Every finding on record at Rolla Presbyterian Manor

Based on observation, interview and record review, the facility staff failed to store food in a manner to prevent potential contamination and out-dated use. Facility staff also failed to use food in a first in-first out method when facility staff opened multiple containers of the same food item for use. These failures have the potential to affect all residents. The facility census was 19. 1. Review of the facility's Food Storage policy, revised [DATE], showed: -Food is stored immediately after receipt and maintained in a manner that prevents damage, spoilage, infestation and bacterial contamination; -All products are labeled and dated with the receiving date. Move old supplies to the front of the shelf to ensure rotation of products and place new supplies to the rear of the shelf; -The policy did not contain information related to storage of opened and prepared food items or management of food items past their best by or use by dates. Observation on [DATE] at 6:47 A.M., showed the reach-in freezer by the kitchen break room contained three undated plastic resealable bags of prepared cinnamon rolls, an opened and undated bag of uncooked cinnamon rolls, and an opened and undated bag of blueberries. Observation on [DATE] at 6:55 A.M., showed the basement dry goods pantry contained an opened and undated bag of shredded coconut, an undated five pound bag of egg noodles opened to the air, and an undated 25 pound bag of short grain brown rice opened to the air. Observation on [DATE] at 7:23 A.M., showed the walk-in freezer contained: -a plastic resealable bag of salami with an opened date of [DATE] and a facility printed use-by date of [DATE]; -a cases of chicken fried breaded beef patties, beef patties, turkey bacon, hashbrown patties and double chocolate chip cookie dough opened to the air and undated; -an opened and undated plastic bag of pork chops removed from original packaging; -an opened and undated 10 pound bag of pepperoni slices; -an opened and undated bag of jumbo raw shrimp stored in an undated plastic resealable bag; -an opened and undated bag of whole kernel corn stored in an undated plastic resealable bag; -an opened and undated bag of okra stored in an undated plastic resealable bag; -an opened and undated plastic bag of french fries removed from original packaging; -an undated and unlabeled plastic resealable bag of unidentifiable breaded ball shaped items; -a large bag of shredded hashbrown's opened to the air and undated; -opened and undated bags of peas, green beans, and sugar snap peas. During an interview on [DATE] at 7:35 A.M., the kitchen supervisor said the breaded ball shaped items in the bag were hushpuppies. The kitchen supervisor said he/she did not know when the hushpuppies were put in the bag and the bag should have been labeled with what it is and when it was opened. Observation on [DATE] at 7:40 A.M., showed the walk-in refrigerator contained: -a plastic resealable bag labeled as Reese's cup candy with an opened date of [DATE] and facility printed use-by date of [DATE]; -a plastic resealable bag labeled as Reese's cup candy dated ,d+[DATE]; -a four pound bag of candy coated chocolate pieces opened to the air and undated; -two plastic bags of whipped topping opened to the air and undated; -an opened and undated five pound bag of shredded carrots; -a case of sausage patties opened to the air and undated. Observation on [DATE] at 8:39 A.M., showed the cabinet under the counter in the cook's station contained: -an opened bag of plain bread crumbs dated [DATE] with a manufacturer use-by date of [DATE]; -a 42 ounce box of quick oats opened to the air and undated; -three bags of light brown sugar dated [DATE] opened to the air; -a 32 ounce bottle of vanilla opened to the air and undated; -a 36 ounce carton of augratin potatoes opened to the air and undated; -a bag of peppered gravy mix dated [DATE] opened to the air; -four opened and undated bags of powdered sugar. During an interview on [DATE] at 8:45 A.M., the kitchen supervisor said staff should use all of one food item before they open another container, staff should date and label opened and prepared food items, and staff should discard food items past their use-by dates. The kitchen supervisor said he/she had not been able to do much organizing or supervise as he/she should due to staffing issues and he/she knew they had a lot of work to do. Observation on [DATE] at 9:05 A.M., showed an undated bulk bin of flour removed from its original packaging and an undated bulk bin of sugar removed from its original packaging and measuring cup with its handle buried in the sugar. During an interview on [DATE] at 9:06 A.M., the kitchen supervisor said bulk food containers should be dated when they are filled and scoops should not be stored inside the containers. The kitchen supervisor said he/she did not know why the containers were not dated or why staff left the scoop inside the sugar. During an interview on [DATE] at 10:22 A.M., the Certified Dietary Manager (CDM) said opened and prepared food items should be stored in sealed containers, dated with their open or made dates and labeled with the product name if it is not easily identified. The CDM said staff should use the entirety of one food package before they open another of the same thing and staff are expected to discard food items that are past their use-by dates. The CDM said bulk containers of food should be dated when filled and scoops should not be stored inside the bins. The CDM said the receiving dietary aide is delegated to check the food storage twice a week on Tuesdays and Fridays to ensure food items are stored in correct areas, in sealed container, dated, labeled and not expired. The CDM said he/she is ultimately responsible to monitor the food storage and he/she looks daily, but he/she could not explain why their were food items past their use-by dates in active storage. The CDM staff are trained on food storage requirements and he/she had a discussion with staff about multiple packages of the same food items being opened when he/she cleaned out the cabinet in the cook's station about five weeks ago. During an interview on [DATE] at 10:42 A.M., the administrator said opened and prepared food items should be stored in sealed containers, dated with their open or made dates and labeled with the product name if it is not easily identified. The administrator said staff should use the entirety of one food package before they open another of the same thing unless the product is expired and staff are expected to discard food items that are past their use-by dates. The administrator said bulk containers of food should be dated when filled and scoops should not be stored inside the bins. The administrator said staff are trained on food storage requirements upon hire and the cooks are responsible to monitor the food storage at least weekly.

Based on observation, interview and record review, the facility staff failed to properly contain waste and refuge to prevent the harboring and/or feeding of rodents and pests when the facility failed ensure indoor waste containers remained covered when not in actual use. This failure has the potential to affect all facility occupants. The facility census was 19. 1. Review of the facility's Garbage policy, undated, showed: -Team members must handle garbage in a manner that will minimize contamination and prevent pests; -This procedure applies to all units and the manger/person in charge is responsible to ensure that the removal and disposal of garbage is handled properly to minimize contamination and prevent pests; -Ensure garbage containers have bags and the containers must be covered when not in use. Observations on 03/05/25 at 6:22 A.M., 6:42 A.M., 7:50 A.M. and 10:07 A.M., showed the waste container near the mechanical dishwashing station, which contained food and paper waste, uncovered and the area unattended by staff. Observations on 03/05/25 at 6:33 A.M., 6:42 A.M., 7:50 A.M. and 10:07 A.M., showed the waste container in the cook's station, which contained food and paper waste, uncovered and the area unattended by staff. Observations on 03/05/25 at 06:42 A.M.,7:50 A.M. and 10:07 A.M., showed the waste container between the ice machine and reach-in refrigerator, which contained food and paper waste, uncovered and the area unattended by staff. Observation showed dead pests and a pest trap with dead pests on the floor behind the waste container. During an interview on 03/05/25 at 10:07 A.M., the kitchen supervisor said the waste containers had not had lids during his/her employment at the facility which began about a month ago. The kitchen supervisor said he/she believed the waste containers should be covered, but he/she did not know why they did not have lids to cover them. During an interview on 03/05/25 at 10:19 A.M., the Certified Dietary Manager (CDM) said trash cans should be covered when not in actual use to not attract pests, but someone previously said that the containers were in such constant use that they did not need to cover them. The CDM said staff were not trained to cover the waste containers when not in-use. During an interview on 03/05/25 at 10:38 A.M., the administrator said waste containers should be covered when not in actual use, all staff are responsible to ensure they are covered, and staff are trained on this requirement. The administrator said he/she did not know staff thought they did not need to cover the waste containers.

Based on record review and interview, facility staff failed to document a complete and accurate Minimum Data Set (MDS) assessment (a federally mandated assessment instrument) when staff did not complete a discharge summary for resident (Resident #5), did not document a weight loss or injections received for one resident (Resident #6), failed to accurately document medication use for one resident (Resident #9), did not document a pressure injury for one resident (Resident #11), and failed to complete a significant change of status assessment (SCSA) for one resident (Resident #17) for hospice services. The facility census was 21. 1. Review of the facility's MDS Data Accuracy policy, dated [DATE], showed: -It is the responsibility of those who complete sections of the MDS to ensure data entered accurately reflects the resident's status and is coded according to Resident Assessment Instrument (RAI) Manual guidelines (universal guide for completion of the MDS); -RAI coordinator will import any data via interfaces/links; -RAI coordinator will work with staff to ensure any erroneous data is corrected and MDS is accurate; -The policy did not contain direction for when to complete an MDS assessment. Review of the Centers for Medicaid and Medicare Services (CMS) Long Term Care Facility RAI 3.0 User Manual, Version 1.18.11 dated [DATE] showed: -Comprehensive assessments are completed when a significant change of status occurs; -A SCSA is required to be performed when a terminally ill resident enrolls in a hospice program and the Assessment Reference Date (ARD) must be within 14 days from the effective date of the hospice election; -From the medical record, compare the weight in the current observation period to the weight in the observation period 30 days ago, if less than the weight in the observation 30 days ago, calculate the percentage of weight loss; -From the medical record, compare the weight in the current observation period to the weight in the observation period 180 days ago, if less than the weight in the observation 180 days ago, calculate the percentage of weight loss; -Check anticoagulant if an anticoagulant was taken by the resident in the 7-day lookback period; -Record the number of days the resident received any type of medication by injection in the lookback period, including insulin; -Enter the number of days insulin injections were administered; -Check if a resident has a stage I or greater pressure injury/ulcer over a bony prominence. -A discharge return not anticipated assessment is required to be performed 14 calendar days from the date of discharge from the facility 2. Review of Resident #5's Quarterly MDS dated [DATE], showed the resident admitted on [DATE]. Review of the resident's nurse notes, dated [DATE] through [DATE], showed the resident expired in the facility on [DATE]. Review of the resident's medical record showed the record did not contain a completed or submitted discharge return not anticipated assessment. During an interview on [DATE] at 12:26 P.M., the Director of Nursing (DON) said he/she was not aware of the missing discharge assessment for the resident. 3. Review of Resident #6's Quarterly MDS, dated [DATE], showed staff assessed the resident did not have a 5% or more weight loss in the last month or loss of 10% or more in the last six months. Review of the resident's weight record, dated [DATE], showed the resident weighed 193.8 lbs. On [DATE], the resident weighed 183.8 pounds which was a 5.16 % loss in one month. Review of the resident's Quarterly MDS, dated [DATE], showed staff assessed the resident as: -Cognitively impaired; -Did not receive injections of any type. Review of the resident's Physician Order Sheet (POS), dated [DATE], showed: -On [DATE], an order for Lantus Solostar U-100 Insulin to be given 37 units subcutaneous daily at bedtime; -On [DATE], an order for Insulin Aspart U-100 Insulin to be given by sliding scale three times daily at 6:00, 11:00 and 4:00. During an interview on [DATE] at 12:26 P.M., the DON said he/she was not aware of the incorrect coding for the resident. 4. Review of Resident #9's SCSA dated [DATE], showed the resident received an anticoagulant. Review of the resident's POS, dated [DATE] through [DATE], did not contain a physician order for an anticoagulant medication During an interview on [DATE] at 12:26 P.M., the DON said he/she was not aware of the incorrect coding for the resident. 5. Review of Resident #11's SCSA, dated [DATE], showed the resident did not have a stage I or greater pressure area over a bony prominence. Review of the resident's weekly skin assessments, showed on [DATE] a deep tissue injury to the right heel measured 0.8 centimeters (cm) by 1.0 cm. Review of the resident's POS, dated [DATE], showed an order on [DATE] for skin prep and a foam dressing to be applied daily to the right heel. During an interview on [DATE] at 12:26 P.M., the DON said he/she was not aware of the incorrect coding for the resident. 6. Review of Resident #17's Annual MDS, dated [DATE], showed the resident did not receive hospice services. Review of the resident's hospice coordination of care document, dated [DATE], showed the resident admitted to hospice services on [DATE]. Review of the resident's medical record showed the record did not contain a completed or submitted SCSA. During an interview on [DATE] at 12:26 P.M., the DON said he/she was not aware the significant change of status assessment was not complete for the resident. 7. During an interview on [DATE] at 12:26 P.M.,The DON said it is the MDS Coordinators responsibility to ensure the MDS assessments are accurate and completed timely. He/She said the MDS nurse recently left the position and he/she has been trying to keep up along with his/her other duties. The DON said there has been issues with the software pulling over data to the MDS and working on getting that fixed. During an interview on [DATE] at 12:41 P.M., the Administrator said he/she expects the MDS nurse to keep the MDS data accurate and completed timely. 43327

