the following information: -The facility must have evidence that all alleged violations are thoroughly investigated, and must prevent further potential abuse, neglect or exploitation or mistreatment while the investigation is in progress; -The facility must report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with Federal regulation and State law, including to the State Survey Agency, within 5 working days of the incident, if the alleged violation is verified appropriate corrective action must be taken. 1. Record review of Resident #32's face sheet showed the following information: -admission date of [DATE], with a readmission date of [DATE]; -[DIAGNOSES REDACTED]. Record review of Resident #32's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument, completed by facility staff, dated 5/30/18, showed the following information: -Moderately cognitively impaired; -Verbal behaviors including yelling, screaming, threatening; -One person assist with transfers, dressing, eating, hygiene, and bathing. Record review of Resident #32's care plan last updated, 6/6/18, showed the following information: -Redirect as needed when the resident is verbally aggressive or threatening; -Maintain a calm approach; -Resident at risk for adverse consequences related to receiving an antipsychotic and antidepressant medications; -Monitor medications for side effects and mood response. Record review of Resident #35's face sheet showed the following information: -admission date of [DATE]; -[DIAGNOSES REDACTED]. Record review of Resident #35's quarterly MDS, dated [DATE], showed the following information: -Moderately cognitively impaired; -The resident had behaviors that did not affect others; -Independent with transfers, dressing, grooming, and eating. Record review of Resident #35's care plan, last updated 6/29/18, showed the following information: -The resident wanders, and may wander into other resident rooms; -Approach from the front before redirecting; -Remove resident from other resident rooms and unsafe situations. Record review of Resident #32's (MONTH) (YEAR) nurses' notes showed the following information: -On 6/2/18, at 10:07 A.M., a nurse documented that around 9:00 A.M., the resident was in the hall outside his/her room and told the nurse an old woman swiped in front of his/her face. No other resident was close. About five minutes later, a certified nursing assistant (CNA)/certified medication technician (CMT) reported Resident #32 said Resident #35 struck him/her in the face. The nurse asked Resident #32 about the incident, and the resident denied he/she was hit, but said Resident #35 took a swipe at him/her. The nurse notified the resident's family member and the physician. -On 6/4/18, at 10:14 A.M., the Director of Nursing (DON) documented she reviewed camera footage from 6/2/18, 8:30 AM to 9:30 AM as the resident reported another resident swiped at him/her with a cane. This was not observed on the camera footage. Resident #35 passed Resident #32 in the hall several times, but no contact was made. One time, Resident #32 stopped Resident #35 in the hall to talk to him/her, and Resident #35 turned Resident #32's wheel chair around and went in Resident #32's room, and an aide took over. Record review of Resident #35's (MONTH) (YEAR) nurses' notes showed the following information: -On 6/2/18, at 12:06 P.M., a nurse documented Resident #35 may have hit Resident #32 with his/her cane. The nurse spoke with the resident who stated he/she did not touch the resident, but did swipe the cane near his/her face. Observation on 8/7/18, at 4:20 P.M., showed Resident #32 awake in bed. During an interview on 8/9/18, at 10:00 A.M., Resident #32 said he/she did not remember being hit or swiped at by another resident. 2. Record review of Resident #8's quarterly MDS, dated [DATE], showed the following information: -Severe cognitive impairment; -Continuous inattention and disorganized thinking; -Delusional; -[DIAGNOSES REDACTED]. -Extensive assistance of one staff with bed mobility, transfers, toileting, and personal hygiene; -Uses wheelchair for mobility with limited assistance of staff. Record review of the resident's progress notes, dated 4/23/2018, at 4:55 P.M., showed the (former) activity director (AD) documented the following information: -AD passed the resident in the hallway and the resident stopped the AD and informed the AD the resident had been dragged out of (his/her) room by the blonde aide, and hit repeatedly in (his/her) left arm. -AD will report to nursing, and administration for further investigation. Record review of the resident's progress note, dated 4/23/2018, at 4:56 P.M., showed the DON documented the following information: -Behavior: resident observed in another resident's room going through the resident's items; -An aide (CNA) entered the room, told the resident he/she was in the wrong room, and needed to leave the other resident's belongings alone; -The aide assisted the resident to leave the room via wheelchair; -As the aide propelled the resident's wheelchair through the doorway, the resident grabbed the doorway; -The aide asked the resident to put his/her arms inside the wheelchair boundary and assisted him/her to do so; -The resident became very agitated with the aide; -The aide attempted to redirect the resident from going into another resident's room and going through their belongings; -Will monitor. Observation on 08/09/18, at 3:47 P.M., showed the resident wandering down the hallway in his/her wheelchair. During an interview on 08/09/18, at 3:54 P.M., the resident's responsible party said the following: -He/she never received a call from the facility regarding the resident making any accusations of staff or resident mistreatment; -The resident never said anything to the responsible party about resident or staff mistreatment; -The resident has been progressively declining. During an interview on 08/09/18, at 4:30 P.M., Licensed Practical Nurse (LPN) S said the following: -The nurse said he/she worked part-time on the evening shift; -The resident came to him/her in the hall and complained of his/her arm hurting; -The resident said someone was rough with him/her, but he/she was not able to tell him/her who it was; -He/she believed this was in (MONTH) of (YEAR); -He/she documented the resident's complaint and asked the resident if he/she needed a pain pill; -The resident denied the need for a pain pill; -He/she might not have reported the resident's accusations to anyone since it was evening shift, but instead probably just documented it in the resident's medical record. During an interview on 08/09/18, at 4:50 P.M., Nursing Assistant (NA) A said the following: -Approximately two months ago, while providing care for the resident, he/she reported a man tried to pick him/her up and hurt his/her arm; -The NA reported the accusation to a night charge nurse; -The NA said he/she believed the nurse said this incident was already documented; -The off going shift had also reported the resident's accusation to the NA, but he/she could not remember who the aides were; -The NA did not see any visible injuries to the resident's skin. During an interview on 08/09/18, at 5:39 P.M., the DON said the following: -She remembered CNA B said the resident became upset with him/her when he/she caught the resident going into another resident's room; -The CNA reported as he/she attempted to propel the resident in a wheelchair through the doorway of the other resident's room, he/she asked the resident to put his/her arms inside the wheelchair, and the resident started yelling; -The CNA did not report the resident made an allegation of abuse; -The DON said the AD did not report anything about the incident to the DON; -The DON said she later saw the resident in the hallway and he/she acted like she normally does; -The DON said one minute, the resident is very calm; and then the next minute, he/she is confused; -The assistant director of nursing (ADON) and DON review the resident progress notes daily, but the DON did not recall seeing a note from the AD about the resident's accusation; -The DON said if she saw the note from the AD about the resident's accusation, she would investigate it -The DON said she would have suspended the AD for not reporting, suspended the CNA involved, and conducted an investigation; -The DON said the previous AD resigned in (MONTH) (YEAR); -The DON said the facility did not investigate the resident's allegation of abuse. During an interview on 8/10/18, at 2:45 P.M., CNA B said the following: -On 4/23/18, he/she saw Resident #8 in another resident's room; -The CNA entered the room to assist the resident out of the room; -The CNA said he/she told the resident it was not his/her room; -The resident became agitated and did not want to leave the room; -The resident raised his/her arms and the CNA placed his/her open hands on the resident's bilateral arms and pushed the resident's arms down, so the resident's elbows would be inside of the wheelchair armrests to get through the doorway; -The CNA said he/she was eventually able to get the resident out of the room; -The AD came to the CNA a few minutes later and said the resident accused the CNA of dragging him/her out of the room and hurting his/her arm; -The AD said she would document the allegation in the resident's medical record; -He/she informed the DON of the situation and that the resident was mad at the CNA; -The CNA said he/she notified the charge nurse, LPN Q, of the situation; -The resident constantly wandered up and down the halls, and opened other residents' rooms; -The CNA said the resident refuses cares. Observation on 08/13/18, at 10:46 A.M., showed a staff member redirected the resident out of another resident's room without incident. During an interview on 8/13/18, at 3:22 P.M., LPN T said the following: -The nurse did not know of the resident's accusation of abuse; -He/she would probably report the resident's allegations of abuse, even though the resident was confused. During an interview on 8/13/18, at 4:45 P.M., the DON said the following: -If the resident made an allegation of abuse, staff should report the information to the DON; -The DON said she did not know of the resident's allegation of abuse until this past week; -The DON said the facility did not investigate the resident's allegation of abuse. 3. Record review of Resident #31's face sheet showed the following information: -admitted to the facility on [DATE]; -[DIAGNOSES REDACTED]. Record review of the resident's quarterly MDS, dated [DATE], showed the following information: -Severe cognitive impairment; -[DIAGNOSES REDACTED].>-Required extensive assistance of two staff with personal hygiene and bed mobility; -Total dependence on two staff for transfers and toileting; -Used wheelchair for mobility. Record review of the resident's progress note, dated 5/08/18, showed LPN T documented the following information: -At 5:42 P.M., resident observed to have an approximate 3.75 centimeters (cm) by 2.0 cm sized bump with dark blue discoloration to the right side of his/her scalp. Staff asked the resident what happened and the resident said it happened in the morning. The resident said he/she hit it on the bed. No further injuries noted to the resident. The resident denied being hit by anyone. The resident's family member currently in the facility and aware. Staff will continue to monitor. -At 8:06 P.M., the resident's nurse practitioner notified of the bump on the resident's head. No new orders received. Staff will continue to monitor. -At 9:10 P.M., the resident's family member called, tearful and stated he/she was concerned regarding the bump on the resident's head and no one had reported it previously. This nurse informed the family member the resident had been laying on his/her left side and the view of the bump was obstructed. The resident stated, I am fine. The resident appeared agitated with neuro checks and had his/her eyes closed tightly to prevent the nurse from checking. The nurse eventually checked the resident's eyes and the resident's pupils were equal and reactive to light and accommodation. The resident's family member requested the resident's physician see the resident tomorrow (5/09/18). The resident's family member is concerned that the resident bumped his/her head on the bed and that he/she denied anyone else in the room at the time. The nurse again reassured the family member the resident would be monitored for 72 hours and would be placed on the physician's callboard. Record review of the resident's progress note, dated 5/09/18, showed the DON documented the following information: -At 9:53 A.M., the DON spoke with the resident regarding his/her blue discoloration to the top right of his/her head. The resident said he/she hit (his/her) head on that pipe. The DON asked the resident what pipe he/she was talking about and the resident said, on that machine. The DON asked if he/she meant the machine that gets him/her in and out of bed and the resident responded yes. The resident said he/she bumped his/her head on the pipe which would be the bar on the Hoyer lift. The DON asked the resident if it hurt and the resident said, It did when I did it, but doesn't now. The DON asked the resident if anyone hurt him/her and he/she said, oh no. The resident takes [MEDICATION NAME] (an anticoagulant) which increases bruising risk. Staff reminded to watch the resident when in the Hoyer lift so he/she does not lean forward and bump his/her head on the bar. Will monitor. -At 10:25 A.M., the DON spoke with the resident's family member. The resident's family member wanted to know what happened with the resident's bruise to 'forehead'. The DON corrected that the injury was on the top of his/her head and discussed what the resident told this nurse earlier. The DON educated the resident's family member that the resident is on [MEDICATION NAME] and it does not take much pressure to cause bleeding and he/she agreed. The family member asked if the DON trained the staff on the use of the Hoyer lift and the DON explained she did. The DON discussed how the resident said he/she bumped his/her head on the pipe. The DON informed the family member that the bar swings on the Hoyer lift and the resident could have easily bumped his/her head while in midair. The resident's family member wanted to know why staff did not report the injury and the DON explained the staff might not have noticed it as they were moving the resident and the machine also and it might not have been an obvious bump to the bar. The resident's family member said he/she did not notice the injury at around 4:00 P.M., but noticed the injury at suppertime. The resident's family member said he/she was present for the Hoyer transfer to get out of bed for supper and did not notice anything out of the ordinary. The DON again reiterated the resident said no one hurt him/her. The resident's family member said he/she did not think that anyone intentionally hurt the resident or was being mean, but wanted to make sure training was done with staff on the use of the Hoyer lift. The DON assured the family member she did training. Record review of the resident's physician visit, dated 5/09/18, showed the following information: -The resident seen today on a follow-up visit. -Recently staff transferred the resident from the bed to the wheelchair using a Hoyer lift, unfortunately he/she hit his/her right frontal region. The resident has developed a hematoma. The resident does relate some pain. The resident has been undergoing routine neurological checks. The resident is having some discomfort over the right frontal and parietal region; -Demonstrates a small goose egg over the right frontal and parietal region. Area is mildly to moderately tender; -Resident to receive routine Tylenol twice daily for the next two days, staff to put an ice pack on the hematoma, and staff to continue the neurological checks. Observation on 08/07/18, at 11:03 A.M., showed the resident sat in his/her room in a high back wheelchair with elevated foot rests. The resident sat on a Hoyer lift pad. The resident had no obvious signs of injuries or distress. During an interview on 8/10/18, at 10:15 A.M., the resident's responsible party said he/she arrived at the facility on 5/08/18 to find the resident sitting in the dining room. The resident had a raised dark purple bruise to his/her head, the approximate size of a half dollar. The resident informed his/her family member the area really hurt. The family member said he/she was concerned because staff had not reported the injury to the family member. The resident said he/she hit his/her head on the headboard, but the family member did not see how that could have occurred. The family member said he/she spoke to the DON. The DON said she would write up the injury as the resident reported it, rather than investigate. The family member did not think the resident remembered what happened. The DON later said the resident hit his/her head on a Hoyer lift (a mechanical lift used to transfer residents from one location to another, such as bed to wheelchair), but the family member did not see how that could have occurred without staff being aware of the injury. The family member said the resident suffers from dementia and has memory problems. During an interview on 8/13/18, at 3:22 P.M., LPN T said the following: -The nurse said he/she remembered discussing the resident's head injury with the resident's family member, but did not remember the specifics of the conversation; -The resident did not know who injured him/her; -No staff reported the resident's head injury; -The facility could not determine which staff was involved; -The resident could have injured him/her self. During an interview on 8/13/18, at 4:45 P.M., the DON said the following: -On 5/08/18, one of the nurses on duty observed the resident had a bruise on his/her forehead at suppertime. The resident's family member was in the dining room at suppertime. The resident initially said he/she hit his/her head on a pipe, but after talking to him/her further, the DON said she figured out it was the Hoyer lift. Newly hired nurses' aides worked that evening, so the DON provided education on the proper use of the Hoyer lift. The day shift or evening shift nurses' aides did not report any problems with transfers. The DON said she spoke to one of the aides from day shift and one from evening shift and neither of them noticed any problems with the resident's transfers. The resident said no one hurt him/her, so the DON ruled out abuse. The nursing staff did not record neurological checks for the resident. The DON said the facility staff probably should have done neurological checks on the resident. Staff did not see the bruise to the resident's forehead because the resident was in bed with his/her face turned away prior to supper. No staff witnessed the cause of the resident's injuries, but staff are not watching his/her head during the Hoyer lift transfers. The DON said the facility did not report the incident to DHSS because the resident said the injuries were from the Hoyer lift. The DON said she did not do a full investigation into the resident's injury because she believed the Hoyer lift caused the injury. 4. Record review of Resident #15's face sheet showed the following information: -Resident admitted to the facility on [DATE]; -[DIAGNOSES REDACTED]. Record review of Resident #15's quarterly MDS, dated [DATE], showed the following information: -Severe cognitive impairment; -Unclear speech; -Required extensive assistance of one staff with bed mobility and transfers; -Required extensive assistance of two staff with dressing, toileting and personal hygiene. Record review of the resident's progress note, dated 5/13/18, at 9:45 P.M., showed LPN F documented the following: -A CNA notified this nurse that this resident has a discoloration on his/her right inner thigh. The nurse observed a discoloration approximately 3 centimeters (cm) wide by 9 cm long to the resident's right inner thigh. The color of the discoloration varies in multiple shades of purple to yellow. The nurse asked the resident what had happened, the resident denied any occurring harm to self, staff or family. The resident did not know of when or how this discoloration happened. The nurse notified the Registered Nurse (RN) supervisor H, about the discoloration. The LPN notified the oncoming nurse of the situation during change of shift report, The LPN told the night nurse to report to the day shift charge nurse, so he/she could notify the resident's family and physician in the morning. Record review of the resident's progress note, dated 5/14/18, at 3:11 A.M., showed LPN E documented the following information: -Discoloration noted to the resident's right inner thigh. The center of the discoloration is dark purple with yellow surrounding the outer edges. The resident denied pain or discomfort. Nurse will continue to monitor. Record review of the resident's progress note, dated 5/14/18, at 9:40 A.M., showed the DON documented the following information: -The DON, along with the charge nurse, spoke with the resident about the discoloration to his/her right inner thigh; -The discoloration is the location that staff hold the resident's leg to perform pericare; -The resident has right sided weakness from [MEDICAL CONDITION](stroke) and the muscle is tight which staff must hold firmly when performing care to keep leg abducted (to move away from the other leg); -The resident confirms this is the area they hold his/her legs when performing incontinent care; -The resident denied anyone hurting him/her; -The resident takes aspirin that can cause increased bruising risk; -The resident remains one assist of staff with transfers; -Staff encouraged to be gentle in holding the resident's leg; -Will monitor. Record review of the resident's progress note, dated 5/14/18, at 9:42 A.M., showed the DON documented she notified the resident's family member of the resident's discoloration. Record review of the resident's progress note, dated 5/14/18, at 12:20 P.M., showed LPN S documented he/she notified the resident's physician of the discoloration. Record review of the resident's progress note, dated 5/17/18, showed the DON documented the following information: -Weekly event meeting, interdisciplinary meeting discussed resident's skin issue from 5/13/18; -Discoloration noted to the resident's right inner thigh from staff holding the resident's leg for incontinent care as right leg is affected [MEDICAL CONDITION] muscle is tight and requires staff to hold leg to perform care; -Resident denies anyone hurting him/her; -Restorative nursing assistant plan to be set up for resident; -Staff reminded to hold the resident's leg gently and carefully to avoid discoloration; -Will monitor. Record review of the resident's care plan, revised on 5/18/18, showed the following information: -Never or rarely capable of making daily decisions related [MEDICAL CONDITION] resultant deficits in verbal and functional ability; -At risk for bleeding related to anticoagulant therapy of aspirin; -Required moderate to maximum assistance of 1-2 staff with mobility, transfers, ambulation, personal hygiene, self cares, and toileting; -Resident had difficulty making self understood related to [MEDICAL CONDITION] post history of cerebral infarction, and had minimal receptive communication deficit. During an interview on 08/09/18, at 9:42 A.M., CNA Q said the resident is anxious when new people take care of him/her or when men care for him/her. During an interview on 08/09/18, at 9:43 A.M., NA A said he/she worked at the facility for about three months and the resident was just now getting comfortable with him/her assisting the resident with care. Observation on 08/09/18, at 10:02 A.M., showed CNA Q assisted the resident to the bathroom in his/her wheelchair. The resident did not have any obvious bruising to his/her skin. The resident tolerated the assistance well and showed no signs of anxiety with cares. During an interview on 08/09/18, at 4:30 P.M., LPN S said the following: -The nurse remembered the resident having bruises on his/her inner thigh; -The nurse said he/she and the DON examined the resident's bruises together; -The nurse did not know if anyone figured out the cause of the resident's bruises; -The resident becomes upset very easily and is resistive to cares; -The resident gets upset with him/her self due to communication difficulties; -The nurse believed he/she notified the resident's family, but could not remember if he/she notified the resident's physician of the bruising. During an interview on 08/09/18, at 4:50 P.M., NA A said the following: -He/she worked at the facility for approximately 2 and 1/2 months; -For the first two months he/she worked, the resident appeared scared and did not want the NA caring for him/her; -The resident would point at the door or slap at him/her; -In general, the resident does not like men taking care of him/her. During an interview on 8/13/18, at 12:47 P.M., LPN F said the following: -CNAs came to the nurse at the end of the evening shift one night and reported the resident's inner thigh bruises; -The nurse said he/she notified the on call nurse, RN H of the bruising; -The nurse reported to the oncoming night nurse and informed him/her to pass the information onto the day shift the next day; -The nurse said the bruising was different shades of purple; -The nurse said the resident did not know what happened; -After the incident, the DON said the resident bruising occurred when staff held the resident over on his/her side for cares; -The nurse said the facility could assume the resident's bruising came from staff holding the resident over onto his/her side; -The nurse said because of the time of night, he/she did not report the bruising to the physician or the resident's family, but instead passed it on for the day shift to do so the next day. During an interview on 8/13/18, at 1:27 P.M., RN H said the following: -The RN said he/she worked at the facility as a weekend supervisor and worked as the RN on-call for the facility one weekend per month; -The RN said he/she remembered getting a call from one of the nurses about the resident's inner thigh bruise; -The RN said the charge nurse thought maybe the bruise was from the resident's wheelchair armrest, but the cause was unknown; -The RN said he/she asked the charge nurse on duty if he/she asked the resident if anyone harmed him/her and the resident replied no. If the resident had said yes, the RN would have called the ADON or DON; -The bruise was oblong shaped to the resident's inner thigh; -The RN said the resident's bruise did not look like a hand print; -The RN said the bruise was an injury of unknown origin and he/she probably notified the ADON or DON. During an interview on 8/13/18, at 3:22 P.M., LPN T said the following: -The resident has communication difficulties, which frustrate the resident; -The resident does not always tell the truth; -The resident sometimes says yes, when she means no; -The nurse said he/she has heard the resident and a family member bicker, and the resident hits at the family member; During an interview on 8/13/18, at 4:45 P.M., the DON said the following: -An evening charge nurse, LPN F, documented in the nurses' progress notes that aides notified him/her of the resident's bruises; -The evening charge nurse reported the bruising to the RN supervisor on call; -The facility staff then notified the DON the next day on 5/14/18 about the resident's bruising; -The resident denied anyone abusing him/her; -The resident can answer questions appropriately and the facility trusts what the resident says; -The DON determined the resident was not abused based on her interview with the resident; -The resident is combative at times; -The DON determined the bruising to the inner thigh was caused by staff holding the resident's leg during personal cares; -The DON said the facility did not report the injuries to DHSS; -The facility had not conducted any abuse investigations in the last three months. 5. During an interview on 8/13/18, at 4:45 P.M., the DON said the facility had been conducting investigations to determine if abuse, neglect, or injuries of unknown origin had occurred or could be explained before calling in to the state agency or hotline. The facility had not completed a full investigation reported to the state agency since (MONTH) (YEAR). The facility would now call all incidents in within the two hours, and conduct a formal investigation and submit the results within 5 days. 6. During an interview on 8/13/18, at 6:20 P.M., the administrator said the facility would call incidents involving abuse or injuries of unknown origin in within 2 hours. The facility had not completed a full investigation reported to the state agency since March. The facility had been making a predetermination as to what needed to be called in to the state agency. With the help of nursing, the investigation would be submitted within 5 days. Complaint # MO 841

Based on observation, interview, and record review, the facility failed to assess, identify, and provide an appropriate fitting wheelchair with appropriate footrest to support one resident's (Resident #38) feet comfortably decreasing the potential for discomfort and injury, when he/she sat in the wheelchair out of a sample of 17 residents selected for review. The facility census was 62 residents. 1. Record review of Resident #38's face Sheet showed the following information: -admission date of [DATE]; -[DIAGNOSES REDACTED].>-[MEDICAL CONDITION] both eyes; -Anxiety disorder; -Unspecified acute [MEDICAL CONDITION] (inflammation or infection of the membrane that lines the eyelid; -Stage II pressure ulcer (partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough (dead tissue)) of unspecified buttock; -Stage IV pressure ulcer (full thickness tissue loss with exposed bone, tendon, or muscle. Slough or eschar (dead tissue) may be present on some parts of the wound) of right buttock; -Other chronic pain, gas pain; -Diabetes mellitus with diabetic [MEDICAL CONDITION] (nerve damage due to diabetes); -Ventral hernia without obstruction (a bulge of tissues through an opening; -Ulcerative chronic proctitis (Inflammation of the rectum). Record review of the resident's annual Minimum Data Set (MDS), a federally mandated assessment instrument, completed by facility staff, dated 6/11/18, showed the following information: -Cognitively intact; -No vision or severely impaired vision ([MEDICAL CONDITION] in both eyes); -Ability to understand; -No disorganized thinking; -Ability to express ideas and wants to others, and understood others; -Total dependence upon two plus persons to assist activities of daily living (ADL's) for bed mobility, transfers, dressing, toilet use and personal hygiene; -Total dependence on two plus persons to assist with transfer between surfaces including to or from: bed, chair, wheelchair, and standing position; -The resident used a wheelchair as the primary mode of ambulation with the assistance of one staff member. Record review of the resident's care plan, dated 7/3/18, showed the following information: -Resident's ability to independently complete activities of daily living such as transfer, dress, eat, toilet, use of wheel chair, bed mobility and to maintain personal hygiene had deteriorated; -History of fractured femur; -He/she is chronically hindered by [MEDICAL CONDITION]; -Blind in both eyes. -Weight bearing as tolerated to right leg until further mobility orders are given by the physician; -Complaints of acute pain; -Nursing staff should anticipate resident's needs and check with him/her often to ensure his/her needs are met and to ensure safety. Record review of the resident's progress note, dated 7/8/18, at 1:31 P.M , showed the following information: -The resident refused to get up for lunch; -Began hollering midway through his/her lunch and scooted down in the wheelchair; -Nursing transferred the resident from the wheelchair to his/her bed using a Hoyer lift (a mechanical device with a sling attached to the lift for transfer of a non ambulatory resident); -During the transfer, the resident scraped the back of his/her left forearm. Record review of the resident's nursing progress note, dated 7/8/18, at 5:20 P.M., showed the following information: -The resident said he/she was not going to get in his/her wheelchair until he/she got a new wheelchair; -Staff documented they would pass the message to social services for a new wheelchair. Record review of the resident's nursing progress notes showed the following information: -On 7/13/18, at 10:31 P.M., the resident refused to get out of bed for the evening meal. He/she said his/her wheelchair was uncomfortable; -On 7/15/18, at 07:13 A.M., the resident refused to get up in the wheelchair for breakfast. Record review of the social services notes, dated 7/16/18, at 11:13 A.M., showed the ombudsman came to visit with the resident and social services documented the following information: -The resident told the ombudsman he/she wanted his/her wheel chair checked; -The armrests on his/her wheelchair hurts the resident; -The resident told the ombudsman when the wheelchair problem was fixed he/she would like to attend bingo sessions. -Social services director documented she talked to therapy about the resident's wheelchair; -Therapy told the social services director, the resident's wheelchair would be assessed when the resident was eligible for Medicare Part B, (which covers therapy). Record review of the resident's nursing progress notes showed the following information: -On 7/20/18, at 12:13 P.M., the resident refused to get up in the wheelchair for breakfast; -On 7/23/18, at 6:15 A.M., the resident refused to get up in the wheelchair for breakfast; -On 7/28/18, at 5:30 P.M., the resident refused to get up in the wheelchair for breakfast. Record review of the resident's nursing progress note, dated 8/4/18, at 12:20 P.M., showed the following information: -The resident told staff his/her wheelchair hurts; -The resident asked staff to put a pillow behind his/her wheelchair to relieve pain. Observation and interview on 8/7/18, at 2:04 P.M., showed the resident lay in bed on his/her back. The resident said the following: -He/she has problems with his/her wheelchair; -The armrest on the wheel chair is rough on his/her elbows; -The footrest on his/her right leg, cannot be adjusted; -It hurts when staff put him/her inside the wheelchair; -He/she cannot fit in the wheel chair; -Staff force him/her into the wheelchair; -He/she has repeatedly told staff he/she cannot fit inside the wheelchair; -Would like to participate in activities, such as bingo, when his/her wheel chair is fixed. Observation and interview on 8/8/18, at 8:44 A.M., showed staff set the resident's breakfast on the bedside stand. He/she lay on his/her bed and said the following: -He/she would prefer to eat in the dining room; -Has told staff his/her wheelchair hurts his/her knees and sides; -He/she told staff on numerous occasions, his/her wheelchair is uncomfortable. During an interview on 8/8/18, at 3:20 P.M., Certified Nursing Assistant (CNA) J said the resident stays in his/her room most of the time. He/she does not like his/her wheelchair. He/she says the wheelchair is uncomfortable. During an interview on 8/9/18, at 2:45 P.M., the resident continued to voice concerns about his/her wheelchair and said the following: -He/she does not believe the facility will help him/her with a new wheelchair; -The facility has not done anything about his/her wheelchair; -He/she has been using the same wheelchair since he/she has been at the facility. During an interview on 8/9/18, at 2:56 P.M., CNA I said the following: -The resident hates getting in his/her wheelchair; -The wheelchair causes him/her pain. Observation and interview on 8/9/18, at 3:10 P.M., showed the following information: - Two nursing assistants, CNA I and CNA J used a Hoyer lift and lifted the resident from his/her bed. -Staff lowered the Hoyer and placed the resident in his/her wheelchair; -The resident said the armrest on his/her wheelchair hurts his/her arms; -The footrest on the resident's wheelchair was short in length, his/her right foot rested beyond the footrest by approximately a foot . -The resident sat in the wheelchair for approximately a minute and yelled the wheelchair,hurts. -CNA I said he/she could not adjust the footrest any further; During an interview on 8/10/18, at 8:11 A.M., the Director of Rehabilitation said the following: -The resident is not in restorative therapy; -She never received an order for [REDACTED].>-Staff have not brought any concerns from the resident or any other issues to her attention. During an interview on 8/10/18, at 8:15 A.M.,CNA/Certified Medication Technician (CMT) L said the following: -He/she was in charge of restorative therapy; -The resident refuses to go in his/her wheelchair and complains of pain in his/her lower back; -Staff provided a rubber cushion per the resident's request; -He/she did not know the footrest on the resident's wheelchair could not be adjusted; -He/she will ask the therapy department to adjust the footrest on the resident's wheelchair. During an interview on 8/10/18, at 8:09 A.M., CNA M said the following: -Staff use a Hoyer lift when they take the resident for showers; -The resident complains his/her wheelchair hurts when staff push him/her in the wheelchair. During interview on 8/10/18, at 09:29 A.M., Licensed Practical Nurse (LPN) C said the following: -The resident has voiced concerns about his/her wheelchair; -He/she reported the resident's concerns to therapy; -Therapy can make wheelchair adjustments; -Therapy has not done any adjustments to the resident's wheelchair since he/she reported it; During an interview on 8/10/18, at 11:23 A.M., CNA N said the following: -He/she was familiar with the resident; -The resident does not like getting inside his/her wheelchair; -On numerous occasions, he/she heard the resident screaming from the hallway during transfers; -The resident says his/her wheelchair is uncomfortable and it hurts his/her legs and bottom; -Staff is aware he/she does not like being in the wheelchair. During an interview on 8/10/18, at 12:15 P.M., CNA P said the following: -The resident complains of pain when he/she is in a wheel chair; -The wheelchair hurts the resident on his/her right side; -He/she screams during transfers from the Hoyer to the wheelchair. Record review of the resident's progress note, dated 8/10/18, at 12:55 P.M., showed staff documented the resident was up in the wheelchair for lunch. Staff assisted the resident back to bed due to pain from the wheelchair. Staff talked to the Assistant Director of Nursing (ADON) about changing the resident's wheel chair. During an interview on 8/13/18, at 4:45 P.M., the ADON said the following: -He/she did not know the resident's right foot did not fit on the footrest; -Staff did not complete a screening for a wheel adjustment or wheelchair replacement for the resident's wheelchair; -There is an insurance problem; -Therapy screens are not free; -A bigger chair will cause the resident to fall. During an interview on 8/13/18, at 4:45 P.M., the Director of Nursing (DON) said the following: -She expects all residents to be treated according to their preferences and within reason; -She did not know the resident had problems with his/her footrest. During an interview on 8/10/18, at 2:26 P.M., the administrator said the following: -He was aware of the resident's wheelchair concerns; -The resident's insurance won't pay for a bigger wheelchair because the wheelchair costs more money; -He will try to get a quote for a bigger chair. -On 8/13/18, at 6:35 P.M., the administrator said the following: -He expects the facility to address residents' preferences; -There were problems with the resident's insurance; -Therapy will evaluate and address the resident's discomfort immediately.