Based on observation, interview, and record review, facility staff failed to maintain an accident free environment when staff failed to provide a safe mechanical transfer for two residents (Resident #6, and #17). Facility staff failed to store razors in a safe and effective manner in an unlocked shower room. The facility census was 21. 1. Review of the facility's Lifting and Transferring Residents policy, dated October 11, 2007, showed staff were directed as follows: -The facility will provide a safe work environment for resident care areas by providing and requiring the use of safety materials, equipment and training designed to prevent injury; -Staff is accountable for utilizing proper body mechanics, lifting techniques and resident safety. Failure to utilize a mechanical resident lift when the use of the equipment is indicated in the resident's care plan may result in disciplinary action up to and including termination of employment. Review of the mechanical lift manufacturer's user manual, dated 10/01/18, showed when using an adjustable base lift, the legs must be in the maximum opened/locked position before lifting the patient. 2. Review of Resident #6's Quarterly Minimum Data Set (MDS), a federally mandated assessment dated [DATE], showed staff assessed the resident as: -Severely cognitively impaired; -Dependent on staff for transfers between the bed and wheelchair. Observation on 01/23/24 at 10:45 A.M., showed Certified Nursing Assistant (CNA) B lifted the resident from the bed with the mechanical lift, legs in the closed position, and kept the legs closed while he/she rolled the lift with the resident in the sling to the resident's wheelchair. CNA B did not open the mechanical lift legs in the open/maximal position before he/she lifted and transferred the resident from the bed to the wheelchair. During an interview on 01/23/24 at 03:47 P.M, CNA B said he/she believed the hoyer legs should be closed when a resident is lifted in the sling, but could not remember being trained on how to properly use a hoyer lift. 3. Review of Resident #17's Annual MDS, dated [DATE], showed staff assessed the resident as: -Severely cognitively impaired; -Dependent on staff for transfers between the bed and wheelchair. Observation on 01/23/24 at 03:34 P.M., showed CNA C raised the resident with the mechanical lift and said, we have to close the legs so we can get through, CNA C and CNA D rolled the resident from the couch to the resident's bed with the lift legs in closed position. CNA C and CNA D did not open the mecanical lift legs in the open/maximal position before he/she lifted and transferred the resident from the couch to the bed Observation on 01/23/24 at 03:44 P.M., showed CNA C and CNA D did not open the mechanical lift legs in the open/maximal position before he/she lifted and transferred the resident from the bed to the wheelchair. During an interview on 01/23/24 at 03:47 P.M, CNA C said he/she believed the mechanical lift legs should be closed. CNA C said he/she did not learn about the position the mechanical lift legs should be, or if it had been taught, it was a long time ago. 4. During an interview on 01/25/24 at 12:30 P.M., the Director of Nursing (DON) said the legs of a mechanical lift should be open because there is a risk for tipping. Staff should be educated on this procedure. During an interview on 01/25/24 at 1:00 P.M., the administrator said the legs of a mechanical lift should be open to the widest position possible to safety stabilize a resident. 5. Review of the facility's Storage of Chemicals and Environmental Services Supplies policy, dated 11/2022, showed the policy did not contain direction for the safe storage of razors or hazardous chemicals in the resident shower room. Observation on 01/23/24 at 2:07 P.M., showed the whirlpool room unlocked and unattended. Observation showed the shower room contained three boxes of 10 count razors and an open box of 10 count razors in a plastic unlocked tote and a single razor on the sink. Observation on 01/24/24 at 3:24 P.M., showed the 100 hall shower door unlocked and unattended with residents in the hall. The shower room contained a unsecured storage bin of resident razors. During an interview on 01/25/24 at 9:34 A.M., CNA F said shower rooms should be locked because there is a risk to the resident's safety with chemicals and razor blades being assessable. During an interview on 01/25/24 at 9:45 A.M., CNA G said shower room doors should be closed and locked when not in use. There is a resident safety issue if the are unlocked. During an interview on 01/25/24 at 10:00 A.M., Licensed Practical Nurse (LPN) H said shower rooms are to be locked due to the risks to a resident getting access to chemicals or razors. During an interview on 01/25/24 at 12:30 P.M., the Director of Nursing said shower rooms doors should be locked and supplies put away due to the risk of injury to a resident. During an interview on 01/25/24 at 1:00 P.M., the Administrator said shower rooms should be locked with chemicals and razors being a risk to residents. We are all responsible for checking this. 42484 43327

Based on observation, interview and record review, staff failed to maintain adequate infection control practices to prevent the transmission of infection when staff failed to use appropriate hand hygiene and perineal cleansing during provisions of personal care for three (Resident #14, #17, and #19) of three sampled residents. The facility census was 21. 1. Review of the facility's Hand Hygiene policy, revised September 7, 2022, showed when hands are visibly dirty or contaminated with proteinaceous material or are visibly soiled with blood or body fluids, wash hands with soap and water. Review showed handwashing may also be used for routinely decontaminating hands in the following clinical situations before and after having direct contact with residents, before and after contact with body fluids or excretions, mucous membranes, non-intact skin, and wound dressings, even if hands are not visibly soiled, when moving from a contaminated body site to a clean body site during resident care, before and after contact with inanimate objects including medical equipment in the immediate vicinity of the resident. Review showed after removing gloves. The use of gloves does not eliminate the need for hand hygiene, change gloves during elder care if moving from a contaminated body site to a clean body site and decontaminate hands after removing gloves by appropriate hand hygiene. 2. Review of Resident #14's Quarterly Minimum Data Set (MDS), a federally mandated assessment, dated 12/08/24, showed staff assessed the resident as: -Severely cognitively impaired; -Required substantial/maximal assistance for toileting hygiene; -Required substantial/maximal assistance for lower body dressing; -Frequently incontinent of urine; -Frequently incontinent of bowel. Observation on 01/24/24 at 02:15 P.M., showed Certified Nursing Assistant (CNA) C and CNA E entered the resident's room and applied gloves. Observation showed CNA C removed the residents soiled slacks. CNA C continued to wear the same soiled gloves, placed the resident clean slacks on the bed, removed the resident feces soiled brief and wiped the resident's peri-area multiple times with the same cleansing wipe. Observation showed CNA E used one wipe multiple times to clean fecal material from the resident's leg and wiped from the leg up toward the perineal area. CNA E removed his/her gloves and left the resident's room and returned with supplies and did not wash his/her hands before he/she re-entered the room and applied the resident's brief. During an interview on 01/24/24 at 02:31 P.M., CNA E said hands should be washed when entering and leaving a resident room, and gloves should be changed and hands sanitized using hand sanitizer when hands are contaminated. CNA E said when using wipes, one section of the wipe should be used for each section of the wipe. He/She said it was acceptable to repeat using the wipe as long as there was a clean area on the wipe left. 3. Review of Resident #17's Annual MDS, dated [DATE], showed staff assessed the resident as: -Severely cognitively impaired; -Required substantial/maximal assistance for toileting hygiene; -Dependent for lower body dressing; -Frequently incontinent of urine; -Occasionally incontinent of bowel. Observation on 01/23/24 at 03:34 P.M., showed CNA D removed the resident's soiled brief, changed gloves and put a clean brief on the resident. CNA D did not perform hand hygeine between glove changes. CNA C wiped fecal material from the resident's buttocks, changed gloves, then cleaned the front of the resident's perineal area. CNA C did not perform hand hygeine between glove changes. CNA C wiped the resident's perineal area multiple times with the same wipe. CNA C completed perineal care and did not remove his/her gloves or perform hand hygiene before he/she touched the mechanical lift. During an interview on 01/23/24 at 03:47 P.M., CNA C said hands should be sanitized before and after entering the room, and between glove changes. Glove changes with hand sanitization should be done when moving care to a different area of the resident's body. He/She said being observed made staff nervous and more mistakes are made. 4. Review of Resident #19's Quarterly MDS, dated [DATE], showed staff assessed the resident as follows: -Cognitively intact; -Dependent on staff for lower body dressing and toileting; -Used a catheter; -Incontinent of bowel; -Diagnosis of neurogenic bladder (lack bladder control due to nerve problem). Observation on 01/24/24 at 03:52 P.M., showed CNA C and CNA J performed catheter and perineal care on the resident. CNA J wiped down the mechanical lift, removed his/her gloves, applied new gloves and did not perform hand hygiene between glove changes. CNA C pulled down the resident's blankets and sheet, removed his/her gloves, applied new gloves and did not perform hand hygiene between glove changes. CNA J sprayed a foam cleaner directly on the resident's genitals, cleansed the genitals and used the same portion of a wet wipe multiple times over the area. CNA C and CNA J used the same area of the wipe and wiped the resident's groin folds. CNA J used the same wet wipe used on the groin folds and went over the resident's genitals again. CNA J removed his/her gloves, did not perform hand hygiene, applied clean gloves, cleansed the resident's catheter, removed his/her gloves, touched a throw blanket and clean brief, applied new gloves, applied a barrier cream to the genitals and inner thighs, removed gloves and did not perform hand hygiene. CNA C and J rolled the resident, cleansed the buttocks area, removed gloves, did not perform hand hygeine, applied clean gloves, secured a clean brief, pulled up the resident's pants, and positioned the mechanical lift sling. CNA C did not perform hand hygeine before he/she applied new gloves and hooked the resident's catheter to the wheelchair. During an interview on 01/24/24 at 4:15 P.M., CNA J said he/she was really nervous being watched and knows he/she should have washed his/her hands between glove changes to decrease germs from spreading. He/She said he/she did not think about changing the portion of the wipe but probably should have. Was just trying to get the job done. During an interview on 01/24/24 at 4:22 P.M., CNA C said when wiping a resident the wipe should be discarded after each swipe or at least change the position to keep the dirt from getting on the clean areas. He/She said he/she was aware he/she did it, but thought he/she corrected it when it was noticed. He/she said staff are instructed to wash hands between glove changes but was nervous and missed the step. 5. During an interview on 01/24/24 at 12:26 P.M., the Director of Nursing (DON) said staff should wash hands or sanitize between glove changes, when going into and out of a room, when visibly soiled. He/She said the same portion of a wet wipe should not be used over the skin multiple times or could risk introducing bacteria to the resident. The DON said a skills day was scheduled for the current week but due to survey, was canceled. During an interview on 01/24/24 at 12:41 P.M., the administrator said hand hygiene should be performed when hands are visibly soiled and between glove changes. He/she said using a wet wipe multiple times over one area causes germs and dirt to spread. 43327