Based on observation, interview, and record review, the facility failed to timely assess and treat one resident (Resident #55) when he/she developed two Stage II pressure ulcers (partial thickness lossof dermis presenting as a shallow open ulcer with a red pink wound bed, without slough (dead tissue). It may also present as an intact or open/ruptured serum-filled blister). A sample of 17 residents were selected for review in a facility with a census of 62. Record review of the facility policy titled, Care and Prevention of Pressure Ulcer, dated (MONTH) (YEAR), showed the following information: -Purpose to prevent and treat further breakdown of pressure ulcers; -treatment of [REDACTED]. -The nurse is responsible for carrying out the treatment as ordered by the attending physician and for implementing measures to prevent pressure ulcers; -Staff to observe skin. Any persistent area that remains after pressure is relieved is a high risk area for a pressure ulcer to begin. 1. Record review of Resident #55's face sheet showed the following information: -Resident originally admitted to the facility on [DATE] and readmitted from the hospital on [DATE]; -Resident had [DIAGNOSES REDACTED]. Record review of the resident's 30 day Minimum Data Set (MDS), a federally mandated comprehensive assessment instrument, completed by facility staff, dated 7/12/18, showed the following information: -Cognitively intact; -Extensive assistance of one staff with personal hygiene and bed mobility; -Extensive assistance of two staff with transfers and toileting; -Resident had an indwelling urinary catheter; -Occasionally incontinent of bowel; -At risk for the development of pressure ulcers; -Pressure reducing device to chair and bed; -No pressure ulcers at this time. Record review of the resident's care plan, dated 4/04/18, showed the following information: -At risk for pressure ulcers due to moisture; -Staff to avoid using hot water, staff to use mild soap and soft cloths or packaged cleanser wipes; -Staff to check the resident's incontinence pads frequently (every 2 hours) and change as needed; -Staff to moisturize the resident's dry unbroken skin; -Staff to assess and inspect the resident's skin every week with close attention to the resident's heels; -Staff to use moisture barrier ointments (protective skin barriers) on the resident; -Resident has the potential for complications related to a [DIAGNOSES REDACTED]. -Staff to monitor skin and avoid drying agents; -Staff to apply moisturizers to prevent dryness, cracking, and fissures; -Staff to report any slow or unhealing wounds, such as skin tears and ulcers. Record review of the resident's form titled, Braden Scale for Predicting Pressure Sore (ulcer) Risk, dated 7/05/18, and completed by the assistant director of nursing (ADON) showed staff assessed the resident with a score of 17, indicating the resident was at risk for the development of pressure ulcers. Record review of the resident's weekly skin assessment completed by Licensed Practical Nurse (LPN) C, dated 8/07/18, showed the following information: -Head to toe assessment complete; -[MEDICAL CONDITION] to lower legs; -Buttocks red and blanches; -Barrier cream applied to resident; -Buttocks very dry and scaly. Observation on 08/09/18, at 11:19 A.M., showed the following: -Certified Nursing Assistant (CNA) Q entered the resident's room to provide cares; -The CNA assisted the resident onto his/her side, revealing a Stage 2 pressure ulcer to the resident's right buttocks, approximately 1 centimeter (cm) in size with red tissue present to the wound bed; -The resident's surrounding skin showed some superficial peeling in a butterfly shaped area to the coccyx and bilateral upper buttocks, pink in color; -The CNA cleaned the resident's skin and applied [MEDICATION NAME] ointment (a skin protectant containing zinc oxide) to the resident's pressure ulcer and buttocks. During an interview on 8/09/18, at 11:19 A.M., CNA Q said he/she had not worked at the facility for a few days and was previously unaware the resident had a pressure ulcer. Record review of the resident's shower aide skin assessment sheet, dated 8/10/18, showed an open area to the resident's buttocks. Record review on 8/10/18, of the resident's current physician order sheet, did not show any orders for treatment to the pressure ulcer. Observation on 08/13/18, at 11:00 A.M., showed the following: -CNA N and Nursing Assistant (NA) R assisted the resident onto his/her side in bed; -The resident had two stage 2 pressure ulcers, one on the left upper buttock and one on the right upper buttock, each area appeared approximately dime sized, with pinkish red tissue to the wound bed of each; -The resident had a large butterfly shaped area of peeling skin surrounding the pressure ulcers, pink in color, and appeared to be approximately 4 by 8 inches in size. During an interview on 8/13/18, at 11:05 A.M., the ADON/wound nurse said the resident had two areas of shearing to his/her buttocks, which she considered Stage II pressure ulcers. The ADON said she just found out about them today. The ADON said she was currently in the process of notifying the resident's physician and family. Record review of the resident's initial and weekly wound documentation, completed on 8/13/18, at 11:22 A.M. by the ADON, showed the following information: -Partial skin assessment from report of wounds on 8/13/18 of bilateral upper buttocks shearing with dry area surrounding wounds; -Type of skin condition is pressure sore (ulcer); -Area acquired in house; -Upper right buttock pressure ulcer measured 1.0 centimeter (cm) long by 0.5 cm wide with 0 cm depth; -Upper left buttock pressure ulcer measured 0.5 cm long by 1.0 cm wide with 0 cm depth; -Stage of ulcer is Stage II; -Surrounding skin (peri-wound) dry and flakey; -New treatment of [REDACTED].M.; -Staff educated not to scoot the resident in bed; -Staff attempt to reposition the resident every two hours, however the resident is resistant to turning on his/her side; -Resident's skin was very dry. Record review of the resident's physician orders, dated 8/13/18, showed the following order: -Staff to apply A and D ointment to the resident's upper bilateral buttocks as needed. Record review of the resident's risk for pressure ulcer care plan showed the following revision, dated 8/13/18: -Current shearing areas noted; -Treatment as ordered; -Refer to entire care plan for other interventions. During an interview on 8/13/18, at 4:45 P.M., the ADON said the following: -On 8/10/18, a bath aide documented on the resident's bath sheet about a problem with the resident's skin, but staff did not report the issue to the ADON; -On 8/12/18, charge nurse LPN S left a note for the ADON stating the resident had issues on his/her buttocks, but the ADON did not see the note until 8/13/18; -On 8/13/18, staff notified the ADON of Resident #55's pressure ulcers for the first time; -The bath aide or certified nursing assistant should report any skin concerns to the charge nurse or to the ADON; -If a charge nurse is aware of a resident's pressure ulcer, the charge nurse needs to call the physician and obtain an order or notify the ADON of the area; -The ADON said she assessed the resident's skin on 8/02/18 and the resident did not have any pressure ulcers at that time.

Based on observation, record review and interviews, the facility failed to ensure staff followed acceptable professional standards of infection control when staff failed to perform hand hygiene during an ice water pass for four sampled residents (Residents #4, #5, #6 and #13) and four randomly observed residents; during a medication pass for two sampled residents (Resident #2 and #8) and four randomly observed residents; and during meal assistance for one randomly observed resident. Staff failed to perform appropriate hand hygiene and glove changes during perineal care for one resident (Resident #3). Staff failed to ensure the oxygen cannula tubing for one resident (Resident #1) did not rest on the floor while unattached from the oxygen source. These deficient practices could affect any resident whom staff provided with ice water in their room, administration of medications, personal hygiene assistance, and/or supplemental oxygen. A sample of thirteen residents was selected for review; the facility census was 76. 1. Record review of the facility's procedure for passing fresh ice water showed the following: -Step one instructs staff to wash and/or sanitize hands; -Step four instructs staff to sanitize hands prior to entering resident rooms; -Step ten instructs staff to sanitize hands between residents. Observations made on 10/12/16, at 3:02 P.M., showed Nursing Assistant (NA) B passing ice on the B-Hall. While passing ice to Resident #13 and to his/her roommate, the NA took off lids from water cups, poured ice into the cups, filled the cups with water using the sink in resident rooms, and then put the lid back on and returned the cup to each resident. NA B was observed passing ice in the same manner to the rooms of Residents #4, #5, and #6. In room [ROOM NUMBER], the NA assisted a randomly observed resident to lift his/her leg by grabbing onto the resident's pant leg, then the NA continued to pass ice without performing hand hygiene. During the entire observed ice pass, the NA did not use gloves and did not perform hand hygiene between residents or between rooms. This observation was made between four resident rooms. During an interview on 10/13/16, at 1:47 P.M., the administrator and the Director of Nursing (DON) said that during ice pass staff should use hand sanitizer between assisting each resident. 2. Record review of a facility document entitled Medication Administration (Nursing Guidelines Manual, March 2015) showed staff to wash hands prior to all medication administration. Observation on 10/11/16, beginning at 3:04 P.M., showed the following: -Certified Medication Technician (CMT) C prepared a medication for one randomly observed resident who sat in his/her room. The CMT handed the pill cup and the resident's water pitcher to the resident, waited until he/she took the pill, and retrieved the empty cup and threw it into the trash can. CMT C did not wash his/her hands prior to leaving the resident's room. -CMT C returned to the medication cart in the hallway, did not utilize hand sanitizer, and proceeded to prepare two medications for a second randomly observed resident. CMT C retrieved a pharmacy labeled bubble pack card from the cart drawer, punched out one pill into a pill cup, and returned the card to the drawer. CMT C retrieved a stock bottle (utilized for any resident requiring administration of that medication), poured one pill from the bottle into the lid, and tipped the pill from the lid into the pill cup. CMT C entered the resident's room and handed the pill cup and the resident's water pitcher to him/her, who then took the pills and handed the empty cup back to the CMT to throw away. CMT C did not wash his/her hands prior to leaving the resident's room. -CMT C returned to the medication cart in the hallway, did not utilize hand sanitizer, and proceeded to prepare medications for a third randomly observed resident, who sat in his/her room. CMT C retrieved a pharmacy labeled bubble pack card from the cart drawer, punched out one pill into a pill cup, and returned the card to the drawer. CMT C retrieved a stock bottle from a drawer, poured one pill from the bottle into the lid, and tipped the pill from the lid into the pill cup. CMT C entered the resident's room and handed the pill cup and the resident's water pitcher to him/her, who then took the pills and handed the empty cup back to the CMT to throw away. CMT C did not wash his/her hands prior to leaving the resident's room. -CMT C returned to the medication cart in the hallway, did not utilize hand sanitizer, and proceeded to prepare medications for a sampled resident (Resident #2). CMT C retrieved two pharmacy labeled bubble pack cards from the cart drawer, punched out one pill from each into a pill cup, and returned the cards to the drawer. CMT C retrieved a stock bottle from a drawer, poured one pill from the bottle into the lid, and tipped the pill from the lid into the pill cup. Prior to entering the resident's room, CMT C donned a protective gown and gloves. CMT C entered the resident's room and handed the pill cup and the resident's water pitcher to him/her, who then took the pills and handed the empty cup back to the CMT to throw away. CMT C removed the gown and gloves and washed his/her hands in the resident's bathroom sink prior to leaving the room. -CMT C returned to the medication cart in the hallway and prepared and administered medications for another sampled resident (Resident #8). CMT C did not wash his/her hands prior to leaving the resident's room. -CMT C returned to the medication cart in the hallway, did not utilize hand sanitizer, and proceeded to prepare medications for a fourth randomly observed resident, who sat up in his/her bed. CMT C retrieved two stock bottles from a drawer, poured one pill from each bottle into its lid, and tipped the pill from the lid into the pill cup. CMT C entered the resident's room and handed the pill cup and the resident's water pitcher to him/her, who then took the pills and handed the empty cup back to the CMT to throw away. CMT C did not wash his/her hands prior to leaving the resident's room and did not utilize hand sanitizer from the cart at that time. During an interview on 10/13/16, at 1:45 P.M., the DON said staff should sanitize their hands, either by washing them or applying alcohol hand sanitizing gel, between every resident during a medication pass. 3. Record review of a facility document entitled Perineal Care (Nursing Guidelines, March 2015), showed no guidelines regarding hand hygiene and/or glove changing during the process of perineal care. Observation on 10/10/16, at 2:13 P.M., showed Certified Nursing Assistant (CNA) D and NA B washed their hands and donned gloves prior to performing incontinent care for Resident #3. CNA D sprayed peri wash cleanser onto a washcloth and cleaned fecal matter smearing from the resident's coccyx (anal area). CNA D folded the cloth and used a clean area of the cloth to clean the resident's buttocks. CNA D did not perform hand hygiene or change gloves and proceeded to use a fresh cloth to clean the resident's front perineal area and catheter insertion site. CNA D did not perform hand hygiene or change gloves and proceeded to assist the other CNA to place the resident's feet and lower legs on a pillow and cover the resident with the sheet and bedspread. CNA D placed the resident's call light in reach and then removed his/her gloves and washed his/her hands in the resident's sink. During an interview on 10/12/16, at approximately 12:15 P.M., Licensed Practical Nurse (LPN) E said staff should wash or sanitize their hands and change gloves between all contaminated and clean parts of resident care or treatment. 4. Observations made on 10/10/16, at 1:25 P.M., in the dining room showed CNA A assisted a randomly observed resident eat lunch. The CNA then assisted another resident move his/her wheelchair by pushing on the chair and turning the wheel. CNA A was not wearing gloves and did not perform any hand hygiene before he/she resumed assisting the other resident with eating his/her lunch. During an interview on 10/13/16, at 1:47 P.M., the DON said that staff should use alcohol gel between assisting different residents in the dining hall. Record review of the facility policy for assistance with meals showed no direction for staff to perform any hand hygiene while assisting residents with meals. 5. Record review of Resident #1's quarterly Minimum Data Set (MDS), a federally mandated comprehensive assessment completed by the facility staff, dated 7/19/16, showed the following information: -admitted to the facility on [DATE]; -[DIAGNOSES REDACTED]. -Total dependence on staff for transfers; -Short of breath (SOB) with exertion. Record review of the resident's physician order sheet (POS), dated 8/08/16, showed staff to administer oxygen at 3 liters continuous per nasal cannula. Observation on 10/12/16, at 8:02 A.M., showed the resident at his/her table not eating the breakfast in front of him/her. The oxygen tubing was on the dining room floor next to the resident. The resident had an oxygen tank on the back of his/her wheelchair, but the tubing was not hooked to the tank nor was the resident's portable oxygen concentrator. The attending nurse in the dining room, LPN F said he/she normally has a concentrator and staff do not normally leave his/her tubing in the floor.

Based on observation, interview, and record review, the facility failed to maintain the highest practical well-being for one resident (Resident #1) when the facility failed to consistently administer the resident's oxygen per physician's orders [REDACTED]. [REDACTED]. Record review of Mosby's Pocket Guide to Nursing Skills and Procedures, Eighth Edition, 2015, showed the following: -Pulse oximetry has become the standard method for non-invasive monitoring of peripheral arterial oxygen saturation in most health-care areas; -Pulse oximetry normal range is between 95 and 100 percent. Ninety percent is a red flag and anything less represents [MEDICAL CONDITION] (abnormal deficiency of oxygen in the cells); -Some characteristic signs of [MEDICAL CONDITION] are increased restlessness, decreased level of consciousness, elevated respiratory rate, confusion, and [MEDICAL CONDITION](rapid heartbeat). Record review of the facility's policy titled, Oxygen Administration, dated March 2015, showed the following: -The purpose of oxygen administration is to administer oxygen to the resident when insufficient oxygen is carried by the blood to the tissues; -Nasal cannulas: connect tubing to humidifier outlet and adjust liter flow as ordered. Place prongs of cannula into the resident's nostrils; -At regular intervals, check and clean oxygen equipment, masks, tubing, and cannulas; -At regular intervals, check liter flow, contents of oxygen and assess resident's respiration to determine further need for oxygen therapy. 1. Record review of Resident #1's quarterly Minimum Data Set (MDS), a federally mandated comprehensive assessment completed by facility staff, dated 7/19/16, showed the following information: -Cognitively intact; -admitted to the facility on [DATE]; -[DIAGNOSES REDACTED]. -Adequate hearing and vision; -Makes self-understood with clear speech; -Extensive assistance needed for toileting, hygiene and putting to bed; -Total dependence on staff for transfers and dressing; -Short of breathe (SOB) with exertion. Record review of the resident's care plan, dated 9/22/16, showed staff care planned the following on 7/12/16: -Resident is at risk for complications related to respiratory disease; -Assess for changes in level of consciousness, coherency and report changes; -Monitor and report signs of respiratory distress; -Monitor oxygen saturation via pulse oximetry as ordered; -Administer medications as ordered; -Resident at risk for complications from history of and current [DIAGNOSES REDACTED]. Record review of the resident's physician's orders [REDACTED]. Record review of the resident's Medication Administration Record [REDACTED]. Record review of the resident's nurses' notes, dated 7/12/16 to 7/31/16, showed the following: -On 7/12/16 at 6:38 P.M., the hospital provided a report showing that the resident was oxygen dependent and had an oxygen saturation of 96 percent on 2 1/2 to 3 liters flow rate of oxygen; -On 7/23/16 at 4:33 P.M., the resident was alert and oriented with slight confusion at times. The resident's lung sounds were diminished bilaterally (both lungs) and oxygen flow rate was at two liters per nasal cannula continuously; -On 7/31/16 at 2:38 P.M., during an assessment the resident's oxygen saturation was at 78 percent. The staff administered to the resident two puffs of the [MEDICATION NAME] inhaler, positioned the resident more upright in the bed, and increased the oxygen flow rate to three liters. The oxygen saturation levels for the resident were reevaluated several times, and oxygen saturation levels stayed in the 80's. The registered nurse on duty was notified and he/she contacted the doctor; -On 7/31/16 at 3:19 P.M., the resident was short of breath and his/her oxygen saturation was at 85 percent. Staff assessed the resident's lung sounds and documented they heard crackles and wheezes throughout. The resident appeared pale. The physician gave the order for the resident to go to the hospital. The resident's oxygen level was 75 to 77 percent on three liters and the resident transported to hospital. Record review of the resident's physician progress notes [REDACTED]. Record review of the resident's POS, dated 8/08/16, showed the physician ordered staff to administer oxygen to the resident at three liters continuous per nasal cannula. Record review of the resident's Medication Administration Record [REDACTED]. Record review of the resident's nurses' notes, dated 8/23/16 to 9/21/16, showed the following: -On 8/23/16 at 9:31 P.M., the resident was alert and oriented with episodes of confusion; -On 8/25/16 at 11:03 A.M., the resident's oxygen was at 2 lpm per nasal cannula, denied being short of breathe and oxygen saturation was 90 percent. The resident had a dry cough, with pale dry skin; -On 8/29/16 at 12:17 P.M., the resident's oxygen was at 2 lpm per nasal cannula; -On 8/29/16 at 4:08 P.M., the resident's lungs sounded diminished with a nonproductive cough at times. Oxygen was at 2 lpm per nasal cannula; -On 9/03/16 at 1:49 A.M., the resident's lungs sound diminished throughout. The resident's oxygen was at 2 lpm per nasal cannula; -On 9/09/16 at 12:47 A.M., the resident's lungs sounded diminished throughout. The resident's oxygen was at 2 lpm per nasal cannula; -On 9/15/16 at 1:07 A.M., the resident's lungs sounded diminished, with a cough and slight wheezing noted. The resident's oxygen was at 2 lpm per nasal cannula; -On 9/16/16 at 4:44 P.M., the resident was alert and oriented with occasional periods of confusion. The resident's lungs sounded coarse bilaterally with expiratory wheezing; -On 9/18/16 at 4:51 A.M., the resident's lungs sounded diminished and oxygen was at 2 lpm per nasal cannula; -On 9/20/16 at 3:15 A.M., the resident's lungs sounded diminished and a dry cough was noted. The resident's oxygen was at 2 lpm per nasal cannula; -On 9/21/16 at 3:49 A.M., the resident's lungs sounded diminished and a dry raspy cough was noted. The resident's oxygen was at 2 lpm per nasal cannula; -On 9/21/16 at 7:26 P.M., the physician saw the resident and ordered antibiotics (Z-pak) and a [MEDICATION NAME] nebulized inhaler. Record review of the resident's care plan, dated 9/22/16, showed the facility staff added the following to the care plan on 9/22/16: -Resident has risk for complications related to recent [DIAGNOSES REDACTED]. -Administer oxygen as ordered; -Monitor resident to be sure oxygen is delivered at ordered liters; -Observe and report cyanosis (skin that appears blue), difficulty breathing, [MEDICAL CONDITION] and confusion indicating worsening symptoms. Record review of the resident's nurses' notes, dated 9/23/16 to 9/27/16, showed the following: -On 9/23/16 at 3:14 A.M., the resident's lungs sounded coarse with slight wheezing and a dry raspy cough. The resident continued on an antibiotic for upper respiratory infection. The resident's oxygen was at 2 lpm per nasal cannula; -On 9/23/16 at 8:35 P.M., the resident was alert and oriented, with occasional confusion. The resident's lungs had an audible wheezing; -On 9/24/16 at 3:57 A.M., the resident's lungs sounded coarse, with slight wheezing and a dry raspy cough. The resident's oxygen was at 2 lpm per nasal cannula; -On 9/25/16 at 3:59 P.M.,. the resident's skin was warm, dry, and pale in color. The resident's oxygen was at three lpm per nasal cannula with oxygen saturation at 90 percent. The resident received a nebulizer treatment had a non-productive cough. Record review of the resident's physician progress notes [REDACTED]. Record review of the resident's nurses' notes, dated 9/28/16 to 10/11/16, showed the following: -On 9/28/16 at 3:13 P.M., the physician gave new orders for [MEDICATION NAME] (antibiotic) 500 milligrams (mg) daily for seven days and [MEDICATION NAME] treatment four times a day for one week for an upper respiratory infection; -On 9/29/16 at 4:19 P.M., the resident's oxygen level was at 3 lpm per nasal cannula and oxygen saturation was at 90 percent; -On 10/5/16 at 6:53 P.M., the physician saw the resident and ordered [MEDICATION NAME] 500 mg for three days. Record review of the resident's Medication Administration Record [REDACTED]. Observation and interview on 10/12/16, at 8:02 A.M., showed the resident at his/her table not eating the breakfast in front of him/her. The resident's oxygen tubing was on the dining room floor next to the resident. The resident had an oxygen tank on the back of his/her wheelchair, but the tubing was not hooked to the tank nor was a portable oxygen concentrator present. The Licensed Practical Nurse (LPN) F assisted the resident after it was brought it to his/her attention by the state surveyor that the resident was not receiving oxygen. LPN F said the resident normally has a concentrator and staff do not normally leave his/her tubing in the floor. Observation and interview on 10/12/16, at 8:07 A.M., showed a certified nursing assistant (CNA) brought LPN F a concentrator for the resident. LPN F said he/she would hook it up when they received some clean tubing. LPN F assessed the resident's oxygen saturation at 74 percent. LPN F said he/she would like to see his/her levels above 90 percent. Observation on 10/12/16, at 8:14 A.M., showed a CNA brought LPN F new oxygen tubing for the resident. The nurse removed the previous nasal tubing and applied the new clean tubing and connected tubing to the oxygen concentrator. The oxygen concentrator was set for 3 lpm of oxygen as prescribed by the physician. LPN F stayed with the resident until the residents SPO2 was at 91 percent. Record review of the resident's nurses' notes showed on 10/12/16, at 8:15 A.M., the resident's oxygen saturation was at 74 percent. The nurse encouraged the resident to deep breathe until oxygen was reapplied after being off. The oxygen level went up to 90 percent, then progressed to 95 percent. During an interview on 10/12/16, at 11:37 A.M., the resident said the staff forgot to connect his/her continuous oxygen three other times since arriving at the facility on 7/12/16. The resident said staff would tell him/her, We just forgot and They got busy for reasons that his/her continuous oxygen was not provided as ordered by the physician. The resident said he/she came in with an order for [REDACTED]. During an interview on 10/12/16, at 2:10 P.M., CNA G said he/she took the resident to breakfast that morning. The CNA said she just forgot the resident's oxygen concentrator that morning. The CNA said he/she brought the resident to his/her table, went back for the concentrator, and was side tracked by answering a call light for another resident. The CNA said this had happened before. The CNA said he/she did not think his/her oxygen level had dropped that much. In response to a question regarding where to find information about the residents oxygen use in the care plan, CNA G said, I do not know where the care plans are. During an interview on 10/12/16, at 2:37 P.M., the Director of Nursing (DON) said the CNAs are able to view the residents' care plans on the computer. The DON said she makes a roster sheet for each hall and updates it weekly for the aides to use as a tool for resident care. The DON presented the most recent copy of the resident roster care notes. The DON said CNA's are educated on where to find the residents' care plans on the computers during orientation and in multiple in-services. Record review of the resident roster sheet given to staff on the halls, obtained on 10/12/16 at 2:37 P.M., showed the resident used supplemental oxygen. The sheet did not show the oxygen was ordered to be continuous or that the flow rate was ordered for 3 lpm via nasal cannula. During an interview on 10/12/16, at 2:57 P.M., at the A hall nurses' station, CNA D said the residents' care plans are in a book at the nurses desk. The CNA was unable to provide a care plan book from the nurses' station. The CNA said there was not a whole lot of information on their computer system. During an interview on 10/13/16, at 9:24 A.M., LPN E said he/she discussed the oxygen protocol with CNA G, who brought the resident to the table with no oxygen. The LPN said he/she explained to the CNA that the resident should not have a nasal cannula in their nose without oxygen because it will decrease the residents SPO2. The nurse said the resident has oxygen ordered at three liters per nasal cannula to maintain a SPO2 of 91 to 92 percent.

Based on observations, interviews and record review the facility staff failed to follow the correct menu portion sizes for the 10 residents, the facility identified as having a clinical need and physician's orders [REDACTED]. 1. Record review of the menu spreadsheets, provided by the facility, showed the facility used a four-week rotating menu cycle, approved by their consulting Registered Dietitian. The spreadsheet for 09/24/14 was Wednesday Week Two of their rotating menu. Wednesday Week Two menu showed food for the noon meal for the residents who required pureed food included the following portioned items. -Six ounce ladle (liquid measurement) of pureed meat sauce over a #8 scoop (one/half cup) of pureed spaghetti; -Three ounce ladle of marinara sauce (for added moisture); -#16 Scoop (one/fourth cup) of pureed green beans; -#24 Scoop (one/sixth cup) of pureed garlic bread; -One serving of cheesecake. Record review of the "Diet Roster Roll-up" (usually called Diet Count) provided by the facility showed the facility staff identified 10 residents who had a clinical need and a physician's orders [REDACTED]. Observations and interview on 09/24/14, beginning at 11:00 A.M., showed the following information: -Dietary Cook A finished preparing the regular menu items and began pureeing those items; -The cook said he/she had to prepare pureed foods for 10 residents; -He/she carefully measured the food and followed the pureed food recipes. Observations and interview on 09/24/14, beginning at 12:15 P.M., showed dietary staff continued dishing foods for the residents' plates. Staff used the following portion control utensils instead of what their menu stated: -#8 Scoop (one/half cup or four liquid ounces) instead of the six liquid ounces of the pureed meat sauce; -#10 Scoop (two/fifth cup) of pureed spaghetti instead of a #8 Scoop; -Two ounce ladle of marinara sauce instead of three ounces. At 12:20 P.M., observations and interviews continued and showed the following information: -Dietary staff members finished serving food and gave the surveyors a closer look at the portion control utensils they had just used to dish the residents' foods. -The dietary manager confirmed the sizes the surveyors had written down (as stated above); -Staff had not used the pureed meat sauce that Dietary Cook A had carefully measured during food preparation. About one/third of the pureed meat sauce remained in the steam-table pan, unused; -Dietary Cook A said he/she had measured the food for 10 residents and had served 10 residents; -The dietary manager said staff should not have used the #8 scoop, but should have used a six ounce ladle instead for the meat sauce; staff should have used a #8 scoop instead of a #10 scoop for the pureed spaghetti, and should have used a three ounce ladle for marinara sauce instead of the two ounce ladle; -Dietary Cook A said the facility did not have a three-ounce ladle; -The dietary manager said staff had not followed the correct menu portions.