Based on observation, interview and record review, the facility staff failed to perform hand hygiene as often as necessary using approved techniques to prevent cross-contamination. The facility census was 28. 1. Review of the facility's Hand Hygiene policy, dated 05/2018, showed Staff will perform hand hygiene when indicated, using proper technique consistent with accepted standards of practice. Review showed the policy directed staff to wash their hands before and after handling contaminated items and after they remove gloves. Review showed the policy directed staff to not reuse or wash disposable gloves. Review also showed the policy directed the staff to use the following technique when performing hand hygiene using soap and water: -Wet hands with water; -Apply enough soap to cover all hand surfaces; -Rub their hands together vigorously for at least 15 seconds over all surfaces of their hands and fingers; -Rinse hands with water; -Dry hands thoroughly with a single-use towel; -Use a towel to turn off the faucet. Observation on 12/20/22 at 10:28 A.M., showed Dietary Aide (DA) A washed his/her hands at the handwashing sink. Observation showed the DA used a paper towel to turn off the faucet and then used the same paper towel to dry his/her hands. Observation showed the DA continued to perform clean tasks, which included bare hand touching of food contact surfaces used to prepare and serve food items to residents at the lunch meal. Observation on 12/20/22 at 10:30 A.M., showed DA B washed his/her hands at the handwashing sink. Observation showed the DA used a paper towel to turn off the faucet and then used the same paper towel to dry his/her hands. Observation showed the DA continued to perform clean tasks, which included bare hand touching of food contact surfaces used to prepare and serve food items to residents at the lunch meal. Observation on 12/20/22 at 10:38 A.M., showed DA C washed his/her hands at the handwashing sink. Observation showed the DA turned the faucet off with his/her wet bare hands and then handled food service kitchenware. Observation on 12/20/22 at 12:44 P.M., showed DA A washed his/her hands at the handwashing sink. Observation showed the DA scrubbed his/her hands with soap for four seconds, rinsed his/her hands, turned the faucet off with a paper towel and then used the same paper towel to dry his/her hands. Observation showed the DA then put away sanitized dishes from the clean side of the mechanical dishwashing station. During an interview on 12/20/22 at 12:45 P.M., DA A said staff should turn the faucet off with a paper towel so they do not touch the handles that have germs on them. The DA said he/she did not think about the paper towel being contaminated when he/she used it to dry his/her hands. Observation 12/20/22 12:57 P.M., showed DA D washed his/her hands at the handwashing sink. Observation showed the DA scrubbed his/her hands with soap for four seconds, rinsed his/her hands and then turned the faucet off with his/her wet bare hands. Observation showed the DA put a bandage on over an open wound on his/her hand, donned a glove over his/her bandaged hand and then put sanitized dishes away from the clean side of the dishwashing station. Observation on 12/20/22 at 12:59 P.M., showed DA D washed his/her hands at the handwashing station while he/she wore the used glove on his/her bandaged hand. Observation showed the DA scrubbed his/her hands for three seconds, rinsed his/her hands, and then turned the faucet off with his/her wet bare hand. Observation showed the DA continued to put away sanitized dishes from the clean side of the mechanical dishwashing station. During an interview on 12/20/22 at 1:05 P.M., DA D said he/she had worked at the facility for about six months and thought he/she had been trained on handwashing procedures upon hire. The DA said staff should scrub their hands with soap for 15 seconds, rinse, dry their hands with paper towel and then turn the faucet off with a paper towel. The DA said he/she did not know why he/she did not scrub his/her hands long enough or turned the faucet off with his/her wet bare hands other than it was out of habit. During an interview on 12/20/22 at 1:11 P.M., the Certified Dietary Manager (CDM) said, when staff wash their hands, they should scrub their hands all over with soap for 20 to 30 seconds, rinse, dry their hands with a towel, and use a towel to turn off the faucet. The CDM said staff should not use the same paper towel to dry their hands that they used to turn of the faucet. The CDM said staff are trained on handwashing procedures upon hire and the Infection Control Preventionist audits handwashing in all departments. The CDM said staff's performance of hand hygiene had been an identified concern during past audits. During an interview on 12/20/22 at 1:37 P.M., the administrator said, when staff wash their hands, they should scrub their hands for 15 to 20 seconds with soap, rinse, dry their hands with a paper towel and then turn the faucet off with a paper towel. The administrator said staff should not wash their gloves or use the same paper towel to dry their hands that they used to turn off the faucet. The administrator said staff are trained on infection control, which includes hand hygiene procedures, upon hire. The administrator said each director is supposed to do audits for their own department, so the CDM would be responsible to do them for the dietary staff along with dietary services management company.

Based on interview and record review, facility staff failed to perform Gradual Dose Reductions (GDRs) on psychotropic medications for one resident (Resident #2) and failed to ensure that as needed (PRN) psychotropic medication orders were limited to 14 days unless specific duration and clinical rationale were provided for two residents (Resident #3, and #18). The facility census was 28. 1. Review of the facility's Psychoactive Psychopharmacological Medications policy showed the following: For the purposes of this policy, psychoactive medications includes antidepressants, anxiolytics, hypnotics, sedatives and antipsychotics. For any of these type of medications, gradual dose reductions and behavioral interventions will be done per physician orders, unless clinically contraindicated, in an effort to discontinue the medication or to reach the lowest effective dose. -A drug regimen review is conducted and documented monthly by a licensed nurse, pharmacist, or PCP. -PRN psychotropic medications (anti-depressant, anti-anxiety and hypnotics) are limited to 14 days unless the attending physician believes a prescription for longer than 14 days is appropriate and documents rationale in the medical records. -PRN antipsychotic medications are limited to 14 days. The prescribing physician must evaluate the resident before writing a new order for an antipsychotic medication. 2. Review of Resident #2's Quarterly Minimum Data Set (MDS), a federally mandated assessment tool, dated 11/22/22, showed the following: -Received antipsychotic and antidepressant medications 7 out of 7 days in the look back period (7 day period of time before the assessment is completed to capture the status of a resident); -Diagnosis of anxiety, and major depressive disorder. Review of the resident's Physician Order Sheets (POS), dated December 2022 showed the following: -On 07/01/21 Trazadone (antidepressant/sedative medication) 100 milligrams (mg) daily at Bedtime (HS); -On 05/27/22 Xanax (antianxiety medication) 0.25mg BID (twice a day) and Xanax 1mg at HS. Review of the resident's medical record showed the record did not contain an attempt for a GDR for the resident's psychotropic medications or a clinical rationale by the physician to continue the medication without a GDR. 3. Review of Resident #3's annual MDS, dated [DATE], showed the following: -Did not receive antianxiety medications; -Diagnosis of Alzheimer's disease (a progressive mental deterioration that can occur in middle or old age, due to generalized degeneration of the brain), Anxiety, and Major Depressive Disorder. Review of the resident's POS, dated December 2022 showed the following: -An order on 11/7/22 Lorazepam Intensol (antianxiety medication) 0.5 milliliters (ml) by mouth every twelve hours as needed for anxiety; -The order did not contain a 14 day stop date. Review of the resident's medical record showed the record did not contain a specific duration or clinical rationale by the physician for the use beyond the 14 days. 4. Review of Resident #18's significant change MDS dated [DATE], showed diagnoses of Dementia, Major Depressive Disorder, Generalized Anxiety Disorder. Review of the resident's POS, dated December 2022, showed the following: -An order on 9/8/22 Lorazepam Intensol 0.25ml Sublingual every six hours PRN for anxiety and restlessness; -The order did not contain a 14 day stop date. Review of the resident's medical record showed the record did not contain a specific duration or clinical rationale by the physician for the use beyond the 14 days. During an interview on 12/21/22 at 5:45 P.M., the Licensed Practical Nurse (LPN) G said to his/her knowledge, all pharmacist recommendations for GDRs and PRN psychotropic medication orders, are put into a folder for the physician to review. After the physician has reviewed, made changes, or has provided a rationale for continuing the drug, it is the Director of Nursing's (DON) responsibility to update the resident charts. During an interview on 12/21/22 at 6:22 P.M., the Administrator and DON said the monthly GDRs were reviewed by the physician and the physician must either implement the GDR or provide a rationale for continuing an order for psychotropic medication. 47193

Based on interview and record review, facility staff failed to provide notice related to transfers of residents to the hospital to the Ombudsman (a resident advocate who provides support and assistance with problems and/or complaints regarding the facility) for five of four sampled residents (Resident #9, #11, #30, and #230). The facility census was 28. 1. Review of the facility's Admission, Transfer and Discharge Policy, revised 12/6/21, showed the policy did not include direction for staff to notify the ombudsman for resident discharges or transfers. Review of an email from the Ombudsman on 12/15/22 at 8:44 A.M., showed the Ombudsman wrote the facility does not send him/her monthly notifications of discharged or transferred residents. 2. Review of Resident #9's medical record showed the following: -Transferred to the hospital on 8/35/22; -The record did not contain written documentation staff notified the Ombudsman of the resident's transfer to the hospital. 3. Review of Resident #11's medical record showed the following: -Transferred to the hospital on 8/11/22 and readmitted to the facility on [DATE]; -Transferred to the hospital on 9/30/22; -The record did not contain written documentation staff notified the Ombudsman of the resident's transfer to the hospital. 4. Review of Resident #30's medical record showed the following: -Transferred to the hospital on 11/23/22; -The record did not contain written documentation staff notified the Ombudsman of the resident's transfer to the hospital. 5. Review of Resident #230's medical record showed the following: -Transferred to the hospital on 8/1/22; -The record did not contain written documentation staff notified the Ombudsman of the resident's transfer to the hospital. 6. During an interview on 12/20/22 at 11:50 A.M., the Social Services Director (SSD) said he/she does not notify the Ombudsman of transfers or discharges. He/She has worked at the facility for six years but was not aware this needed to be done. During an interview on 12/21/22 at 6:22 P.M., the Administrator and Director of Nursing (DON) said the Ombudsman was not notified of resident transfers or discharges.

Based on observation, interview, and record review, facility staff failed to implement appropriate infection control measures related to COVID-19 (an infectious disease caused by severe acute respiratory syndrome coronavirus 2 ([DIAGNOSES REDACTED]-CoV-2)). Staff failed to follow Center for Disease Control & Prevention (CDC) guidelines for facemask use. In addition, staff failed to prevent the spread of bacteria and other infection causing contaminants during the provision of care for one resident (Resident #1) when staff failed to complete thorough incontinence care and by not disinfecting multi-resident use equipment. Facility census was 25. Review of the facility's in-service summary, dated 5/29/2020, showed staff were instructed to sanitize all equipment, such as vital sign equipment and lifts, between each use. Further review of the in-service summary showed it did not identify who was responsible to clean the equipment or instruct staff how to sanitize the equipment. Review of the facility's policy Lifting and Transferring Residents, revised 5/2/2019, directed staff as follows: -Handle grips that come in contact with resident's hands, will be covered in plastic or cleaned with a sanitizing wipe and allowed to dry prior to the resident grasping the handle. Review of the facility's Perineal Care Procedure, undated, showed staff were directed as follows: -After washing, rinsing, and drying the perineal area and genitalia, staff are to: -Wash and rinse other skin areas between the legs; -Wash and rinse the anal area; -And then pat the perineal area dry. 1. Observation on 6/3/2020 at 11:10 A.M., showed Resident #1 in his/her bed wearing a wet brief. Certified Nursing Assistant (CNA) A & CNA B pulled the resident's brief down, in the front, while CNA A used disposable wipes to clean the resident's groin creases, and then placed a clean brief under the resident without washing the resident's buttocks or thighs. Upon being positioned to his/her back the resident was incontinent of urine a second time. CNA B used disposable wipes to clean the resident's groin creases, removed his/her gloves, and threw them across the resident's bed to the trash can, where one glove landed on the floor. CNA A placed a clean brief under the resident without washing the resident's buttocks or thighs. Further observation showed CNA A and CNA B used a mechanical lift (device used to lift and move residents who are unable to do so on their own) to transfer the resident, and then placed the lift in the hallway, without being sanitized. Observation on 6/3/2020 at 11:27 A.M., showed housekeeping staff passed the lift in the hallway without disinfecting it. Observation on 6/3/2020 at 11:35 A.M., showed the mechanical lift still in the hallway without being disinfected. Observation on 6/3/2020 at 11:45 A.M., showed the mechanical lift still in the hallway without being disinfected. During an interview on 6/3/2020 at 11:20 A.M., CNA B said the facility had three residents who used the lift. He/She said staff usually store the lift in the shower room, but if they were going to be using it quickly, they left it in the hallway. He/She said housekeeping comes by and disinfects the lift with wipes. He/She said CNAs do not disinfect the lift. During at interview on 6/3/2020 at 12:10 P.M., CNA A said staff should wash hands, apply gloves, clean the resident from front and back, change gloves and put a new brief on the resident when performing perineal care. He/She said they did not wash Resident #1's bottom when performing perineal care, but did not say why. He/She went on to say CNAs are supposed to wipe down the mechanical lift with bleach wipes right after use, and he/she sometimes goes back to do it before using the lift on someone else. During an interview on 6/3/2020 at 12:00 P.M., the Director of Nursing (DON) said lifts should be disinfected between residents. He/She said ideally staff should wipe lifts down after use, but staff do not know if the person who used the lift before them wiped it down, so the lift should be wiped down before it's used. He/She said CNAs should use sani-cloths to wipe the lifts down, and they had been trained to wipe them down after use. Furthermore, he/she said if a resident is incontinent of urine, he/she expected staff to wash the resident's creases, groin, genitalia, gluteal crease (where the buttocks meets the thighs), and buttocks. During an interview on 6/3/2020 at 12:30 P.M., the Executive Director (ED) said multi-use equipment should be sanitized after every use with sani-wipes or bleach wipes. 2. Review of the CDC's, Sequence for Removing Personal Protective Equipment, showed: -The front of the mask/respirator is contaminated-DO NOT TOUCH; -If your hands get contaminated during mask/respirator removal, immediately wash your hands or use alcohol based hand rub; -And grasp bottom ties or elastics of the mask/respirator, then the ones at the top, and remove without touching the front. Observation on 6/3/2020 at 10:50 A.M., showed dining service assistant C wearing a cloth facemask. He/she touched the middle of his/her facemask with his/her fingers, and took food trays from the hot cart and placed them on the steam table. Dining service assistant C did not perform hand hygiene after touching his/her contaminated mask, and before touching trays that held resident food. Additional observation showed dining service assistant C touched his/her mask two more times, and then adjusted the lids on the steam table. He/She did not perform hand hygiene, after touching his/her contaminated mask and before touching the steam table that held resident food. During an interview on 6/3/2020 at 10:55 A.M., dining service assistant C said the facility provided an in-service on how to properly wear a facemask. He/She said staff are not supposed to touch the front, or inside of the mask. He/She did not say why he/she touched his/her mask during the dining service. During an interview on 6/3/2020 at 12:00 P.M., the DON said staff training for mask use included covering their mouth and nose, wearing masks at all times, and not touching the mask with their fingers. He/She said staff were instructed to use the mask's ear loops for adjustment. He/She said if staff touch their mask they are expected to perform hand hygiene after doing so.