Based on observation, interview and record review, the facility failed to follow accepted standards of practice when 21 residents and 25 staff members developed rashes. The facility did not provide adequate education to staff regarding the rashes, and did not maintain tracking records of residents and staff with a rash. The staff continued to work, having skin to skin contact with residents, while having the signs and symptoms of the rash and not receiving treatment for [REDACTED].#1, #2, #3, #5, #6, #8, #11, #14, #15, #18, #20, #22, #32, and #33) out of the 21 residents with rashes were chosen for review. The facility had a census of 75 residents. 1. According to the State Operations Manual, Infection Prevention and Control Program, an effective infection control program is necessary to control the spread of infection and/or outbreaks. Program development and oversight emphasize the prevention and management of infections. Program oversight involves establishing goals and priorities, monitoring the program and responding to problems and other identified issues. Additional activities involved in program development and oversight may include but are not limited to: -Monitoring and documenting infections, including tracking analyzing outbreaks of infection as well as implementing and documenting actions to resolve related problems. -Surveillance, including process and outcome surveillance, monitoring, data analysis, documentation and communicable disease reporting. 2. Review of Infection Control Guidelines for Long Term Care Facilities, Infectious Disease Fact Sheets, subsection "Scabies", issued 7/1/99, showed: - Scabies is a highly communicable skin disease caused by tiny human mites that burrow under the skin to lay eggs. Scabies causes intense itching and a red, generally raised skin rash. Itching is most intense at night. The rash can start anywhere on the body (generally the face is spared) and continues to spread over the body until appropriately treated; - Scabies most commonly passed from one infested person to another through direct skin to skin contact. Occasionally scabies can been transferred from undergarments, bedding or other articles having skin contact with the infested person; - Scabies can look like many other skin problems; - For a person getting scabies for the first time, itching and the rash can take up to eight weeks to appear. Normal range is two to six weeks; - Persons who are yet to show symptoms can transfer the mite prior to their knowledge of having scabies. This is why outbreaks of scabies can occur within institutions like long term care facilities; - Because the rash caused by scabies can look like many other types of rashes, [DIAGNOSES REDACTED]. - Once one resident or employee is found to have scabies it is important to check all residents who may had skin-to skin contact with the infested individual for skin rashes and to complete a questionnaire for all employees again who may have had contact with the affected resident or employee to learn of possible rashes; - treatment for [REDACTED]. Clothing, furniture and other household items require cleaning in a specific manner; - Recommendations included: When rashes appear consider scabies. All outbreaks are reportable. Report to your local public health agency, district office or Missouri Department of Health; -The section "Infectious Disease Outbreaks", showed an outbreak can be defined as three or more cases related by time, place and in the same population. By early reporting of an outbreak of illness or infection, a facility can receive assistance in identifying the causative organism and probable mode of transmission, and reviewing appropriate precautions to take to prevent a larger outbreak or more serious health outcomes; -The section "Guidelines for Scabies Prevention and Control" recommendation to record epidemiologic and clinical information on suspected and confirmed cases of scabies, provide an intensive educational program to all employees, and multiple-use walking belts can serve as a potential reservoir for mites. 3. Review of the Centers for Disease Control and Prevention website showed the following: -The [DIAGNOSES REDACTED]. Whenever possible, a confirmed [DIAGNOSES REDACTED]. A person can be infested even if mites, eggs or fecal matter cannot be found. Fewer than 10-15 mites may be present on an infested person who is otherwise healthy; -Common symptoms of scabies, itching and skin rash are caused by the sensitization or allergic reaction to the proteins and feces of the parasite. Severe itching, especially at night, is the earliest and most common symptom of scabies. A pimple-like itchy scabies rash is also common. The most common areas affected on the body are between the fingers, wrist, elbow, armpit, male genitalia, nipples, waist, buttocks and shoulder blades. Tiny burrows sometimes are seen on the skin. The female scabies mite tunneling just below the skin surface causes these. These burrows appear as tiny raised and crooked grayish-white or skin colored lines on the skin surface. Because mites are often few in number (only 10-15 mites per person), the burrows can be difficult to find, they are most commonly found in the webbing between the fingers, in skin folds of wrist, elbow or knee, on the male genitalia, breast or shoulder blades; -Early detection, treatment, and implementation of appropriate isolation and infection control practices are essential in preventing scabies outbreaks. Institutions should maintain a high index of suspicion that undiagnosed skin rashes and conditions may be scabies, even if characteristic signs and symptoms of scabies are absent. Appropriate isolation and infection control practices (e.g. gloves and gowns) should be used when providing hands on care to patients who might have scabies. A scabies outbreak suggests that transmission has been occurring within the institution for several weeks to months, thus increasing the likelihood that some infested staff or patients may have had time to spread scabies elsewhere in the community, including other facilities; -Consult with an experienced dermatologist for assistance in differentiating skin rashes and confirming the [DIAGNOSES REDACTED]. -Maintain records with patient name, age, sex, room number, roommate(s) name(s), skin scraping status and results, and name(s) of all staff that provided hands-on care to the patient before implementation of the infection control measures. Symptoms can take up to two months to appear in exposed persons and staff; -Use epidemiologic data about distribution of confirmed cases by building, room, floor, wing, occupation, dates of admission, and onset of scabies like condition to determine levels of risk for patients and staff, extent of outbreak, and temporal relationship among cases; -Identify and treat all persons (e.g. staff, relatives, patients, etc.) having prolonged, direct skin to skin contact with infested persons before he/she was treated; -Offer treatment to household members (e.g. spouses, children) of staff who are receiving scabies treatment. 4. Record review of the facility policy, titled "Scabies", dated January 2014, showed the following: -The purpose of this procedure is to treat residents infected with and sensitized to Sarcoptes scabiei (scabies) and to prevent the spread of scabies to other residents and staff; -Scabies is an itching skin irritation caused by the microscopic human itch mite, which burrows into the skin's upper layers and eventually causes itching, tiny irregular red lines just above the skin and an allergic reaction. Secondary bacterial skin infections may result from untreated scabies. Incubation period can be 2-6 weeks before onset of itching for persons with no previous exposure. Symptoms develop more rapidly in previously infested persons, 1-4 days after re-exposure; -Common locations of scabies are anterior axillary region or under breasts, around waist, between finger and palm of hand, inner thighs groin or buttocks, wrist and elbows, any area of skin that may come in contact with linens, bedding or clothing, upper back of nursing home residents and hands of employees; -Skin to skin contact with the infected area, through contact with bedding, clothing or privacy curtains and some furniture will spread scabies; -An established [DIAGNOSES REDACTED]. Failure to identify scrapings as positive does not necessarily exclude the diagnosis. It is difficult to obtain a positive scraping because only one to two mites may cause multiple lesions. Often, [DIAGNOSES REDACTED]. -Affected residents should remain on contact isolation until 24 hours after the last treatment; -Staff should notify family and friends of residents who have had close contact and be given instructions regarding self-examination and treatment; -Staff members who were exposed should report any rashes developing on their bodies to the Infection Control Coordinator or Director of Nurses; -Staff should carefully examine residents sharing a room with someone infected with scabies. If symptoms are present, the staff should treat the resident in accordance with these procedures. If symptoms are not present, staff should make daily skin assessments until the case has been resolved; -Individuals, who come in contact with infected residents, or potentially infected bedding or clothing, should wear a gown or other protective clothing as by the facilities infection and exposure control program; -treatment of [REDACTED]. Day two, remove the cream 8-14 hours after application by showering or bathing the resident. Identification of living mites or symptoms after 14 days indicates the need for retreatment. Residents who do not respond to treatment should be retreated with an alternative treatment such as [MEDICATION NAME] or Ivermectin. 5. Record review of the facility form titled, "Infection Control Guidelines for All Nursing Procedures", dated January 2014, showed the following: -The purpose of the policy is to provide guidelines for general infection control while caring for residents; -The staff must have appropriate in-service training on general infection and exposure control issues. The in-service must review standard and transmission based precautions, personal protective gear, exposure control plan and protocol for occupational exposures to blood-borne pathogens; -The staff must have appropriate in-service training on managing infections in residents. The in-service must include types of healthcare associated infections, methods of prevention the spread, to recognize and report signs and symptoms of infection and preventions of the transmission of multi-drug resistant organisms; -Standard precautions used in the care of all residents in all situations regardless of suspected or confirmed presence of infectious disease; -Transmission based precautions used whenever measures more stringent than standard precautions needed to prevent the spread of infection. 6. Record review of Resident #20's admission face sheet showed the following: -The facility admitted the resident on 8/30/13; -The resident had [DIAGNOSES REDACTED]. -The resident discharged from the facility on 1/2/14. Record review of a nurse's note, dated 8/30/13, at 11:20 A.M. showed the nurse documented the resident had a "couple" scratches to both upper arms. The resident reported "it hurt to touch it. " Record review of the facility form titled, "Weekly Skin Condition Report", dated 8/30/13, at 4:21 P.M., showed the resident's skin was dry and intact with no skin concerns. The nurse did not check mark the box for rash present. The nurse documented the resident's skin was pink, dry and intact under the comments section. Record review of a physician's order, dated 9/4/13, showed an order for [REDACTED]. Record review of the resident's Weekly Wound Condition report showed on 9/4/13, at 4:33 P.M., the resident had a light pink rash on his/her abdomen. The resident denied itching or pain. The nurse check marked the box under skin concerns indicating the resident had a rash. Record review of a nurse's note, dated 9/4/13, at 8:48 P.M. showed a late note documented by the staff that the nurse practitioner was in and ordered for TAC cream for the rash on the resident's extremities. Record review of the resident's Weekly Skin Condition report, dated 9/11/13, at 1:30 P.M., showed the resident's skin was warm and good with no skin concerns noted. The nurse failed to check mark the box under skin concerns indicating the resident had a rash. Record review of the resident's Weekly Skin Condition report, dated 9/12/13, at 3:31 P.M., showed a bath aide reported the resident had a light red rash to his/her abdomen, chest and sides. The resident scratched at the area during the assessment. The charge nurse was to notify the physician. The nurse failed to check mark the box under skin concerns indicating the resident had a rash. Record review of a nurse's note, dated 9/12/13, showed the resident had a red pinpoint patchy rash covering his/her abdomen and chest. The nurse notified the nurse practitioner and received an ordered for [MEDICATION NAME] (an [MEDICATION NAME] that is used to treat itching) 25 milligrams (mg) by mouth every six hours for rash. The nurse documented the medication was pulled and given to the resident. Record review of a physician's order, dated 9/12/13, showed an order for [REDACTED]. Record review of the resident's Weekly Skin Condition report, dated 9/18/13, at 12:52 P.M., showed the resident had a pink rash remaining on his/her abdomen. The nurse asked the resident if the area itched and the resident responded, "I don't know." The nurse added the resident's name to the doctor board for the physician to see the resident on his/her the next visit to the facility. The nurse check marked the box under skin concerns indicating the resident had a rash. Record review of the resident's Weekly Skin Condition report, dated 9/25/13, at 12:35 P.M. showed the nurse failed to document about the resident's rash on his/her abdomen. The nurse failed to check mark the box under skin concerns indicating the resident had a rash. Record review of the September 2013 medication adminstration record (MAR) showed the resident received as needed [MEDICATION NAME] on 9/12/13, 9/19/13, 9/23/13, 9/24/13, 9/25/13, twice on 9/26/13 and 9/28/13 for treatment of [REDACTED]. Record review of a physician's order, dated 10/2/13, showed an order for [REDACTED]. Record review of the nurses' notes showed the following: -On 10/3/13, a late entry for 10/2/13. The nurse documented he/she notified the resident's physician that the resident continued to have a rash on the trunk. The physician gave orders for a [MEDICATION NAME] Dose Pack 4 mg by mouth as directed; -On 10/8/13, a note showed the physician gave orders to do a skin scraping to test for scabies and to discontinue the scheduled and as needed [MEDICATION NAME] (antipsychotic). Record review of a physician order, dated 10/8/13, showed an order for [REDACTED]. Record review of the resident's Weekly Skin Condition report, dated 10/9/13, (two weeks later) showed the resident had a rash to the abdomen and trunk that had been present for several weeks. The staff had treated the rash with [MEDICATION NAME], TAC cream and a [MEDICATION NAME] Dose Pack. The rash was lighter in color than the previous week. The rash was light pink in color. The nurse check marked the box under skin concerns indicating the resident had a rash. Record review of a nurse's note, dated 10/13/13, (five days after the order) showed the staff performed a skin scraping on the resident to test for scabies and sent the specimen to the lab. Record review of the lab report showed the staff collected the skin scraping on 10/13/13. The lab reported the results to the facility on [DATE] as "none seen". Record review of the resident's Weekly Skin Condition report, dated 10/16/13, showed the resident had a rash to his/her abdomen and trunk that had been present for several weeks. The staff had treated the rash with [MEDICATION NAME], TAC cream and a [MEDICATION NAME] Dose Pack. The rash was negative for scabies. The charge nurse notified the physician the rash continued and placed the resident's name on the board for rounds the next time the physician visited. The charge nurse did not receive any new orders from the physician. The nurse check marked the box under skin concerns indicating the resident had a rash. Record review of the nurses' notes showed the following: -On 10/16/13, at 9:49 P.M., a late note for 5:30 P.M., showed the staff notified the nurse practitioner that the resident continued to have a rash on the upper torso. The resident's family member said he/she wondered if the rash could be caused by the laundry detergent. The nurse received no new orders from the nurse practitioner and put the resident's name on the call board for the physician to see the next time the physician was in the facility; -On 10/17/13, at 9:08 P.M., a late note for 5:30 P.M. showed the nurse applied TAC cream on the back of the resident's arms due to itching. The certified medication tech (CMT) gave the resident [MEDICATION NAME]. The resident's family member voiced concerns over the spread of the rash. The nurse placed the resident's name on the call board for the physician to see the next time the physician was in the facility; -On 10/18/13, at 12:27 P.M., the staff performed a head to toe assessment of the resident that showed the presence of a rash to his/her trunk area and upper arms without open areas. The staff treated the resident with TAC cream twice daily and as needed on trunk and extremities. The resident received [MEDICATION NAME] 25 mg as needed every six hours and had completed a [MEDICATION NAME] Dose Pack. The nurse documented the resident had a skin scraping to test for scabies on 10/8/13, (actual scraping date 10/13/13). The scraping was negative. The resident had a pending referral to a dermatologist. The resident's family member wanted the resident sent to emergency room for the rash; -On 10/18/13, at 2:15 P.M., the nurse documented he/she placed calls to the nurse practitioner at 9:00 A.M. and 11:00 A.M., and had not received call back; -On 10/18/13, at 3:05 P.M., the staff did not apply TAC cream to the rash on the resident's trunk that was due at 6:00 P.M. because the resident was out of the facility (at the hospital). Record review of the Ozarks Community Hospital records showed the following: -The physician's progress note, dated 10/18/13, showed the resident presented with a history of rash for three weeks. The physician documented the rash was on the resident's extremities from his/her neck down to his/her mid thighs and on his/her arms as well. The physician documented contact (dermatitis- skin inflammation) vs. drug reaction. -Urgent Care discharge instructions, dated 10/18/13, showed to change the laundry soap, have the primary care physician review the resident's medications to look for possible drug interactions vs. contact dermatitis and recommended a dermatology exam. Record review of a physician's order, dated 10/18/13, showed the following: -an order for [REDACTED]. -an order for [REDACTED]. -Change the laundry detergent and body soap; -Have the pharmacist and physician review medications for possible reactions or allergens; -Follow up referral with a dermatologist if no improvement (is noted). Record review of the nurses' notes showed the following: -On 10/18/13, at 9:27 P.M., the staff did not apply [MEDICATION NAME] ointment to the resident's rash as scheduled at 10:00 P.M. because the medication had not yet arrived from the pharmacy; -On 10/19/13, at 9:14 A.M., the staff did not apply [MEDICATION NAME] ointment to the resident's rash as scheduled at 10:00 A.M., because they were awaiting pharmacy delivery; -On 10/22/13, at 4:23 P.M., documented as a late entry. The nurse documented the [MEDICATION NAME] ointment had been signed off by a nurse on 10/19/13, 10/20/13, and 10/21/13 as given in error. The staff had not administered the medication on those days; - On 10/22/13, at 9:10 P.M., the staff did not apply [MEDICATION NAME] ointment to the rash scheduled at 10:00 P.M., because the medication not available. Record review of a physician's order, dated 10/22/13, showed an order to use [MEDICATION NAME] soaps and detergents and start the [MEDICATION NAME] ointment four times daily as ordered by the emergency room physician. Record review of the resident's Weekly Skin Condition report, dated 10/23/13, showed the resident's rash continued to his/her abdomen and trunk with improvement noted. The resident received [MEDICATION NAME] ointment and used [MEDICATION NAME] soaps. The resident also received [MEDICATION NAME]. Record review of the October 2013 nurses' medication administration record (MAR) showed staff applied the [MEDICATION NAME] to the resident on 10/20/13 at 6:00 P.M., on 10/21/13 at 10:00 A.M., 2:00 P.M., 6:00 P.M., and 10:00 P.M., on 10/22/13 at 10:00 A.M. and 2:00 P.M., and on 10/23/13 at 10:00 A.M. and 2:00 P.M. Record review of a nurse's note, dated 10/27/13, showed the resident's family member requested a consultation with a dermatologist for evluation of the resident's body rash. Record review of a physician's order, dated 10/29/13, showed an order for [REDACTED]. Record review of the resident's Wound Assessment report, (formerly the form titled, "Weekly Skin Condition Report") dated 10/30/13, showed the resident had a petechiae (pinpoint-sized hemorrhages of small capillaries in the skin) rash on his/her trunk and other areas hidden under clothing that started on 9/4/13 and was improving. The rash measured 35 centimeters (cm) x 25 cm. The resident complained of itching associated with the rash. The nurse documented the rash as diffuse distribution with many lesions. The nurse documented the treatments to the resident for the rash as: -9/25/13: [MEDICATION NAME] 25 mg every six hours as needed; -10/18/13: [MEDICATION NAME] ointment every four hours as needed; -10/18/13: use of [MEDICATION NAME] soaps; -10/18/13: [MEDICATION NAME] 25 mg four times daily; -10/23/13: [MEDICATION NAME] ointment four times daily; -10/29/13: [MEDICATION NAME] 10 mg one tab for four days. Record review of the October 2013 MAR showed the resident received as needed [MEDICATION NAME] on 10/2/13, 10/4/13, 10/6/13, 10/9/13, 10/13/13, 10/14/13, twice on 10/17/13, 10/18/13, 10/23/13 and 10/28/13 for treatment of [REDACTED]. Record review of a physician's order, dated 11/5/13, showed an order to discontinue the [MEDICATION NAME] and start [MEDICATION NAME] (used to treat allergy symptoms) 10 mg daily for urticaria (commonly referred to as hives). Record review of the resident's Wound Assessment report, dated 11/6/13, showed the resident had a petechiae rash on his/her trunk and other areas hidden under clothing that started on 9/4/13 and was unchanged from the previous week. The rash measured 35 cm x 25 cm. The resident had denied itching associated with the rash. The nurse documented the rash as diffuse distribution with many lesions. The nurse documented the treatments to the resident for the rash as: -9/25/13: [MEDICATION NAME] 25 mg every six hours as needed; -10/18/13: [MEDICATION NAME] ointment every four hours as needed; -10/18/13 use of [MEDICATION NAME] soaps; -10/18/13: [MEDICATION NAME] 25 mg four times daily; -10/23/13: [MEDICATION NAME] ointment four times daily; -11/6/13: [MEDICATION NAME] 10 mg daily for urticaria. Record review of the November 2013 MAR showed the resident received as needed [MEDICATION NAME] on 11/6/13 and 11/9/13. Record review of a nurse's note dated, 11/11/13, showed the staff scheduled an appointment for a dermatologist (14 days after the physician wrote the order for a dermatologist). Record review of the resident's Wound Assessment report, dated 11/13/13, showed the resident had a petechiae rash on his/her trunk and other areas hidden under clothing that started on 9/4/13 and was unchanged from the previous week. The rash measured 35 cm x 25 cm. The resident complained of itching associated with the rash. The nurse documented the rash as diffuse distribution with many lesions. The nurse documented the treatments to the resident for the rash as: -9/25/13: [MEDICATION NAME] 25 mg every six hours as needed; -10/18/13: [MEDICATION NAME] ointment every four hours as needed; -10/18/13: use of [MEDICATION NAME] soaps; -10/23/13: [MEDICATION NAME] ointment four times daily; -11/6/13: [MEDICATION NAME] 10 mg daily for urticaria. Record review of a physician's order, dated 11/18/13, showed an order for [REDACTED]. The order directed the staff to repeat the procedure in one week as a [MEDICATION NAME] treatment for [REDACTED]. Record review of nurses' notes on 11/19/13, showed the following: -At 9:55 A.M., social services reported the resident's family member complained on 11/18/13 regarding the resident's rash getting worse. The physician saw the resident and ordered medications for the rash. The resident went to the hospital for the rash. The lab processed a skin scraping for scabies with negative results and the resident had received steroids with no relief. The administrator instructed the nurse to notify the physician for an order to send the resident to the hospital. The nurse contacted the physician and received orders for a new skin scraping for scabies and for [MEDICATION NAME] treatment. The physician requested the nurse to contact the resident's family member and provide education on why the emergency room was not an option, but to send to the emergency room if the family member was adamant. The nurse attempted to notify the family member; -At 12:24 P.M., the family member returned the nurse's phone call. The nurse explained the orders from the physician. The family member requested the resident go to the emergency room ; -At 1:02 P.M., the resident left the facility via ambulance to Ozarks Community Hospital; -At 1:10 P.M., the nurse notified the emergency room of the transfer at family's request; -At 9:45 P.M., the nurse called the medical records staff concerning the order for the skin scraping for scabies and a lack of supplies, and also discussed the orders received from Ozarks Community Hospital duplicated the resident's primary physician's orders. Record review of the prescription, dated 11/19/13, from Ozarks Community Hospital showed an order for [REDACTED]. Record review of a physician's order, dated 11/19/13, showed an order for [REDACTED]. Record review of the November 2013 treatment adminstration record (TAR) showed on 11/19/13, at 2:30 P.M., the staff applied the [MEDICATION NAME] lotion to the resident's skin. Record review of the resident's Wound Assessment report, dated 11/20/13, showed the resident had a petechiae rash on his/her trunk and other areas hidden under clothing that started on 9/4/13 and was deteriorated from the previous week. The rash measured 35 cm x 25 cm. The resident complained of itching associated with the rash. The nurse documented the rash as diffuse distribution with many lesions. The nurse documented the treatments to the resident for the rash as: -9/25/13: [MEDICATION NAME] 25 mg every six hours as needed; -10/18/13: [MEDICATION NAME] ointment every four hours as needed; -10/18/13: use of [MEDICATION NAME] soaps; -10/23/13: [MEDICATION NAME] ointment four times daily; The nurse did not include the treatment [MEDICATION NAME] for urticaria. The nurse failed to document the resident went to the emergency room for the rash and received orders for skin scrapings for scabies and [MEDICATION NAME] treatment for [REDACTED]. Record review of the lab report showed the staff collected the skin scraping on 11/20/13, (after the resident received treatment of [REDACTED]. The report indicated the result was "none seen" for scabies. Record review of the nurses' notes from 11/22/13 through 11/30/13 showed the resident refused the [MEDICATION NAME] treatment for [REDACTED]. Record review of the November TAR showed on 11/27/13, at 2:30 P.M., the staff applied a second treatment of [REDACTED]. Record review of the resident's Wound Assessment report, dated 11/27/13, showed the resident had a petechiae rash on his/her trunk and other areas hidden under clothing that started on 9/4/13 and had deteriorated from the previous week. The rash measured 35 cm x 25 cm. The resident denied itching associated with the rash. The nurse documented the rash as diffuse distribution with many lesions. The nurse documented the treatments to the resident for the rash as: -9/25/13: [MEDICATION NAME] 25 mg every six hours as needed; -10/18/13: [MEDICATION NAME] ointment every four hours as needed; -10/18/13: use of [MEDICATION NAME] soaps; -10/23/13: [MEDICATION NAME] ointment four times daily; -11/6/13: [MEDICATION NAME] 10 mg daily for urticaria. The nurse failed to document they treated the resident for scabies twice. Record review of the dermatologist's progress note, dated 12/2/13, showed the following: -The resident presented with a rash since September. The facility tested the resident for scabies with negative results and changed the laundry soap used for the resident; -The dermatologist documented determining whether the resident had Atopic dermatitis, Scabies dermatitis or a drug eruption; -The dermatologist documented the resident's trunk and extremities presented with eczematous appearing dermatitis; -The resident's palm involvement suggested scabies; -A scabies prep performed that day from the resident's legs and wrist areas were negative, but was performed subsequent to the [MEDICATION NAME] treatment and may have been a false negative; -It took three weeks after [MEDICATION NAME] treatment to see improvement; -The dermatologist recommended the staff apply: -[MEDICATION NAME] foam (a topical steroid that reduces inflammation, itching, redness and swelling caused by certain skin conditions) to the resident's rash on his/her trunk and extremities twice daily for three weeks; -Sarna anti-itch lotion to affected areas to alleviate itching as needed; -[MEDICATION NAME] daily moisturizing cream to skin surface after showers as needed. Record review of a physician's order, dated 12/2/13, showed an order for [REDACTED].

Based on observations in the kitchen and an interview with the dietary manager, the facility failed to maintain food service equipment free of debris and food spills. The deficient practice had the potential to effect all the residents in the facility. The facility had a census of 78 residents. Observations in the kitchen on 8/20/12 starting at 8:25 A.M., on 8/22/12 starting at 9:35 A.M., and on 8/24/12 starting at 12:35 P.M. showed the following examples: 1. An accumulation of food spills and black grime on the surfaces of the can opener, including the blade used to puncture and open the cans. 2. An accumulation of lime scale, and debris on the outer surfaces of the dish washing machine. 3. An accumulation of food spills and debris on and around the control knobs on the toaster. 4. During an interview on 8/24/12 at 12:40 P.M., the dietary manager acknowledged the observations described in examples #1, #2, and #3.

Based on observation, record review, and interview, the facility failed to ensure staff utilized acceptable infection control practices when providing direct care to residents. Facility staff failed to follow contact isolation precautions when providing care to residents, both with and without infectious diarrhea, for three sampled residents (Resident #2, #4 and #7). Facility staff went from isolation rooms to non isolation rooms using gait belts and other supplies between infected and non infected residents. Staff failed to remove dirty gloves after providing incontinent care and before touching resident's personal items for one resident (Resident #3), and staff failed to change feces contaminated gloves before applying one resident's (Resident #1) incontinent brief. This failure has the potential for cross contamination to residents, staff, visitors, and could potentially spread infectious organisms to everyone in the facility. A sample of 16 residents were selected for review in this facility with a census of 78. Record review of the facility policy titled "Isolation-Categories of Transmission-Based Precautions", not dated, showed the following: -An example of infections requiring contact precautions are; diarrhea associated with Clostridium difficile (C-diff) (a bacteria causing diarrhea); -Directs staff to wear gowns during contact precautions and for all interactions that may involve contact with the resident or potentially contaminated items in the resident's environment; -After removing the gown, do not allow clothing to contact potentially contaminated environmental surfaces; -When possible, dedicate the use of non-critical resident-care equipment to avoid sharing between residents. If the use of common items is unavoidable, then adequately clean and disinfect them before use for another resident. Record review of the facility policy titled "Clostridium Difficile", not dated, showed that due to the persistence of Clostridium difficile spore for prolonged periods of time, all feces-contaminated articles must be considered potentially infected and should be disinfected with a disinfecting agent recommended for Clostridium difficile (e.g., household bleach and water solution). 1. Record review of Resident #2's quarterly Minimum Data Set (MDS), a federally mandated comprehensive assessment tool completed by facility staff, dated 7/18/12, showed the resident requires extensive assistance with toileting and personal hygiene and is diagnosed with [REDACTED]. Record review of the resident's care plan, last reviewed on 7/18/12, showed the following: -The resident is on isolation precautions for[DIAGNOSES REDACTED]. Facility staff extended the care plan for 14 days on 8/22/12; -Directs the facility staff to post and follow appropriate isolation precautions per policy; -Directs the facility staff to inform resident/responsible party/visitor/ staff of requirements and monitor for compliance; -The resident requires extensive assistance for transfers, toileting and hygiene; -The resident is incontinent of bowel. -The resident requires extensive assistance with toileting and personal hygiene and is diagnosed with [REDACTED]. Record review of the resident's care plan, last reviewed on 8/22/12/12, showed the following: -The resident is on isolation precautions for[DIAGNOSES REDACTED]. Facility staff extended the care plan for 14 days on 8/19/12; -Directs the facility staff to post and follow appropriate isolation precautions per policy; -Directs the facility staff to inform resident/responsible party/visitor/ staff of requirements and monitor for compliance; -The resident requires moderate assistance for transfers, toileting and hygiene; -The resident is incontinent of bowel. Record review of Resident #7's initial MDS, dated [DATE]/12, showed the resident requires extensive assistance with toileting and personal hygiene. Record review of the resident's admission care plan, dated 8/16/12, showed the resident requires assistance for transfers, toileting and hygiene. Observations and interviews on 8/20/12 showed the following: -At 1:40 P.M. CNA B propelled Resident #2 (diagnosed with [REDACTED]. CNA B failed to don a gown. CNA B donned gloves and propelled the resident to the bathroom. CNA B removed a gait belt from his/her waist and applied the gait belt to the resident's waist. CNA B assisted the resident to stand using the gait belt and pulled his/her pants and brief down. While assisting the resident to pivot to the toilet the resident dribbled a small amount of diarrhea on his/her wheelchair and the floor. CNA B cleaned the wheelchair cushion and the floor with a wet washcloth and placed a dry towel in the wheelchair seat. Without changing gloves, the CNA removed and bagged the resident's soiled pants and brief. Without changing gloves, the CNA obtained wash cloths and wet them in the sink. Without changing gloves, the CNA took his/her peri-wash from his/her pant pocket and sprayed it on the wet wash cloths. CNA B assisted the resident to stand, holding the gait belt with the same contaminated gloves, while he/she cleansed feces from the resident's buttocks. There was a small amount of diarrhea on the toilet seat. Without changing gloves and holding the gait belt, CNA B assisted the resident to pivot and sit in the wheelchair without a brief or pants. The CNA changed his/her gloves and propelled the resident to bed. CNA B assisted the resident to transfer to the bed while holding the gait belt, removed the gait belt and threw it over the back of the resident's wheelchair. The gait belt then fell to the floor. The CNA positioned the resident in bed. The CNA removed his/her gloves and obtained the peri-wash bottle from the bathroom and replaced in his/her pants pocket without disinfecting the bottle. CNA B said that residents on isolation precautions had their own supplies, needed to perform daily cares, in the their room. CNA B said everything stays in the resident's room to prevent the spread of bacteria; -At 2:00 P.M. LPN A entered Resident #2's room without donning a gown. LPN A donned gloves and used wet gauze to clean the resident's buttock and rectum. LPN A threw the gauze, smeared with feces, in the resident's bed side trash can. LPN A changed gloves and applied triad cream to the resident's buttock. LPN A removed his/her gloves and washed his/her hands. LPN A failed to remove the trash can liner containing the feces smeared gauze and place it in the biohazard container. LPN A said for contact isolation precautions you should glove during cares; -At 2:10 P.M. CNA B entered Resident #7's (not diagnosed with [REDACTED]. CNA B found the resident on the toilet needing assistance with perineal care and to transfer to his/her wheelchair. CNA B said to the resident "Hold on a second, I need to go get my gait belt". CNA B left the room and returned with a gait belt around his/her neck. CNA B washed his/her hands and donned gloves. CNA B applied the gait belt to the resident's waist and assisted the resident to stand, holding the gait belt, and provided perineal care to the resident's buttocks. Without changing gloves, CNA B assisted the resident to pull up the incontinent brief, to his/her wheelchair and removed his/her gloves. CNA B propelled the resident to his/her bed and assisted the resident to bed, holding the gait belt. CNA B removed the gait belt from the resident's waist and positioned the resident. At 2:21 P.M. CNA B said she the gait belt she used for Resident #7 had been left in Resident #2's room; -At 3:30 P.M. CNA C exited Resident #4's room without wearing a gown. CNA C said he/she was assisting the resident with toileting. CNA C said the resident is on isolation precautions and a gown should be worn into the room when providing cares to the resident. CNA C said she did not wear a gown into the room while toileting the resident. Observations and interviews on 8/21/12 showed the following: -At 9:30 A.M. CNA D said he/she just finished giving Resident #2 a shower and was cleaning and sanitizing the room before the next resident. CNA D said it was not required to wear a gown for showers. CNA D said the gowns are optional if needed for safety. CNA D said he/she had never had any feces splatter onto his/her clothes during showers; -At 10:45 A.M. LPN E entered Resident #2's room and did not don a gown. LPN E gloved and applied Triad cream to the resident's buttock. LPN E removed gloves and washed hands. During an interview on 8/24/12 at 9:05 A.M., CNA F said if a resident is on isolation precautions for[DIAGNOSES REDACTED], staff should always gown and glove prior to entering the room if providing care for the resident. CNA F said residents on isolation precautions should have all their own supplies in the room such as vital sign equipment and gait belts. If you need to use a piece of equipment in the room it should be cleaned prior to exiting the room with the sanitizing wipes. During an interview on 8/24/12 at 8:35 A.M. LPN A said if a resident was on isolation precautions for[DIAGNOSES REDACTED] he/she would expect staff to gown during pericare or providing care to the resident's buttock. LPN A said the isolation residents should have their own supplies in the room such as gait belts, peri wash and vital sign equipment. If you need to use a piece of equipment in the room it should be cleaned prior to exiting the room with the sanitizing wipes. LPN A said she would not consider a carpeted room to be a sanitary after a resident on isolation was in the room. The resident should be on a tile floor, or one that could be cleaned with bleach. During an interview on 8/24/12 at 9:40 A.M., the Director of Nursing (DON) and Assistant Director of Nursing stated: -The policy of the facility is to use isolation precautions on all[DIAGNOSES REDACTED] residents. -Blood pressure cuffs, stethoscopes, thermometers and gait belts are to stay in the room, and after the resident is taken off of[DIAGNOSES REDACTED] precautions, they are to be properly sanitized. -Staff are to wash hands, and glove when they go into the room. Staff are to put on gowns when giving basic care that would involve putting resident on toilet, or cares given during diarrhea episodes. -It is not preferable to put a resident in a room with carpeting. -Staff should do one and one activities with residents with[DIAGNOSES REDACTED]. 