Based on observation, interview, and record review, facility staff failed to ensure medications were monitored and stored in a safe and effective manner. Staff failed to discard one opened insulin pen after 28 days and failed to document the open date of one insulin vial. The facility census was 23. 1. Review of the facility's Medications - Vials and [MEDICATION NAME] of Injectable Medications policy, revised (MONTH) (YEAR), showed vials and [MEDICATION NAME] of injectable medications are used in accordance with the manufacture's recommendations or the provider pharmacy's directions for storage, use, and disposal. Review of the manufacturer's recommendation for Basagar insulin injection pens (a rapid acting human insulin analog used to lower blood sugar), showed the medication must be discarded 28 days after it is opened, even if it still has insulin left in it. Review of the manufacturer's recommendation for [MEDICATION NAME] vials (a rapid acting human insulin analog used to lower blood sugar), showed the medication must be discarded 28 days after it is opened, even if it still has insulin left in it. 2. Observation on [DATE] at 1:45 P.M., showed the medication room refrigerator with an opened Basagar insulin pen with an open date of [DATE]. Additional observation showed an open vial of [MEDICATION NAME] without an opened date. During an interview on [DATE] at 8:40 [NAME]M., licensed practical nurse (LPN) A said staff are expected to discard insulin based on the manufacturer's recommendations and expected to document an opened date on the insulin or packaging when the insulin is opened. LPN A said staff are expected to check the insulin pen and/or vial prior to administering the insulin to ensure the insulin has not expired past the opened date and to ensure the insulin has an opened date. During an interview on [DATE] at 10:30 [NAME]M., the director of nursing (DON) said he/she expects staff to discard insulin pens 28 days after being opened and expects staff to date insulin when the insulin is opened. During an interview on [DATE] at 1:28 P.M., the administrator said the Basagar insulin pen should have already been discarded and said he/she would expect for all insulin to have an opened date written on the bottle or the insulin packaging.

Based on observation, interview, and record review the facility staff failed to maintain nutritional status, and did not serve each meal to one resident (Resident #17) who had significant (15.8%) weight loss. The facility census was 26. 1. Review of the facility's Nutritional Status policy, dated 8/14/18, showed it directs staff: -The facility will ensure that the resident maintains usual body weight or desirable body weight range and electrolyte balance unless the resident's clinical condition demonstrates this is not possible; -Parameters of nutritional status which need to be addressed include unplanned weight loss; -Nutritional needs will be assessed and evaluated as needed; -Review weights monthly for variances, standard parameters for evaluating unplanned and undesired weight loss are: -30 days, greater than 5% is considered severe loss; -90 days, greater than 7.5% is considered severe loss; -180 days, greater than 10% is considered severe loss; -If monthly weight supports significant unplanned weight loss: -initiate weekly weight monitoring and document in the medical record; -notify dietary, primary physician, and family of weight loss; -document in the interdisciplinary notes; -Resident's receive diets per physician orders; -Diet order obtained from the physician; -Communicate with dietary regarding order; -Explain diet change to resident family, and resident representative; -Update the resident's Care plan. -Risk factors include medication side effects; poor health, hygiene, eyesight, motor coordination, or taste alterations; depression or dementia; therapeutic or mechanically altered diet; lack of access to food; slow eating pace resulting in food becoming unpalatable or in staff removing tray before resident has finished eating; [MEDICAL CONDITION]. 2. Review of Resident #17's significant change in status (SCSA) Minimum Data Set (MDS), dated [DATE], showed staff assessed the resident as: -Severe cognitive impairment; -Required extensive physical assistance of one staff member for eating, and hygiene; -Required extensive physical assistance of two or more staff members for bed mobility, transfers, dressing, and toilet use; -Weighs 120 pounds (lbs.), significant weight loss, not on a physician prescribed weight loss program; -Mechanically altered diet; -Diuretic medication daily; -At risk for pressure ulcers; -One unhealed unstageable pressure ulcer. Review of the resident's weight record, dated 7/1/18-12/31/18, showed staff documented the resident weight as follows: -7/2/18 140.4 pounds (lbs.); -8/6/18 128.8 lbs.; -8/13/18 134.4 lbs.; -8/20/18 138.4 lbs.; -9/3/18 136.4 lbs.; -10/1/18 124.2 lbs.; -11/5/18 123 lbs.; -12/3/18 120.2 lbs.; -12/24/18 118.6 lbs.; -12/31/18 118.2 lbs. (22 lbs. weight loss since 7/2/18, 15.8% weight loss). Review of the resident's physician's orders [REDACTED]. Review of the resident's care plan, dated 7/24/18, shows staff are directed as follows: -The resident is at risk for alterations in nutrition; -Resident to remain within 5 lbs. plus or minus of previous body weight; -The resident is on a pureed diet; -Weigh the resident weekly; -The resident requires assistance and encouragement at times to eat; -2 cal (protein supplement) routinely; -Monitor my intake; -Prosource (protein supplement) daily. Review of the resident's care plan, dated 10/10/18, shows staff are directed as follows: -The resident is at risk for alterations in nutrition; -Resident to remain within 5 lbs. plus or minus of previous body weight; -The resident is on a pureed diet; -Weigh the resident weekly; -The resident requires assistance and encouragement at times to eat; -2 cal (protein supplement routinely; -Monitor my intake; -Prosource (protein supplement) daily. The care plan did not include updates or reevaluations with the resident's continued weight loss, or a plan to include exclusion of any routine meals. Review of the resident's Nutritional Progress Note, dated 9/25/18, showed staff documented the resident is not eating well, but does better if someone engages him/her while he/she is eating. The resident loves dessert and hot tea. Review of the resident's Interdisciplinary Note, dated 11/6/18 showed the staff received new orders to increase the resident's 2 cal to three times a day. Review of the resident's Nutritional Progress Note, dated 12/10/18, showed staff documented the resident's weight down 16.2 lbs. in three months, 11.88% weight loss. Further reviewed showed the resident is on a pureed diet, 2 cal two times daily, and Prosource once daily, continue to encourage intake. Review of the resident's medical record showed it did not contain staff documentation of notification of the physician or family about the resident's continued weight loss. Review of the daily charting, dated 12/1/18-1/4/18, showed staff documented the following: - The meals the resident attended the resident needed extensive assistance of one staff member for eating; -12/4/18 breakfast did not occur for the resident; -12/6/18 lunch did not occur; -12/7/18 breakfast did not occur; -12/8/18 breakfast did not occur; -12/10/18 dinner did not occur -12/18/18 dinner did not occur; -12/20/18 breakfast did not occur; -12/24/18 lunch did not occur, dinner meal did not contain charting; -12/25/18 lunch did not occur; -12/26/18 breakfast did not occur, dinner did not occur; -12/29/18 breakfast did not occur; -12/30/18 lunch and dinner did not occur; -1/1/19 breakfast and dinner did not occur -1/2/19 dinner did not occur; -1/3/19 lunch did not occur; -1/4/19 lunch did not occur. Observation on 1/3/19 from 11:00 A.M. until 12:30 P.M., showed the resident in bed with his/her eyes closed. Additional observation showed the staff did not go to the resident's room to assist the resident to the noon meal, or bring a tray to his/her room for the resident to eat. During an interview on 01/03/19 at 12:15 P.M., Dietary Aide (DA) J said nursing staff told him/her the resident would not be eating lunch but he/she did not know why. During an interview on 1/03/19 at 12:31 P.M., certified nurse assistant (CNA) C said if staff get the resident up for breakfast, they do not get him/her up for lunch because he/she would probably just fall asleep. He/She said the resident doesn't refuse, he/she is always pleasant, but staff just let the resident sleep. He/She said staff do not bring the resident a room tray or hold a tray for the resident for later. Observation on 1/4/18 from 11:00 A.M. until 12:30 P.M., showed the resident in bed with his/her eyes closed. Additional observation showed the staff did not go to the resident's room to assist the resident to the noon meal, or bring a tray to his/her room for the resident to eat. During an interview on 1/4/19 at 12:51 P.M., CNA C said staff did not get the resident up for lunch today because he/she got up for breakfast. He/She said he/she did not know if it is on the care plan, or who decided to get the resident up only for breakfast or lunch, but they have been doing it for a little while. During an interview on 1/4/19 2:18 P.M., registered nurse (RN) E said staff assist all residents to get up for meals, and if they do not go to the dining room, staff are expected to bring them a room tray. He/She said it is important to encourage residents with weight loss at every meal. He/She said the resident has been a weight loss but he/she did not know the resident did not get up for lunch. He/She said he/she did not know if skipping meals is on the resident's care plan. During an interview on 1/4/19 at 3:14 P.M., the dietary manager (DM) said he/she did not know of any resident that staff leave in bed for any routine meals. He/She said if a resident misses a meal, staff should offer them something when they wake up. He/She said he/she did not know staff did not offer the resident lunch or breakfast. He/She said the resident has weight loss and is a weekly weight and receives a supplement. During an interview on 1/4/19 at 4:01 P.M., the director of nursing (DON) said staff are expected to get all resident's up for all meals unless they refuse. He/She said there is not any resident that routinely skip meals. He/She said he/she is not aware the staff have not been getting the resident up for all meals. He/She said the resident is a weight loss and needs to be encouraged to eat. During an interview on 1/4/19, at 4:50 P.M., the administrator (ADM) said he/she is not aware of any resident that is not going to all meals. He/She said he/she expects staff to offer every meal to every resident. The administrator said she did not know staff were not getting the resident up for a meal and not offering the resident a tray. During an interview on 1/14/19 at 4:00 P.M., the registered dietitian (RD) said if residents do not come for a meal, then staff should offer them something when they wake up. He/She said if a resident routinely misses , then there should be a plan in place to make sure their needs are met when they are routinely awake. He/She said staff have not discussed the resident missing meals with him/her. He/She said every resident should be offered three meals a day and a bedtime snack, or have an individualized plan to meet their needs. During an interview on 1/17/18 at 3:24 P.M., the physician said the facility staff did not notify him/her of the resident's weight loss. He/She said he/she expects the facility staff to notify him/her if a resident has weight loss so he/she can address it.