2. Record review of Resident #3's quarterly MDS dated [DATE], showed the following: -Extensive assistance in toileting and hygiene; -Resident is not currently on a bowel or bladder program; -Resident is frequently incontinent of urine and bowel. Record review of the resident's care plan dated 7/4/12 showed the following: -Resident is frequently incontinent of urine; -Resident at times needs assistance with perineal (area in genital region and surrounding skin) cleansing; -Resident requires extensive to limited assistance with dressing, grooming, hygiene, and toileting. Record review of the physician order sheet (POS), dated August 2012 showed that the resident needs continuous care due to inability to live independently and the need for 24-hour assistance, observation, and planning. Observation on 8/20/12 at 1:42 P.M. showed Resident #3 in his/her wheelchair in his/her room. CNA I washed hands, donned gloves, and put resident to bed. CNA removed the resident's shoes, pants and undid the sides of the resident's brief while wearing gloves. The resident's brief had small amount of feces on it. While still wearing his/her gloves, CNA I cleaned the resident's genital area and then the buttocks free of feces. After cleaning the resident of feces and while wearing the same gloves he/she provided incontinent care with, the CNA applied barrier cream, repositioned resident's bed covers and pillows, turned on resident's bed alarm, and handed the resident his/her call light. CNA I then removed the dirty gloves and washed his/her hands. During an interview on 8/20/12, at 2:00 P.M., CNA I said that he/she always did his/her incontinent care in this same manner. When asked when he/she should change gloves, CNA I stated when they are soiled. CNA I agreed that gloves should be changed after providing incontinent care and prior to touching the resident and/or his/her personal belongings. CNA I said he/she would consider feces to have soiled the gloves. 3. Record review of Resident #1's admission MDS, dated [DATE] showed the resident required extensive assistance of two staff for bed mobility, dressing, toileting and personal hygiene. The resident was frequently incontinent of urine and always incontinent of bowel. Record review of the care plan, dated 7/10/12, directed staff to keep the resident clean and dry after incontinent episodes and to toilet the resident every two hours and as needed. Observations on 8/23/12 at 6:45 A.M., showed CNA G and CNA H washing hands and donning gloves. CNA G provided incontinent care to the resident's front perineal area. CNA H assisted to roll the resident to his/her right side. CNA G provided incontinent care to the resident's buttock with feces present. Without changing gloves, CNA G applied a clean dry incontinent brief and pants on the resident with assistance from CNA H. CNA G and CNA H sat the resident on the side of the bed, applied the gait belt around the resident's waist and transferred the resident to his/her wheelchair. During an interview on 8/24/12 at 9:05 A.M. CNA F said after providing perineal care on a resident, staff should change their gloves before applying barrier cream, applying a clean dry brief or touching the resident's clothing or personal belongings. During an interview on 8/24/12 at 9:40 A.M. with the Director of Nursing (DON) and Assistant Director of Nursing (ADON), stated: -Staff should gown and glove when they enter a[DIAGNOSES REDACTED] room to give personal care, and are going to come in contact with urine/feces (a lot of diarrhea). If just giving basic care it is not necessary to put on a gown. A gown is not needed If putting a resident on the toilet unless the resident is incontinent and splash back is expected. -Staff should should always change gloves and wash hands after giving peri care, then they can put on barrier cream. After changing gloves and washing hands staff can then transfer resident to wheelchair with a gait belt , use a Hoyer lift for transfer, and give personal care such as combing hair and brushing teeth. 4. Record Review of facility policy titled "Perineal Care", not dated, showed that after performing perineal care, staff should: -Remove gloves and discard into the designated container; -Wash and dry hands; -Reposition the bed covers and make the resident comfortable; -Place the call light within easy reach of the resident; -Wash and dry hands thoroughly. Record Review of the facility policy titled, "Hand washing/Hand Hygiene", not dated, states: -All personnel shall follow the hand washing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents and visitors; -Employees must wash his/her hands under the following conditions: -After handling soiled or used linens, dressings, bedpans, catheters and urinals; -After performing personal hygiene. Record review of the manual titled, "Nurse Assistant in a Long-term Care Facility" 2001 Revision edition, regarding hand washing and use of gloves showed staff are instructed as follows: - Wash hands before and after contact with the resident, which is the single most important means of preventing the spread of infection; - Always wash hands after using gloves; - Wash hands before and after glove use; and, - After contact with any waste or contaminated material; and, - Use gloves when doing mouth care, perineal care, skin care, and other procedures involving body fluids; - Gloves do not eliminate the need to wash your hands; they just provide a barrier between you and potentially infectious microorganisms; - Never touch unnecessary articles in the room or one's face, hair, contact lens, or glasses when wearing gloves;

Based on observation, record review, and interviews, the facility failed to ensure a medication error rate of less than 5% when four staff made four administration errors during 45 randomly observed medication passes, resulting in a medication error rate of 9%. One LPN gave insulin in an inappropriate site for one resident (Resident #20). This failure had potential to harm the resident, by causing his/her blood sugar to drop too low. The facility also failed to ensure that one resident (Resident#12 - a resident dependent upon staff help in care) received all of his/her nebulizer medication. This failure had the potential to harm the resident by increasing his/her risk for respiratory distress. Two CMTs failed to appropriately administer eye drops, by not shaking the bottle of medication, not instructing one resident (Resident #18) to hold his/her eye shut for one to two minutes per manufacture's recommendations and failed to monitor the resident and/or hold the inner part of the eye for the recommended one to two minutes. A sample of 16 residents were reviewed in the facility with a census of 78. 1. Record review of Resident #20's Quarterly MDS assessment dated [DATE], showed an active [DIAGNOSES REDACTED]. Record review of resident's care plan, dated 6/13/2012 showed the following: -Resident has a potential for complications related to [DIAGNOSES REDACTED]. -Staff should administer/monitor effects and effectiveness of medications as ordered to include both scheduled and sliding scale insulin (additional insulin dosages based on specific blood sugar levels). Record review of the resident's physician order [REDACTED]. Give five units subcutaneous (placed just beneath the skin) (Sub-Q) with meals. Observation on 8/23/2012 at 11:05 A.M. showed LPN E properly prepared and drew up five units of Humalog insulin. LPN E entered the resident's room where the resident was seated in his/her wheelchair. LPN E donned gloves and rubbed the resident's right deltoid (a large, triangular muscle covering the joint of the shoulder) with alcohol. The resident's upper arm was thin and did not have much fatty tissue covering the shoulder area. LPN E pinched the area that he/she had cleaned with alcohol, and at a 90-degree angle, injected the insulin into the deltoid region. Record review of facility's policy titled "Intramuscular Injections" (IM), not dated, states that a deltoid is a chosen site for an IM injection. This policy also states that an appropriate angle for an IM injection is 90 degrees. Record review of the facility's policy titled "Subcutaneous Injections", not dated, states that staff should do a Sub-Q injection at a 45 to 90-degree angle into an appropriate injection site. According to Mosby's "Pharmacology and the Nursing Process", Insulin should be injected into the thigh areas (front and back), outer areas of the upper arm (middle third area of the upper arm between the shoulder area and the elbow), and the abdomen. According to "Medical-Surgical Nursing: Critical Thinking for Collaborative Care" (fourth Edition) regarding insulin, an IM injection produces a faster absorption than does the Sub-Q injection. This reference states that an IM injection is not recommended for routine insulin administration because of the risk for [DIAGNOSES REDACTED] (low blood sugar level). During an interview on 8/24/12 at 9:20 A.M., LPN J stated that Sub-Q injections should be given in the fatty regions of the body, such as the abdomen or the back of the arm. The LPN stated that the injection should be given at a 45-degree angle. The LPN stated that giving a Sub-Q injection into the deltoid is not safe because it could go into the resident's muscle. The LPN stated that he/she would consider and injection into the deltoid area at a 90-degree angle an IM injection and not a Sub-Q injection. During an interview on 8/24/12 at 9:40 A.M., the Director of Nursing (DON) and the Assistant Director of Nursing (ADON) stated: -Sub-Q injections should be made in the leg, arm/back of arm not into the muscle. -The injection should be at a 45 degree angle not at a 90 degree angle. 2. Record review of Resident #12's Quarterly MDS Assessment, dated 08/02/12 showed the following: -Resident has short-term and long-term memory problems; -Cognitive skills for daily decision-making is moderately impaired, decisions making is poor, and cues/supervision required; -Altered level of consciousness is present and fluctuates; -An active [DIAGNOSES REDACTED]. Record review of the resident's care plan, dated 8/8/12 showed the following: -Resident had potential for respiratory distress; -Staff to administer medications to include inhalers as ordered; -Resident has difficulty in making decisions; -Resident has short-term and long-term memory deficit and cannot remember things that have happened recently; -Staff to provide reminders as appropriate. Record review of the resident's POS, dated August 2012 showed the following: -Resident needs continuous care due to inability to live independently and the need for 24-hour assistance, observation, and planning; -[MEDICATION NAME] (a medicated inhalation solution that is inhaled into the lungs by using a mouthpiece or a mask attached to a nebulizer reservoir) 2.5-0.5 mg/ml Solution. Give by nebulizer machine four times a day; -An additional [DIAGNOSES REDACTED]. Observation on 8/21/12, at 9:08 A.M., showed LPN K asked resident to return to room from television area so that he/she could administer his/her nebulizer treatment. The resident returned to his/her room. LPN K entered room, washed hands, assessed lung sounds and properly prepared the nebulizer solution in the nebulizer machine. LPN K gave resident instruction on how to hold the nebulizer and to take slow and even breaths in and out. Approximately one minute later, the LPN had to reinstruct the resident to take deep breaths. The resident removed the nebulizer from his/her mouth and began taking deep breaths. The LPN instructed the resident to have the nebulizer in his/her mouth when taking the deep breaths. The LPN had to demonstrate the technique for deep breathing and cued resident to keep lips sealed around the nebulizer. After approximately one to two minutes, the LPN exited the resident's room. The resident sat on his/her bed with nebulizer in mouth. At 9:18 A.M., the nebulizer treatment lay on the resident's bed, still running, with approximately one-half the medication still in the machine. The resident, nor the LPN, were in resident ' s room. Record review of the resident's Medication Administration Record (MAR) dated 8/22/12, at the 8:00 A.M. time, showed that LPN K documented he/she gave the [MEDICATION NAME] treatment. Record review of the resident's MAR and general notes for 8/22/12 showed that LPN D did not document partial administration of nebulizer and/or resident's refusal to complete nebulizer treatment. Record review of facility's policy titled "Administering Medications through a Small Volume (Handheld) Nebulizer" not dated, states that staff should remain with the resident for the treatment and administer therapy until medication is gone. This policy also states that staff should document the amount of medication that was administered on the MAR. During an interview on 8/24/12 at 9:20 A.M. LPN J said that for a dependant resident he/she would try and use a mask nebulizer instead of a hand-held nebulizer. The LPN said that if he/she found a breathing treatment unfinished, he/she would turn the treatment of [REDACTED]. During an interview on 8/24/12 at 9:40 A.M., the DON and ADON stated: -If the resident is dependent on nursing staff, the staff should position so that the resident has a mask on during the treatment and is comfortable, staff should monitor the resident during the treatment. -If the resident is able to use a hand-nebulizer, the resident should be cued and staff should monitor the resident during the treatment. -Staff should document if the resident refuses the medication, or does not finish his/or her treatment. 3. Record review of the Textbook of Basic Nursing from Lippincott 2008, ninth edition, Nursing Procedure: eye drops showed the following information regarding eye drop administration: -Instruct the client to close the eyelids and place gentle pressure on the inner canthus (near the bridge of the nose) after instilling eye drops. Maintain this pressure for 1 to 2 minutes; -Rationale: Applying gentle pressure helps to prevent the solution from draining into the lacrimal (tear) duct. It also minimizes the risks of systemic effect of the bacteria being washed into the lacrimal duct. Staff should assist the resident or remind the resident that closing the eyelid while applying gentle pressure facilitates better distribution of the eye medication. Record review of Resident #18's August POS showed, [MEDICATION NAME] AC 1% Eye Drop, one drop in left eye every day, 8:00 A.M., for eye disorder. During observation on 8/21/12 at 8:50 A.M., CMT L (Certified Medication Technicon) administered Resident #18's [MEDICATION NAME] Acetate Ophthalmic Drops, one drop in the left eye, per the physicians order. The CMT did not shake the medication bottle, as recommended per the manufacture's instruction. The CMT did not instruct the resident to gently hold her left eye shut at the tear duct of his/her left eye for two to three minutes per manufactures' instruction, nor did the CMT offer to hold the resident's inner eye. During an observation on 8/22/12 at 8:35 A.M., CMT M administered the resident's [MEDICATION NAME] Acetate Ophthalmic Drops, one drop in the left eye, per the physicians order. The CMT did not shake the medication bottle, per manufacturer's instructions. The CMT did not ask the resident to close her eyes and gently hold pressure on her the tear duct of his/her left eye for two to three minutes per the manufactures instructions. During an interview on 8/24/12 at 9:00 A.M., CMT L stated: -Staff should hold the inner corner of the eye for about one minute. -When asked by the surveyor if the resident's [MEDICATION NAME] needed any specific steps, the CMT answered no. -The CMT did not mention the the [MEDICATION NAME] needed to be shaken, the medication was within reach so he/she could have referred to the medication instructions. -He/she does not hold the resident's inner eye because he/she feels the resident is capable of doing that step him/herself. He/she does not remind the resident to hold his/her inner eye. During an interview on 8/21/12 at 9:55 A.M., the ADON stated: -The CMT should follow basic instructions, wash hands, glove, give the resident privacy, and tell the resident what he/she is going to do. -Staff should follow basic instruction, tilt the head back, pull down the lower eyelid, to form a pouch, drop the medication in the corner of the eye, and press the tear duct for one minute. -The CMT should follow the manufacturer's instruction as far as shaking the bottle before administering the eye drop, and hold the inner eye/or remind resident to hold the inner eye per the manufacturer's instructions.