Based on observation, interview and record review, facility staff failed to provide restorative nursing services to prevent the development of contractures (shortening or hardening of muscles, skin, or connective tissue at the joints related to lack of use), or worsening of existing contractures, or range of motion (ROM) for four residents (Resident #7, #11, #13, and #17) out of 12 sampled residents. The facility census was 26. 1. Review of the facility's policy Nursing Restorative Care Program, last updated 7/11/18, showed it directed the staff: -Nursing interventions that focus on achieving and maintaining optimal physical, mental, and psychosocial functioning, improve or maintain function in physical abilities and activities of daily living (ADLs), and prevent further impairment; -Restorative goals must be descriptive and measurable as to distance, number of assists, number of days of the week, etc.; -Daily restorative activity is documented in the electronic health record, an update to the resident's care plan, and a weekly note; -Restorative modalities must be carried out or supervised by members of the nursing staff; -Restorative groups can have no more than four resident's per supervising caregiver, who have been trained in restorative modalities; -Although therapist may participate, members of the nursing staff are responsible for the overall coordination and supervision of the restorative program; -Restorative nursing does not require a physician's orders [REDACTED].>-The Registered nurse Restorative Nurse Coordinator or registered nurse designee creates the Restorative plan, reviews the weekly documentation, and evaluates effectiveness and revise the program as needed. 2. Review of Resident #7's annual Minimum Data Set (MDS), a federally mandated assessment tool, dated 10/23/18, showed staff assessed the resident as: -Cognitively impaired; -Required total assistance of two or more staff members for bed mobility, transfers, dressing, and toileting; -Required extensive assistance of two or more staff members for locomotion and personal hygiene; -Functional range of motion impaired in one upper extremity; -Use splint or brace assistance every day. Review of the resident's care plan, dated 11/14/18, showed the plan directs staff the resident refuses a palm protector or a rolled washcloth in his/her left hand daily. The care plan did not contain direction to staff to prevent further decline or worsening of his/her left hand contracture. Further review showed staff to refer to the physician's orders [REDACTED]. The POS does not contain orders for a restorative program. Review of the resident's medical record showed it contained a restorative nursing plan that directs staff to continue a restorative program for the left hand contracture and decreased ROM. Staff are directed to perform active range of motion/passive range of motion (AROM/PROM) and to apply a palm protector to the left hand daily for an 8 hour span. Review of the resident's restorative minutes for the month of (MONTH) (YEAR), showed the resident did not receive AROM/PROM. He/She did not receive a splint or a brace to the left hand for 16 out of 31 days, as well as the required 8 hours daily on the days the splint was applied. The document did not contain staff documentation of refusal of care. Observation on 1/3/19, at 11:58 A.M., showed the resident in a wheelchair in the dining room. Further observation showed the resident's left hand in his/her lap throughout the meal. The resident did not have a splint or a rolled wash cloth in his/her left hand. Observation on 1/4/19, at 11:30 A.M., showed the resident in bed with his/her left hand to his/her side with his/her fingers curled. The resident did not have a splint or a rolled wash cloth in his/her left hand. During an interview on 1/3/19, at 11:58 A.M., RN E said the resident will not let anyone touch his/her left hand because he/she said it is broken. During an interview on 1/4/19, at 11:30 A.M., RN E said the resident had an x-ray on his/her left hand that showed it was not broken. The RN said the resident acts like it hurts him/her when they try to move it. 3. Review of Resident #11's quarterly MDS, dated [DATE], showed staff assessed the resident as: -Cognitively intact; -[DIAGNOSES REDACTED]. -Functional limitation in range of motion to one lower extremity; -The resident did not receive restorative nursing. Review of the resident's care plan, dated 9/4/18, showed it did not contain direction to the staff regarding the resident's limited range of motion. Review of the resident's record showed it did not contain a restorative plan to prevent further decline in range of motion. During an interview on 1/3/19 at 1:45 P.M., the resident said he/she received therapy before. He/She said facility staff help him/her ambulate short distances but he/she said staff do not work with his/her left leg now. 4. Review of Resident #12's quarterly MDS, dated [DATE], showed staff assessed the resident as: -Moderate cognitive impairment; -Functional limitation in range of motion to both lower extremities; -The resident did not receive restorative nursing. Reviewed of the resident's care plan, dated 12/6/18, shows it directs staff the resident is unable to fully straighten his/her legs due to contractures. The care plan did not contain direction to staff to prevent further decline or worsening of the resident's contractures. Review of the resident's medical record showed it did not contain a restorative nursing plan. Observation on 1/3/19, at 2:05 P.M., showed the resident in his/her bed. Additional observation showed the resident's legs with contractures. During an interview on 1/3/19 at 2:06 P.M., the resident said he/she cannot straighten his/her legs. He/She said he/she does not remember staff helping him/her to stretch his/her legs, or move his/her legs. He/She said he/she has a lot of pain in his/her legs and back. 5. Review of Resident #13's MDS, dated [DATE], showed staff assessed the resident as: -Severe cognitive impairment; -No behaviors; -Extensive two person assist dressing; -Limitations in functional ROM in one upper and one lower extremity; -Splinting/bracing five out of seven days; -One person assist eating. The MDS did not contain staff documentation of ROM services. Review of the resident's interdisciplinary notes dated, 11/21/18, shows staff documented the following: -Resident continues on restorative program for splint use to the left wrist. Hand washed with warm water and soap then dry completely before donning splint. PROM to left wrist and digits prior to donning splint for a 6 hour span every evening once in bed for the night. Splint is to be placed at HS (hour of sleep) and removed the following morning. AROM of right upper extremity, self feeding with minimal to stand by assist with encouragement. Review of the resident's restorative chart for December, (YEAR) showed staff did not document any PROM and did not chart any AROM. Staff documented they applied the resident's splint 21 out of 31 days in December, (YEAR). Observation on 1/04/19, at 8:51 A.M., showed the resident in his/her wheelchair. Additional observation showed his/her left arm and hand contractured. Further observation showed the resident did not have on protective devises or splints. 6. Review of Resident #17's significant change in status (SCSA) MDS, dated [DATE], showed staff assessed the resident as: -Severe cognitive impairment; -Required extensive physical assistance of one staff member for eating, and hygiene; -Required extensive physical assistance of two or more staff members for bed mobility, transfers, dressing, and toilet use; -The resident does not have functional limitation in range of motion; -The resident did not receive restorative nursing. Observation on 1/3/19 at 3:04 P.M., showed the resident in bed. Further observation showed the resident could not straighten his/her legs and held his/her left hand in a fist while staff turned him/her side to side. Observation on 1/4/19 8:40 A.M., showed CNA C and CNA G transfer the resident from his/her wheelchair to his/her bed. Additional observation showed when staff raised the resident to a standing position, he/she did not fully extend his/her legs. Further observation showed the resident kept his/her left hand in a closed position. During an interview on 1/4/19 at 9:00 A.M., CNA C said the resident keeps his/her left hand in a closed position most of the time. He/She said the resident does not fully extend his/her legs. 7. During an interview on 1/4/19 at 9:00 A.M., CNA C said the CNA's are expected to do whatever task is assigned to the resident, like walk to dine or place a splint. He/She said there is not a restorative aide he/she knows of. He/She said he/she does not know of any residents that are supposed to receive range of motion. During an interview on 1/04/19 at 11:58 A.M., registered nurse (RN) E said the restorative program is set up and reviewed by licensed practical nurse (LPN) G. During an interview on 1/04/19, at 12:02 P.M., licensed practical nurse (LPN) G said he/she sets up and reviews the restorative plans recommended by therapy. He/She said the facility does not have any residents on a restorative plan for range of motion, and residents with contractures are not automatically put on a restorative plan unless therapy sees them for the contractures. He/She said if therapy does not see a resident, the director of nursing (DON) establishes who needs ROM and he/she implements a plan. He/She said the facility does not have a designated trained staff member to perform restorative nursing services, the tasks are listed on the resident's profile for the CNA's to perform. During an interview on 1/04/19 at 2:37 P.M., the DON said residents with contractures or potential for contractures should have range of motion to increase range of motion or prevent worsening contractures. He/She said he/she is not sure if the residents with contractures have a restorative plan or task for the CNA's to perform range of motion.

Based on interview and record review showed staff failed to maintain monthly pharmacist documentation, and ensure the Pharmacist Medication Regimen Review (MRR) is communicated and responded to by the physician for five resident's (Resident #3, #7, #9, #17, and #27) out of 12 sampled residents. The facility census was 26. 1. Review of the facility's policy Drug Regimen Review, dated 5/24/18, showed the policy directed the staff: -Residents medication regimen will be reviewed monthly and as needed by a licensed pharmacist; -The facility staff will inform the consultant pharmacist of any physical and/or mental conditions of the resident which are likely to affect his/her medication therapy outcome; -The facility staff will ensure that the physician/prescribes are provided with copies of the MMRs; -The pharmacist will address copies of residents MRRs to the director of nursing and the attending physician, and to the medical director; -Any irregularities, significant risks or actual/potential adverse consequences should be identified in the report; -The facility staff will encourage physician or other responsible parties receiving the MRR and the director of nursing to act upon the recommendations contained in the MRR, or reject all or some of the recommendations contained in the MRR and provide an explanation as to why the recommendation was rejected; -If the attending physician has decided to make no change in the medication, the attending physician should document the rationale in the resident's health record; -Community will maintain copies of the MRRs in the resident's permanent medical record or in a special file in accordance with applicable law. 2. Review of Resident #3's Minimum Data Set (MDS), an federally mandated assessment tool, dated 10/2/18, showed staff assessed the resident as: - Severe cognitive impairment; - [DIAGNOSES REDACTED]. - No behaviors; - Antianxiety, Antidepressant, Hypnotic, and Opioid medications daily. Review of the resident's Consultant Pharmacist MRR, dated 12/13/18, showed the pharmacist documented he/she sent a recommendation to the physician to assess risk vs. benefit and if the resident would benefit from a reduction of [MEDICATION NAME] (medication for anxiety) 0.5 (milligrams) mg two times per day, [MEDICATION NAME] (medication for depression) 60 mg daily, [MEDICATION NAME] (medication for depression) 15 mg at bedtime, [MEDICATION NAME](medication to induce sleep) 5 mg at bedtime or address in your progress notes that a change is clinically contraindicated. Review of the resident's chart showed it did not contain response from the physician for the 12/13/18 visit. 3. Review of Resident #7's annual MDS, dated [DATE], showed staff assessed the resident as: -Cognitively impaired; -[DIAGNOSES REDACTED]. -No behaviors; - Antidepressant daily. Review of the resident's Consultant Pharmacist MRR, dated 12/13/18, showed the pharmacist documented he/she sent a recommendation to the physician to assess risk vs. benefit and if the resident would benefit from a reduction of the [MEDICATION NAME] (medication for depression)10 mg daily order or address in your progress notes that a change is clinically contraindicated. Review of the resident's chart showed it did not contain a response from the physician for the 12/13/18 visit. 4. Review of Resident #9's MDS, dated [DATE], showed staff documented the resident with: -No cognitive impairment; -No behaviors; -Supervision for eating; -One person assist to toilet; -Antidepressant every day. Review of the resident's physician's orders [REDACTED]. Review of the resident's Pharmacist Medication Regimen Review, dated 10/3/18-12/13/18, showed the pharmacist documented on 10/3/18 and 12/13/18 a request for the reduction of [MEDICATION NAME] ordered. Review of the resident's medical record showed it did not contain the pharmacist consultation report for the months February, (YEAR) through September, (YEAR). 5. Review of Resident #17's significant change in status (SCSA) MDS, dated [DATE], showed staff assessed the resident as: -Severe cognitive impairment; -Receives daily diuretic (for excess fluid) medication; -Significant weight loss. Review of the resident's Consultant Pharmacist Medication Regimen Review Log (MRR), dated 1/4/18-6/7/18, showed the pharmacist documented he/she sent a recommendation to the physician on 6/7/18. Review of the residents chart did not contain a letter from the pharmacist to the physician, or a response from the physician for the 6/7/18 visit. 6. Review of Resident #27's quarterly MDS, dated [DATE], showed staff assessed the resident as: -Severe cognitive impairment; -[DIAGNOSES REDACTED]. -Diuretic medication daily. Review of the resident's physician's orders [REDACTED]. The order did not contain a stop date. Review of the resident's Consultant Pharmacist MRR Log, dated 1/4/18-6/7/18, showed the pharmacist documented he/she sent a recommendation to the physician on 3/7/18. Review of the residents chart showed it did not contain a letter from the pharmacist to the physician, or a response from the physician for the 3/7/18 visit. Review of the resident's medical record, showed it did not contain a response to the MRR progress note for continued use. 7. During an interview on 1/04/19, at 2:18 P.M., registered nurse (RN) E said licensed staff are expected to carry over new orders from the pharmacist request when they are received from the physician. During an interview on 1/04/19, at 4:17 P.M., the director of nursing (DON) said he/she does not know if there are physician responses to the missing pharmacist reviews. He/She said staff can not find the monthly pharmacist recommendations because the facility does not have a medical records person right now and are in the process switching to computer charting, so they may not be filed. He/She said he/she carries through the pharmacy recommendations but he/she does not know if the ones missing were responded to.