Based on medical record review and staff, physician and family interviews the facility failed to provide the assessments, monitoring, and services necessary to prevent the development of pressure ulcers on one resident (Resident #1), admitted to the facility for rehabilitation after surgical repair of a right [MEDICAL CONDITION]. The resident acquired a Stage III sacral coccygeal pressure ulcer and a Stage II pressure ulcer on his/her left heel, thirteen days after his/her admission to the facility. The facility census was 75. 1. Record review of the European Pressure Ulcer Advisory Panel and National Pressure Ulcer Advisory Panel. Prevention and treatment of [REDACTED]. Washington DC: National Pressure Ulcer Advisory Panel; 2009 showed the following pressure ulcer classification system: -Stage I-intact skin with non-blanchable redness of a localized area usually over a bony prominence; -Stage II-partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled blister. Bruising indicates suspected deep tissue injury; -Stage III-full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon, or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling; -Stage IV-full thickness tissue loss with exposed bone, tendon, or muscle. Slough or eschar may be present on some parts of the wound bed. Often include undermining and tunneling; -Unstageable-full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown, or black) in the wound bed. Until enough slough and/or eschar is removed to expose the base of the wound, the true depth, and therefore stage cannot be determined. Stable (dry, adherent, intact without [DIAGNOSES REDACTED] or fluctuance) eschar on the heels serves as the "the body's natural cover" and should not be removed; -Suspected deep tissue injury- purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue. Evolution may include a thin blister over a dark wound bed. The wound may further evolve and become covered by thin eschar. Evolution may be rapid exposing additional layers of tissue even with optimal treatment. 2. Record review of the facility "Management of Pressure Ulcers", not dated, showed the following information: -Objective documented to identify residents with a high risk of pressure ulcer development and to manage the occurrence of pressure ulcers through restorative nursing interventions; -Procedure documented a full body skin condition assessment will be completed on all residents at the time of admission, weekly for four weeks following admission, upon readmission, and prior to each care plan conference or as significant changes in condition occur; -Procedure documented resident that are identified as "high risk" will be assessed weekly. The high-risk assessment will be added to the care plan and preventative approaches will be implemented; -Procedure documented all pressure areas should be observed daily for any redness or change in condition. Determine potential areas where microbial growth may occur (below breasts, gluteal folds, skin folds). 3. Record review of the facility "Skin Care, Management of Pressure Ulcers", not dated, showed the following information: -Objective documented to establish a systematic approach to the treatment of [REDACTED]. -Procedure documented when a pressure ulcer is noticed, its description must be documented on a Skin Condition Report Sheet. The description should include date of documentation, Stage I, II, III, IV, location, size in centimeters of length, width, and depth, drainage, and odor. The director of nurses (DON) or designated registered nurse (RN) will validate this documentation by observing the newly discovered open area and making a notation in the Nursing Progress Notes; -Procedure documented to notify the physician and initiate the treatment of [REDACTED].e. provide a barrier), yellow wound-clean, black wound-debride; -The alteration in skin integrity should be added to the overall plan of care; -A nutritional assessment should be completed. Significant weight loss should be addressed and a weight management program started. Use of vitamin supplements should be considered. Request a serum [MEDICATION NAME] and/or serum protein level for resident with a Stage III and Stage IV; -Establish a turning and repositioning schedule; -Provide the appropriate positioning devices, such as water/gel/air mattresses, heel-boots, foot/bed cradle, foam wedges, pillows, hand cones, foot elevator, pillow boots, etc.; -The DON or designated RN will observe each pressure ulcer weekly and will document the response to treatment on the skin condition progress report. If no progress is noted within four weeks, notify the physician to establish an alternative treatment; -In accordance with the facility Infection Control Policies a culture and sensitivity will be done on all draining wounds. 4. Record review of the physician orders [REDACTED]. -[DIAGNOSES REDACTED]. -Resident to be evaluated for physical, occupational, and speech therapies; -On 5/17/12, order for a regular diet with house supplements three times a day with meals; -On 5/17/12, medications included [MEDICATION NAME] 40 mg subcutaneous daily for 6 weeks for prevention of [MEDICAL CONDITION], [MEDICATION NAME] 5-325 two tablets every four hours as needed for pain, Tylenol Extra Strength 500 mg caplet one daily for pain, Aspirin 325 mg one tablet daily, [MEDICATION NAME] 20 mg one capsule daily, and laxatives as needed; -On 5/17/12, treatment for [REDACTED]. -On 5/20/12, new order for [MEDICATION NAME] 0.5 mg one tablet every eight hours as needed for anxiety. Record review of the care plan for the resident dated 5/24/12, showed the following information: -Staff identified resident at risk for skin breakdown and approaches included: - Staff to clean and dry the resident's skin after each incontinent episode, and apply topical barrier cream/lotions as needed; - During staff assisted showers the staff are to report any areas of redness/breakdown to the charge nurse; -Staff to do weekly and as needed skin checks and report any concerns to the assistant director of nurses (ADON) and physician for treatment orders; -Pressure relieving devices to bed/chair to minimize pressure points and promote skin integrity; -Resident unable to turn/reposition self in bed/chair. Provide turning/repositioning every two hours and as needed. Side rails as indicated for mobility; -Weekly skin checks by licensed staff and quarterly pressure ulcer risk assessment to ensure appropriate plan of care; -Monitor surgical site for complications and signs or symptoms of infection and then intervene as needed. -Staff identified resident at risk for falls and on 6/5/12, added to the care plan the resident will continue on skilled therapy and adjustments made to his/her air bed to improve safety. -Staff identified resident requires extensive assistance for dressing, bathing, toileting, hygiene, transfers, and mobility due to weakness and approaches included:-Observe for changes in skin condition during daily care and on bath days; -Assist resident with repositioning every two hours and as needed; -Resident incontinent of bowel and urine at times, staff to provide peri-care a needed. Record review of the nurses' notes regarding the resident showed the following information:-On 5/17/12, staff documented resident admitted to the facility and he/she was alert and orientated to person and place. Resident's right hip surgical incision was clean, dry and well approximated with no signs or symptoms of infection. The staples were intact. Staff noted the resident had a large, dry, scaly area on his/her left lower extremity. The inner prominence of his/her right foot was dry and reddened, but blanchable. The outer ankle of the resident's right foot had a small, dry, healing abrasion. The resident requires the assistance of one to two staff for personal cares at this time; -On 5/27/12 at 9:24 A.M., registered nurse (RN) A documented the resident complained of coccyx pain and on examination found the resident had a large 3 cm by 5 cm open sore on his/her coccyx between buttocks. The area was white and surrounding area reddened. RN A requested that staff put the resident to bed after meals and reposition the resident from side to side every two hours. Staff to apply Lantaseptic (a skin protectant) cream after each cleansing and as needed. RN A documented he/she will continue to monitor and will inform skin nurse of condition. (RN A did not notify the resident's physician or family regarding this large open sore) -On 5/28/12 at 9:42 A.M., licensed practical nurse (LPN) B called the resident's physician regarding his/her [MEDICATION NAME] medication. (LPN B did not document notifying the resident's physician regarding the pressure ulcer identified on 5/27/12) -On 5/30/12 at 2:16 P.M., the assistant director of nurses (ADON) documented the resident's family was notified regarding the pressure wound on the resident's coccyx and buttock and the wound on the resident's left heel. (This is three days after the initial coccyx wound was identified) The ADON discussed the treatments for the wounds with the family and informed them the resident's physician saw the wounds today. Record review of the care plan conference summary for the resident dated 5/29/12, showed the following information:-Conference attended by resident and family and five facility staff; -Resident cooperative with therapy; -Therapy reported slow progress, resident starting to move leg. Resident needs cueing for safety. Resident tolerates upper extremity exercises well. Resident walks a maximum of 50 feet with a lot of encouragement. His/Her pain has lessened. Speech therapy working with the resident; -Resident more awake this week, his/her level of alertness has improved; -Participates with activities of daily living needing moderate assist; -Walks with assistance of two; -Resident with sore bottom. Record review of the physician nursing home visit on 5/30/12, showed the following information: -Resident is alert, orientated, and well nourished; -Vital signs are noted and stable;-Approximately three days ago the resident complained of some pain in his/her tail bone; -Examination of resident's tail bone showed a sacral coccygeal ulcer with whitish appearance to the bed. There was some slight peri-wound induration and slight bruising along the right lateral aspect, Stage III possible Stage IV ulcer. -Examination of his/her left heel showed a small, intact, clear fluid-filled blister. There does not appear to be bruising or signs of active pressure. - Right hip incision site appeared intact with just some very mild [DIAGNOSES REDACTED] (redness); -Plan included starting local wound care with enzymatic debridement (removal of dead or damaged tissue) to sacral coccygeal ulcer and painting his/her left heel blister, then covering with foam and using a pressure/relief boot. Staff to place the resident on a pressure relief mattress and have a Roho cushion for his/her wheelchair. Staff are to schedule resident for a dietary consultation and resident to be on house supplements and vitamins at this time. Record review of the physician orders [REDACTED]. -On 5/30/12, treatment order for staff to cleanse resident's buttock with normal saline, apply santyl (enzymatic [MEDICATION NAME] agent), AMD gauze and [MEDICATION NAME] twice a day; -On 5/30/12, treatment order for staff to paint resident's left heel blister with [MEDICATION NAME] (topical anti-infective) and cover with foam every three days and as needed; -On 5/30/12, treatment pressure relief boot to left heel while in bed; -On 5/30/12, Zinc Sulfate 220 mg one capsule daily; -On 5/30/12, Calcium 600 & Vitamin D one tablet twice a day; -On 5/31/12, Vitamin C 500 mg caplet daily for 30 days; -On 5/31/12, Vitamin D 2 1.25 mg one tablet on Fridays for eight weeks; -On 5/31/12, Roho cushion to wheelchair and pressure relief mattress; -On 6/1/12, Multivit-Minerals tablet one daily; -On 6/3/12, Protein powder, one scoop to food/drink twice a day. Record review of the facility Pressure Ulcers sheet for the resident showed the following information: -Ulcers identified on 5/30/12; -Coccyx, Stage III, measured at 3.5 cm by 1.0 cm, treatment identified Santyl (enzymatic [MEDICATION NAME] agent) with AMD gauze twice a day; -Right medial buttock, Stage II, measured 1.0 cm by 1.0 cm, treatment same as coccyx ulcer; -Left heel, Stage II fluid filled blister, measured 2.0 cm by 1.5 cm, treatment identified [MEDICATION NAME] swab and podus boot; -Resident to have an air mattress and Roho cushion. During an interview on 6/20/12 at 10:15 A.M., the ADON said the charge nurses are to report to him/her directly if a wound is found on a resident. The ADON does the weekly skin assessments on the residents identified with wounds. He/She said the charge nurse told him/her about the wound on Resident #1. The ADON did not assess and monitor the resident's skin weekly; he/she said the resident just fell through the crack. The resident's physician looked at it on 5/30/12, and was very concerned. During an interview on 6/20/12 at 1:30 P.M., RN A said he/she works week-ends at the facility. RN A said on Memorial week-end an aide came to him/her to see the wound on the resident's bottom. RN A assessed the resident and put a note in the computer charting about the wound. RN A said he/she did not measure the wound but did an approximate. RN A said the skin nurse follows up and does the measurements. RN A said he/she also passed the information on to the next charge nurse. RN A did not notify the physician. RN A said the physician saw the wound that following Wednesday and he/she was not happy about it. During an interview on 6/20/12 at 2:05 P.M., LPN B said an aide told him/her the resident had an open area on his/her bottom. LPN B said the area looked like a triangle about 2 cm by 2 cm. LPN B said they tell the ADON or the wound nurse, RN C, and they do the assessment of the area and call the physician. During an interview on 6/20/12 at 2:15 P.M., RN C said he/she did the initial head to toe admission assessment on the resident. He/She said the resident did not have any skin concerns on his/her bottom on admission to the facility. RN C said the ADON gives him/her a list weekly of skin assessments to complete. RN C said the resident was never on the weekly skin list for him/her to assess. During an interview on 6/25/12 at 12:25 P.M., the resident's physician said he/she was in the facility on 5/30/12, reviewed the resident's medical record and saw the nurses' note made on 5/27/12 regarding the open area on the resident's coccyx. The physician requested staff position the resident in bed for an examination. The physician said the staff had not notified him/her of the open area. The physician said the resident had a Stage III area covered with white slough. The area was tender. The physician started an enzymatic debridement and when the resident was discharged from the facility to home the area had improved. The physician said the staff normally called him/her on any skin concern, this incident was uncommon for the facility. During an interview on 6/25/12 at 2:56 P.M., a family member said when the resident entered the facility for therapy following hip surgery the resident did not have any bedsore. The family member said the therapy was excellent. The family member said the resident got bedsores while he/she was at the facility and one was a large open hole on his/her bottom. The family member said they continue to have home health daily to help with the dressing changes and packing the hole. The family member said they do the dressing changes twice a day and it is slowly healing from the inside out. The family member said the resident's left heel area was getting better. Complaint #MO 148