Based on interview and record review, facility staff failed to monitor for side effects/adverse reactions from [MEDICAL CONDITION] medications, include indication for [MEDICAL CONDITION] medications, monitor behaviors for resident's receiving [MEDICAL CONDITION] medication, or follow through on pharmacist recommendations for Gradual Dose Reductions (GDR) for three residents (Resident #9, #7, and #21) receiving [MEDICAL CONDITION] medications. Additionally facility staff failed to obtain stop dates of 14 days or less on PRN (as needed) [MEDICAL CONDITION] medications ( a chemical substance that changes brain function and results in alterations in perception, mood, consciousness or behavior) for one resident ( Resident #21) out of 17 sampled. The facility census was 26. 1. Review of the facility's policy Psychoactive Psychopharmacological Medications, dated 10/1/17 shows the policy directs staff: -Psychoactive medications will not be used for discipline or for convenience and will not be used unless necessary to treat medical symptoms -Resident's receiving psychoactive medications will be monitored and observed for improvement or decline in functional status, target behaviors and side effect -For the purposes of this policy, psychoactive medications include antidepressants, anxiolytics, hypnotics, sedatives, and anti-psychotics. -For any of these types of medications, gradual dose reductions and behavioral interventions will be done per physicians orders, unless clinically contraindicated, in an effort to discontinue the medication to reach the lowest effective dose. -[MEDICAL CONDITION] medications are given to treat a specific condition diagnosed and documented in the clinical record; -PRN [MEDICAL CONDITION] medications are limited to 14 days unless the attending physician believes a prescription for longer than 14 days is appropriate and documents rationale in the medical record; -Monitoring for residents receiving psychoactive medications will include documentation of target behaviors and side effects; -Behavioral interventions are individualized, non-pharmacological approaches to care that are provided as part of a supportive environment, directed towards stabilizing or improving a resident's mental, physical, or psychosocial well-being. 2. Review of Resident #7's annual Minimum Data Set (MDS), a federally mandated assessment tool, dated 10/23/18, showed the staff assessed the resident as: -Cognitively impaired; -[DIAGNOSES REDACTED]. -Antidepressant medication daily. Review of the resident's Physician Orders, dated (MONTH) (YEAR), showed the physician directed the staff to administer [MEDICATION NAME] (medication for depression) 10 (milligrams) mg one time daily. Review of the resident's Pharmacist MRR's, dated 10/1/17 and 12/13/18, showed the pharmacist requested a Gradual Dose Reduction (GDR) or a progress note for continued use. Review of the resident's medical record, showed it did not contain a response to the Pharmacist MRR, dated 12/13/18, or a progress note for continued use. 3. Review of Resident #9's MDS, dated [DATE], showed staff documented: -No cognitive impairment; -No behaviors; -One person assist toileting; -Antidepressant every day. Review of the resident's care plan, dated 11/20/18, shows staff documented the resident has a potential for depressed mood due to history of depression. Additionally, staff are directed to be patient and reassuring. Staff are further directed to help the resident resolve his/her feelings. The care plan did not address the monitoring of side effects/adverse reactions to [MEDICAL CONDITION] medications. Review of the resident's physician's orders [REDACTED]. Review of the resident's Pharmacist Medication Regimen Review, dated 10/3/18-12/13/18, showed the pharmacist documented: -10/3/18 please assess risk vs benefit and if your patient would benefit from a reduction of the [MEDICATION NAME] 30 mg hs order, 2/18 order, address in your progress note that a change is clinically contraindicated; -11/20/18 no new suggestions; -12/13/18 please assess risk vs benefit and if your patient would benefit from a reduction of the [MEDICATION NAME] 20 mg /d order or address in your progress note that a change is clinically contraindicated. Review of the resident's medical record showed a physician response on 10/3/18 of Pt needs it. Further review of the medical record showed it did not contain behavior monitoring. 4. Review of Resident #21's quarterly MDS, dated [DATE], showed staff assessed the resident as: -Severe cognitive impairment; -admitted to the facility on [DATE]; -[DIAGNOSES REDACTED]. -Antianxiety and antidepressant medication daily. Review of the resident's physician's orders [REDACTED]. -On 8/15/18 to administer [MEDICATION NAME] (medications for anxiety) 0.5 mg one time daily PRN; -On 3/14/18 to administer [MEDICATION NAME] (medication for anxiety) 5 mg two times daily for anxiety; -On 3/14/18 to administer Duloxetine (medication for depression) 60 mg daily. The order did not contain a stop date on the PRN [MEDICATION NAME]. Review of the resident's Pharmacist MRR's dated 3/7/18-12/13/18, showed the pharmacist did not make a recommendation for a gradual dose reduction for the medications. Review of the resident's Pharmacist MRR, dated 12/13/18, showed the pharmacist requested a stop date of 14 days or less or a progress note for continued use for the [MEDICATION NAME]. Review of the resident's medical record showed it did not contain a progress note from the physician for continued use of the PRN [MEDICATION NAME]. 5. During an interview on 1/04/19 at 2:18 P.M., registered nurse (RN) E said PRN [MEDICAL CONDITION] should have a 14 day stop date. He/She said nurse management tracks the GDR's, and pharmacists' requests. He/She said the licensed staff are expected to carry over new orders from the pharmacists' requests when they are received from the physician. During an interview on 1/04/19, at 4:17 P.M., the director of nursing (DON) said staff are expected to obtain a stop date of 14 days or less for PRN [MEDICAL CONDITION]. He/She said he/she does not know the documentation requirements if the physician does not want to attempt the GDR or extend a PRN [MEDICAL CONDITION]. He/She said the facility does not have specific behavior monitoring, and non pharmacological approaches to behaviors are on the care plans but staff do not have a place to chart the interventions prior to administration of the PRN medications.

Based on observation, interview, and record review, facility staff failed to remove soiled gloves and/or properly wash hands to prevent the spread of bacteria and other infection causing contaminants during the provision of care for four residents (Residents #2, #11, #12 and #17), and did not date or bag residents' oxygen tubing for three sampled residents (Residents' #5, #18, #20), and one unidentified resident as per policy. The facility census was 26. 1. According to Infection Control Guidelines for Long Term Care Facilities (Section 3.0 Body Substance Precautions): *Dirty gloves are worse than dirty hands because micro-organisms adhere to the surface of a glove easier than to the skin of your hands. *Hand washing remains the single most effective means of preventing disease transmission; wash hands whenever they are soiled with body substance and when each resident's care is completed. Review of the facility's Handwashing/Hand Hygiene Policy, dated August 2015, showed staff are directed to wash their hands when hands are visibly soiled and after contact with a resident with infectious diarrhea., Further review of handwashing policy showed staff are directed that the use of gloves does not replace hand washing/hand hygiene. Integration of glove use along with routine hand hygiene is recognized as the best practice for preventing healthcare-associated infections. Further review of the policy showed staff are directed to use alcohol-based hand rub or soap and water for the following situations: -Before/after coming on duty; -Before/after direct contact with residents; -Before preparing or handling medications; -Before performing any non-surgical invasive procedures; -Before and after handling an invasive device; (e.g. urinary catheters, IV access sites); -Before donning sterile gloves; -Before handling clean or soiled dressings, gauze pads, etc; -Before moving from a contaminated body site to a clean body site during resident care; -After contact with a resident's intact skin; -After contact with blood or bodily fluids; -After handling used dressings, contaminated equipment, etc. -After contact with objects (e.g. medical equipment) in the immediate vicinity of the resident; -After removing gloves -Before and after entering isolation precaution settings; -Before and after eating or handling food; -Before and after assisting a resident with meals; and -After personal use of the toilet or conducting your personal hygiene. 2. Observation on 12/07/17 at 6:45 A.M., showed Certified Nursing Assistant (CNA) F provide pericare to Resident #12. The CNA did not remove his/her gloves/wash hands before he/she pulled up the resident's pants, removed the gait belt, and positioned the resident in the wheelchair. The CNA put soiled linens on the floor, removed his/her gloves and tied up the trash bag. He/She did not wash his/her hands and made the resident's bed. The CNA picked up the soiled linen off the floor, put the soiled linen under his/her arm, picked up the bag of trash, and took them out of the room while he/she pushed the resident in the wheelchair. The CNA did not wash his/her hands and pushed the resident to the dining room in the wheelchair, put on his/her clothing protector, and went to assist other residents with unwashed hands. Observation on 12/07/17 at 9:40 A.M., showed RN A don gloves and assist Certified Medication Technician (CMT) E to toilet Resident #17. RN A cleaned feces from the resident and assisted the CMT to transfer the resident into a wheelchair. He/She disposed of trash and touched multiple surfaces in the resident's restroom before he/she removed the soiled gloves and washed his/her hands. Observation on 12/07/17 at 10:06 AM, showed RN A enter Resident #11's room to provide a treatment. RN A placed the treatment supplies, including wound cleanser used for multiple residents, on the resident's bed and did not use a barrier. The RN did not wash or sanitize his/her hands before applying gloves. The RN removed the dressings from the resident's right second toe and right little toe and, without washing his/her hands, began to cleanse the wounds. The RN removed the soiled gloves and, without washing or sanitizing hands, put on clean gloves and applied the antibiotic ointment and dressing. The RN removed the soiled gloves, and without washing or sanitizing hands, put on clean gloves and examined the left foot. Observation on 12/07/17 at 10:25 AM, showed RN (Registered Nurse) B entered Resident #2's room and placed the treatment supplies on the bedside table with no barrier in place. The RN did not wash his/her hands and donned gloves before he/she removed the dressing on the right shin, measured the wound, and cut the [MEDICATION NAME] silver (a sterile dressing with silver used to cover acute and chronic wounds that are excreting pus or other fluids) to the wound size. The RN cleansed the wound with wound cleanser and changed his/her gloves without sanitizing or washing his/her hands. The RN applied a clean dressing to the right shin. The RN changed his/her gloves, and without washing or sanitizing his/her hands, removed the dressing from the left outer lower leg. The RN changed his/her gloves, without washing or sanitizing his/her hands, cleansed the wound, measured the wound, and applied the dressing. RN B did not wash his/her hands between glove changes as directed. 3. During an interview on 12/08/17 at 10:52 AM, RN B said hands should be washed or sanitized between glove changes and a barrier should be used, especially if multi-use supplies, such as wound cleanser, are used. The RN also said gloves should be removed after pericare and hands washed before continuing to assist the resident. 4. Review of the facility's Oxygen Therapy Policy, dated January 1, 2004 and revised March 1, 2017, showed staff are directed to change oxygen tubing once a week or when soiled. Further review of the policy showed staff are directed to date, time, and initial tubing when changed. Review of the facility's Treatment Administration Record (TAR) showed staff are directed to change residents' oxygen tubing every week. 5. Observation on 12/05/17 at 11:33 A.M., showed Resident #20 with nebulizer tubing next to bed on nightstand undated and unbagged. Staff did not date or bag the tubing as directed. Observation on 12/05/17 at 12:07 P.M., showed an unidentified resident in the dining room with an oxygen concentrator. Additional observation showed the nebulizer undated and unbagged. Observation on 12/05/17 at 2:19 P.M., showed Resident #18 with his/her oxygen tubing rolled up and placed on his/her nightstand undated and unbagged. Observation on 12/05/17 at 2:27 P.M., showed Resident #5 with his/her oxygen tubing rolled up and placed on his/her nightstand undated and unbagged. Observation on 12/06/17 at 10:19 A.M., showed Resident #5 with his/her oxygen tubing rolled up and placed on his/her nightstand undated and unbagged. 6. During an interview on 12/07/17 at 10:02 A.M., CMT E said the nurse is to put a piece of tape on the tubing with the date and time changed on it in order for staff to know it's been changed. During an interview on 12/07/17 10:05 A.M., RN B said staff are expected to change out the oxygen tubing every three days when the canisters are changed. He/She also said the oxygen tubing should be dated at the base or on the tubing.

Based on observation, interview, and record review, facility staff failed to complete entrapment assessments for two out of two residents with side rails (Residents #3, and #5) to ensure the environment remained safe and free of accident hazards. The facility census was 26. 1. Review of the FDA (Federal Drug Administration) documents entitled, Hospital Bed System Dimensional and Assessment Guidance to Reduce Entrapment dated [DATE] shows 413 people died as a result of entrapment events in the United States. Further review reveals those among the most vulnerable for these entrapment type events are elderly patients and residents especially those who are frail, confused, restless, or who have uncontrolled body movement. Review of the FDA (Federal Drug Administration) documents entitled, Practice Hospital Bed Safety dated February 2013 identifies seven different potential, zones of entrapment. This guidance characterizes the head, neck, and chest as key body parts that are at risk for entrapment. Review of the FDA (Federal Drug Administration) documents entitled, Guide to Bed Safety Rails in Hospitals, Nursing Homes and Home Health Care: The Facts. shows the Potential risks of bed rails may include: -Strangling, suffocating, bodily injury or death when patients or part of their body are caught between rails or between the bed rails and mattress. -More serious injuries from falls when patients climb over rails. -Skin bruising, cuts, and scrapes -Inducing agitated behavior when bed rails are used as a restraint. -Feeling isolated or unnecessarily restricted. -Preventing patients, who are able to get out of bed, from performing routine activities such are going to the bathroom or retrieving something from a closet. 2. Observation on [DATE] at 11:40 A.M., showed the resident lay in his/her bed with half side rails up on both sides of the bed. Observation on [DATE] at 10:17 A.M., showed the resident lay in his/her bed with half side rails up on both sides of the bed. Observation on [DATE] at 7:20 A.M., showed the resident lay in his/her bed with half side rails up on both sides of the bed. Observation on [DATE] at 9:15 A.M., showed the resident lay in his/her bed with half side rails up on both sides of the bed. 3. Review of the resident's medical record showed staff did not obtain a physicians' order for use of half side rails, care plan the use of side rails, or complete a required entrapment assessment for the use of side rails. 4. During an interview on [DATE] at 7:35 A.M., RN A said the facility only has one resident with side rails and the computer generates a side rail assessment for the nurse to complete periodically. He/She said the assessment the nurse completes does not have an entrapment risk assessment with the measurements to assure resident safety for use of side rails. RN A said if there is an assessment that requires measurements then he/she expects maintenance to do this. During an interview on [DATE] at 9:11 A.M., Maintenance Director said he/she does not complete entrapment risk assessment for the use of side rails. He/She said to check with nursing as they may be doing them. He/She said nursing lets maintenance when they have an order for [REDACTED]. During an interview on [DATE] 10:30 A.M. RN B said nursing does the side rail assessments but they don't do any type of measurements. RN B said he/she expects the maintenance department puts the rails on and should be doing measurements on the rails. During an interview on [DATE] 3:11 P.M., the Executive Director said the facility does not have an entrapment risk assessment for side rails. He/She said they hadn't yet developed a program to complete the entrapment assessments as they haven't found the information they needed to develop a program yet. During an interview on [DATE] at 3:17 P.M., the DON (Director of Nursing) said the facility does not have an entrapment risk assessment program yet. He/She said they have looked into it, but haven't gathered the information to set one up. He/She said he/she expects maintenance to complete those assessments/measurements.

Based on interview and record review, the facility failed to offer pneumococcal immunizations to seven residents (Resident #1, #2, #5, #6, #7, #8, and #9) out of ten sampled residents, as directed by facility policy. The facility census was 26. Review of the facility's Immunization-Pneumococcal Policy, dated 11/20/16, showed the following: - Residents are provided the opportunity and encouraged to receive the Pneumococcal vaccination; -At the time of admission, the nurse will determine the resident ' s vaccination history by resident information, family or primary care provider and document on the Immunization Record for Staff/Resident; -If vaccination status is unknown, the Pneumococcal vaccination will be offered upon admission; -The administration of the Pneumococcal vaccination is a manor-community standing admission order; -Residents aged [AGE] years or over should be administered a second dose of the vaccine if they received the vaccine five or more years previously and were aged [AGE] years or less at the time of the first vaccination; -When a resident is vaccinated, record vaccination date on the Immunization for Staff/Resident form and the Medication Administration Record [REDACTED] 1. Review of Resident #1's medical record showed it did not contain documentation to show the resident received the pneumococcal vaccine as directed by facility policy. Further review showed the record did not contain documentation to show staff offered the vaccine or the resident declined. 2. Review of Resident #2's medical record showed it did not contain documentation to show the resident received the pneumococcal vaccine as directed by facility policy. Further review showed the record did not contain documentation to show staff offered the vaccine or the resident declined. 3. Review of Resident #5's medical record showed it did not contain documentation to show the resident received the pneumococcal vaccine as directed by facility policy. Further review showed the record did not contain documentation to show staff offered the vaccine or the resident declined. 4. Review of Resident #6's medical record showed it did not contain documentation to show the resident received the pneumococcal vaccine as directed by facility policy. Further review showed the record did not contain documentation to show staff offered the vaccine or the resident declined. 5. Review of Resident #7's medical record showed it did not contain documentation to show the resident received the pneumococcal vaccine as directed by facility policy. Further review showed the record did not contain documentation to show staff offered the vaccine or the resident declined. 6. Review of Resident #8's medical record showed it did not contain documentation to show the resident received the pneumococcal vaccine as directed by facility policy. Further review showed the record did not contain documentation to show staff offered the vaccine or the resident declined. 7. Review of Resident #9's medical record showed it did not contain documentation to show the resident received the pneumococcal vaccine as directed by facility policy. Further review showed the record did not contain documentation to show staff offered the vaccine or the resident declined. During an interview on 01/12/17, the Health Services Director said no pneumococcal vaccination information was available for Residents #1, #2, #5, #6, #7, #8 or #9. During an interview on 01/12/17 at 8:15 A.M., the Regional Health Services Director said staff is expected to try to get information on previous vaccination and document in the medical record. He/She further said if staff is unable to get the information, staff should ask the medical director. He/She said the information could be documented on the admission assessment. He/She said he/she did not believe the facility had a declination form if the resident/responsible party refused. Additionally, the Regional Health Services Director said the pneumococcal vaccine is always available. He/She said if a resident or family is unable to recall the date of a previous vaccination, staff is expected to ask if a booster is desired. He/She said he/she would hope it would be documented. During an interview on 01/12/17 at 8:55 A.M., the Executive Director said staff is expected to find out when a pneumococcal vaccine was given. Additionally, she said staff is expected to document the vaccine or previous date of vaccine. The Executive Director (ED) said medical records should complete an audit on admission to make sure vaccinations are documented. Additionally, the ED said an audit should be completed annually. During an interview on 01/12/17 at 9:20 A.M., the Medical Records Director said he/she does not complete an audit for vaccinations.

Based on observation, interview, and record review, facility staff failed to provide a treatment for one resident (Resident #2) in a sanitary manner to prevent the spread of infection. Staff failed to change gloves and wash hands during the provision of care to prevent the spread of infection for one resident (Resident #6). The facility census was 26. 1. According to Infection Control Guidelines for Long Term Care Facilities (Section 3.0 Body Substance Precautions): *Dirty gloves are worse than dirty hands because micro-organisms adhere to the surface of a glove easier than to the skin of your hands. *Hand washing remains the single most effective means of preventing disease transmission; wash hands whenever they are soiled with body substance and then each resident's care is completed. 2. Review of the facility's Handwashing/Hand Hygiene Policy, revised August 2015 showed the following: -All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors. -Staff shall use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap and water for the following situations: Before and after direct contact with residents, before moving from a contaminated body site to a clean body site during resident care, and after contact with a resident's intact skin. -Single-use disposable gloves should be used before aseptic procedures, and when anticipating contact with blood or body fluids. 3. Observation on 1/11/17 at 12:39 P.M., showed Registered Nurse (RN) C entered Resident #2's room to measure the resident's wound. Further observation showed RN C palpated the resident's periwound (area surrounding the wound) and measured the wound on the resident's right hip. RN C did not wash his/her hands or apply gloves before he/she touched the resident's wound. During an interview on 1/12/17 at 9:30 A.M., RN C said he/she wears gloves to measure wounds, but did not because he/she did not touch the eschar (hard black surface of wound bed) or open area on the resident's right hip. 4. Observation on 1/12/17 at 8:42 A.M., showed Certified Nurse Aide (CNA) D provide incontinent care to Resident #6. Further observation showed CNA D did not remove his/her soiled gloves, and did not wash his/her hands before he/she touched the resident's clean brief, linens, pillows, and the call light. During an interview on 1/12/2017 at 8:50 A.M., CNA D said he/she should have changed his/her gloves between incontinent care and touching the new brief and the resident's clean items. CNA D said he/she forgot. 5. During an interview on 1/19/2017 at 8:30 A.M., the Health Services Director (HSD) said staff are expected to wash hands, obtain supplies, inform the resident of the procedure and assess pain before he/she administers the wound treatment. Furthermore, he/she said he/she hopes staff would wear gloves before touching a wound. Additionally, the HSD said CNAs are expected to wash their hands upon entering a resident's room, anytime they go from a clean to a dirty surface and certified nurses aides are to remove soiled gloves and wash hands before they touch a clean brief, or other personal items.

Based on observation and interview, facility staff failed to change gloves and wash hands during the provision of care, treatments, and administration of eye drops to prevent the possible spread of bacteria and other infection-causing organisms for residents (Residents #13, #8, #14, #6, #4, and #3). Additionally, facility staff failed to clean and sanitize the multiple use vital signs machine before and after its use for one resident (Resident #14). The facility census was 29. 1. Observation on 11/26/2013 at 10:45 A.M., showed the Assistant Director of Nursing (ADON) entered Resident #4's room. The ADON then washed and gloved his/her hands. The ADON then removed scissors from his/her pocket and cut off the resident's treatment dressing on his/her left foot. He/she replaced the scissors in his/her pocket. The resident's heel wound noted to have a small amount of drainage. The ADON cleansed the wound and applied [MEDICATION NAME] (a cleansing agent used to reduce bacteria on top of the skin) and covered the wound with a gauze wrap. The ADON removed his/her gloves, washed his/her hands, and reapplied gloves. The ADON removed the same scissors from his/her pocket and cut off the resident's treatment dressing on his/her right foot without first cleansing the scissors to prevent cross contamination between the resident's two wounds. The resident's right heel wound noted to have a small amount of drainage. The ADON cleansed the right heel wound with [MEDICATION NAME] and wrapped the wound with gauze. 2. Observation on 11/26/2013 at 4:30 P.M., showed Licensed Practical Nurse (LPN) H wheeled Resident #6 from the dining room to his/her room. LPN H handed the resident a tissue and administered one drop of Artificial tears in both of the resident's eyes. LPN H failed to wash his/her hands and glove before he/she administered the resident's eye drops. 3. Observation on 11/27/13 at 6:08 A.M., showed CNA G and CNA I entered Resident #13's room to get the resident up for the day. CNA G and CNA I wore gloves as they removed the resident's urine soaked brief. CNA G provided frontal perineal care to the resident. CNA G did not change gloves or wash his/her hands to prevent the spread of infection. CAN G then dressed the resident in clean clothes while CAN I bagged the resident's soiled linens. CAN I removed his/her gloves and left the resident's room. CAN I did not wash his/her hands before he/she left the resident's room to prevent the spread of infection. CAN G placed the resident's footrests on his/her wheelchair, then he/she provided hair care. CAN G removed his/her gloves and left the resident's room. CAN G failed to wash his/her hands to prevent the spread of infection. 4. Observation on 11/27/2013 at 6:20 A.M., showed Certified Nurses Assistant (CNA) G entered Resident #14's room. The resident lay on his/her back. CNA G assisted the resident to sat on the edge of the bed and then stand. CNA G walked the resident to the bathroom in his/her room. CNA G applied gloves to his/her hands. CNA G lowered the resident's pants and removed his/her brief. CNA G sat the resident on the toilet. The resident urinated and when finished the CNA applied a new brief and pants on him/her. CNA G stood the resident up and walked him/her to the dining room. CNA G removed his/her gloves. CNA G failed to wash his/her hands when he/she entered the resident's room or when he/she toileted the resident. 5. Observation on 11/27/13 at 6:34 A.M., showed Resident #14 sat at the dining room table. Resident #14 began to vomit. Staff immediately assisted the resident to his/her room. Staff left the resident's place mat soiled with emesis on the dining room table, as well as a tissue soiled with emesis. Observation showed the soiled tissue and place mat sat on the table from 6:34 A.M. to 6:53 A.M. Observation at 6:53 A.M., showed Dietary Aide (DA) K place two glasses of water on the table at the other two place settings. DA K then applied gloves and removed the soiled place mat and tissue from the table. DA K did not remove all place settings from the table. DA K removed his/her gloves, but he/she did not wash his/her hands to prevent the spread of infection. Observation showed emesis on the table where the place mat had been. Staff failed to sanitize the table. Observation at 7:08 A.M., showed Licensed Practical Nurse (LPM) L sanitized the area on the table with emesis. LPM L did not remove all place settings from the table and did not sanitize the entire table. 6. Observation on 11/27/2013 at 6:42 A.M., showed Registered Nurse (RN) D use the vital signs machine on Resident #14 after the resident had an emesis. RN D wheeled the vital sign machine out of the resident's room. RN D failed to cleanse the vital sign machine after he/she used it on the resident who had just had an emesis. 7. Observation on 11/27/13 at 7:08 A.M., showed CAN G and CAN I transferred Resident #8 to his/her wheelchair from the bed with the use of a mechanical lift. CAN I wore gloves as he/she made the resident's bed. CAN I removed his/her gloves and left the resident's room. CAN I did not wash his/her hands to prevent the spread of infection before he/she left the resident's room. 8. Observation on 11/27/2013 at 10:18 A.M., showed Licensed Practical Nurse (LPN) C enter Resident #3's room. The resident lay on his/her back with his/her eyes closed. LPN C offered the resident fluids. LPN C then gloved his/her hands and removed a DuoDerm dressing (a skin like dressing that protects wounds or skin at risk for wounds) cleansed the area and then reapplied a DuoDerm dressing. LPN C swabbed the resident's mouth with a toothette swab (mouth swab to provide oral care) and then removed his/her gloves. LPN C then washed and reapplied gloves to his/her hands. LPN C removed scissors from his/her pocket and cut the dressing on the resident's left arm and replaced the scissors back into his/her pocket. LPN C removed the dressing and then applied Triple Antibiotic Ointment (TAO), [MEDICATION NAME] dressing (thin absorbent dressing) on top of three different scabbed areas on the resident's arm and forearm. LPN C then wrapped the areas with Kerlix (gauze bandage roll). LPN C then removed his/her gloves washed his/her hands and then reapplied gloves to his/her hands. LPN C then removed the scissors from his/her pocket and cut off the dressing on the resident and replaced the scissors in his/her pocket. LPN C then removed the dressing, applied TAO, [MEDICATION NAME] dressing on top of two scabbed areas on the resident's right arm and wrapped the areas with Kerlix. LPN C removed his/her gloves and washed and reapplied gloves to his/her hands. RN D entered the room and washed and applied gloves to his/her hands. RN D removed the residents brief and rolled the resident on his/her right side. LPN C provided incontinent care. LPN C applied a new brief under the resident and rolled the resident on his/her back. LPN C removed his/her gloves, washed his/her hands and left the room. RN D then applied barrier paste (paste to protect the skin from moisture ) and stoma adhesive powder (powder to protect the skin) to open area and reapplied his/her brief. RN D then removed his/her gloves and washed his/her hands and left the resident's room. LPN C failed to clean scissors between the resident's wounds to prevent cross contamination to the wounds. LPN C also failed to change gloves and wash hands between the multiple treatments on the resident's right arm and failed to change gloves and wash hands between the multiple treatments on the resident's left arm and between the treatment on the resident's back and when he/she provided oral care. 9. During an interview on 11/27/2013 at 10:23 A.M., after the treatment to Resident #3's arms LPN C said he/she would normal wash his/her hands and change gloves between each treatment but it was easier and faster to do all of the treatments on one arm at the same time without washing his/her hands and changing gloves between them. 10. During an interview on 11/27/2013 at 1:32 P.M., RN D said the following: -Staff should wash their hands after entering the residents room, before and after care, between glove changes; -Staff should clean and sanitize vital sign machines and scissors after each use; If a resident vomits on a table nursing staff should take remove the resident from the table and immediately sanitize the whole table. 11. During an interview on 11/27/2013 at 1:35 P.M., LPN C said the following: -Staff should wash their hands before and after treatments, before and after medication administration including eye drops, before and after toileting, between changing gloves, when staff enter and exit a resident's room; -Staff are to clean and sanitize the vital sign machine and scissors after each use; -If a resident vomits on a table staff are to remove the resident from the table and clean and sanitize the whole table and that any staff person that is there at that time should sanitize the table. 12. During an interview on 11/27/2013 at 11/27/2013 the Director of Nursing (DON) said the following: -Staff are expected to wash their hands before staff do care, when feasible to wash between changing gloves; -Staff are expected to either use hand sanitizer or wash their hands when they enter or exit a resident's room; -Staff are expected to sanitize scissors and vital signs machine before and after each use; -Dietary staff should have sanitized the whole table after a resident vomits on a dining room table. 13. During an interview on 11/27/13 at 12:41 P.M., CAN I said staff should wash their hands when entering resident rooms, after providing perineal care, after removing gloves, and before leaving resident rooms. 14. During an interview on 11/27/13 at 12:46 P.M., CAN J said staff should wash their hands before and after providing care, after picking up soiled items, before and after feeding residents, before and after applying gloves, after providing perineal care, and before leaving resident rooms.

Based observation, interview, and record review, facility staff failed to provide thorough perineal care for two residents (Residents #7 and #1) out of 10 sampled residents, and for two randomly observed residents (Residents #13 and #14). The facility census was 29. 1. Record review of Resident #13's quarterly MDS, dated [DATE], showed staff assessed the resident as: -Required extensive assistance of two people with transfers, toilet use, and dressing; -Required limited assistance of one person with personal hygiene; -Frequently incontinent of bowel and bladder. Record review of the resident's comprehensive plan of care, last updated 11/20/13, showed staff were instructed to: -Provide total assist of two people with bed mobility, transfers, and toileting; -Assist with toileting before breakfast, after meals, at bedtime, during the night as requested, and as needed; -Provide good skin care/perineal care when incontinent. Observation on 11/26/13 at 4:16 P.M., showed CNA E and CNA F wore gloves as they transferred the resident to the toilet. CNA E and CNA F removed the resident's brief. The resident was incontinent of bowel. CNA E provided perineal care to the resident's buttocks while CNA F assisted the resident in a standing position. CNA E did not provide frontal perineal care to the resident. Observation on 11/27/13 at 6:08 A.M., showed CNA G and CNA I entered the resident's room to get the resident up for the day. CNA G and CNA I wore gloves as they removed the resident's urine soaked brief. CNA G provided frontal perineal care to the resident. CNA G did not provide perineal care to the resident's buttocks to cleanse the urine from his/her skin. 2. Record review of Resident #7's comprehensive MDS, dated [DATE], showed staff assessed the resident as: -Required extensive assistance of two people with transfers and dressing; -Required extensive assistance of one person with personal hygiene, ambulation, and eating; -Incontinent of bowel and bladder. Record review of the resident's comprehensive plan of care, last updated 11/25/13, showed staff were instructed to: -Provide extensive assistance of one to two people with Activities of Daily Living (ADLs); -Assist with toileting upon rising, before and after meals, at bedtime, and as needed; -Check for incontinence and change as needed. Observation on 11/26/13 at 5:29 P.M., showed CNA E and CNA F wheeled the resident in his/her wheelchair to the shower room to toilet the resident. CNA E and CNA F transferred the resident to the toilet and removed the resident's brief. CNA F said the resident was "slightly wet." CNA E provided perineal care to the resident's buttocks but did not provide perineal care to the resident's frontal perineal area. 3. Review of Resident #1's Minimum Data Set (MDS), a federally mandated assessment instrument required to be completed by staff and used for planning care, dated 7/9/13, showed staff assessed the resident as the following: -Incontinent of bowel and bladder; -Required extensive assistance of one person with personal hygiene; -Required extensive assistance of two people with transfers and dressing. Review of the resident's Plan of Care, last updated 10/12/13, showed staff are directed to do the following: -Use a mechanical lift to transfer the resident with two staff to assist; -Check for incontinence and change on routine rounds and as needed; -Encourage to toilet upon rising, before and after meals and activities, at bedtime, and as needed; -Keep skin clean, dry, and well lubricated. Observation on 11/26/2013 at 5:14 P.M., showed Certified Nurse Assistants (CNA) E and CNA F enter the resident's room. The resident lay on his/her back . CNA E rolled the resident to his/her left side and CNA F wiped the resident's bottom with perineal wash and a washcloth. CNA F put a new brief and pants on the resident. CNA E and CNA F transferred the resident to his/her wheelchair. CNA E and CNA F failed to cleanse the resident's frontal perineal area during incontinent care. 4. Review of Resident #14's Admission Minimum Data Set (MDS), a federally mandated assessment instrument required to be completed by staff and used for planning care, dated 11/18/2013, showed staff assessed the resident as the following: -Moderate cognitive impairment; -No rejection of care; -Needs extensive assistance of one staff with transferring, toileting, and personal hygrine. Observation on 11/27/2013 at 6:20 A.M., showed CNA G enter the resident's room. The resident lay on his/her back. CNA G assisted the resident to sat up on the edge of the bed and then to stand. CNA G walked the resident to the bathroom in his/her room. CNA G lowered the resident's pants and removed his/her brief. CNA G then sat the resident on the toilet. After the resident urinated the CNA applied a new brief and pants on him/her. CNA G stood the resident up and walked him/her to the dining room. CNA G failed to provide perineal cleansing after the resident urinated. 5. During an interview on 11/27/13 at 12:41 P.M., CNA I said staff should cleanse the frontal perineal area, buttocks, and anywhere urine or feces has come in contact with the skin when they provide perineal care. 6. During an interview on 11/27/13 at 12:46 P.M., CNA J said staff should cleanse residents' frontal perineal area and the buttocks, and anywhere that the residents' briefs cover. 7. During an interview on 11/27/2013 at 1:32 P.M., Registered Nurse (RN) D said staff should provide perineal care from front to back. RN D also said staff should cleanse frontal perineal area, the buttock, and anywhere urine or feces has touched the resident. 8. During an interview on 11/27/2013 at 1:35 P.M., Licensed Practical Nurse (LPN) C said during perineal cleansing after a resident has used the restroom or been incontinent staff should cleanse the genital areas, inner thighs, buttock, and anywhere urine or feces has touched the resident. 9. During an interview on 11/27/2013 at 2:02 P.M., the Director of Nursing (DON) said during perineal cleansing staff should cleanse the perineal area, the buttocks, the inner thighs, and anywhere urine or feces had touched the resident.