Every finding on record at St Clair Nursing Center

Based on interview and record review, facility staff failed to prevent an injury to one resident (Resident #1) when a Certified Nursing Assistant (CNA) rolled the resident during care, without the assistance of second staff member, as directed in the resident's Plan of Care. The facility census was 57.The administrator was notified on 03/04/26 of past Non-Compliance which occurred on 02/08/26. On 02/08/26 the Director of Nursing (DON) investigated the fall, immediately educated Licensed Practical Nurse (LPN) B and CNA A on proper transfers, two person assist with care, and communication with other staff. The DON in-serviced all direct care staff on where to find information on resident care plans, and the need for two assists for the resident. 1.Review of the facility's Accident and Supervision Policy, undated, showed the purpose of the policy is for the resident environment to remain as free of accident hazards as possible, and to provide adequate supervision and assistive devices to prevent accidents. Review showed accident defined as any unexpected or unintentional incident which results in injury or illness to a resident. Review showed to reduce a resident's risk from hazards in the environment, staff should communicate the interventions to all relevant staff, provide training as needed, and ensuring staff are implementing the interventions. Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment tool, dated 02/17/26, showed staff assessed the resident with cognitive impairment, impairment on both upper and lower sides, dependent for on staff for: toileting, bathing, dressing, rolling in bed, and transfers, and has had a fall with a major injury since admission or prior assessment. Review of the resident's care plan, revised dated 02/18/26, showed staff documented the resident with a diagnosis of severe weakness or total paralysis of one side of the body, and weakness on one side of the body that cause limited mobility, loss of balance, muscle fatigue, and difficulty grasping objects. Staff documented the resident is at risk for falls due to the inability to control his/her body and having poor personal safety awareness and required two staff assistance for daily care, to include bed mobility due to bilateral hand contractures and paralysis of all four limbs and the torso. Review of the resident's nurses' notes, dated 02/08/26, showed Licensed Practical Nurse (LPN) B documented at 3:05 P.M. CNA A notified him/her the resident fell from the bed to the floor. Staff documented the resident was on the floor next to the bed on his/her left side, with complaints of severe pain related to his/her left lower extremity. Staff documented injury and deformity noted to the resident's left lower extremity. Review of the facility's investigation, dated 02/08/26, showed the administrator documented staff notified him/her on 02/08/26 the resident fell from his/her bed and staff sent him/her to the hospital for knee swelling and pain. He/She documented the DON became aware CNA A was alone in the resident's room at the time of the fall. He/She documented the nurse exited the room and the CNA continued to provide care to the resident who fell out of bed. Review of the resident's hospital records, dated 02/08/26, showed hospital staff documented the resident diagnosed with a fracture of near the end of the thigh bone a fracture in the thigh bone that is adjacent to an orthopedic implant, and a tendon tear fracture of left kneecap. During an interview on 2/19/26 at 10:30 A.M., the administrator said LPN B and CNA A were assisting the resident with changing the resident's adult brief. He/She said LPN B went out into the hallway to the treatment cart, CNA A continued to provide care to the resident, the resident's legs slid off the bed, and the resident fell. During an interview on 02/19/26 at 12:20 P.M., LPN B said the resident requires two staff members to assist with all care, and did not have side rails on his/her bed. He/She said he/she provided catheter care for the resident and then stepped into the hallway to the medication cart. He/She said he/she did not tell CNA A he/she was coming back into the room immediately. He/She said CNA A came to him/her in the hallway and notified him/her the resident fell. During an interview on 02/19/26 at 12:27 P.M., CNA A said the resident required one staff member for assistance with peri care and dressing, and two staff members to assist with transfers. He/She said he/she and LPN B were in the resident's room to provide treatments, peri care, and to get the resident out of bed. He/She said LPN B was her second staff member to assist with the transfer, and believed LPN was coming back into the room immediately. He/She said LPN B provided catheter care and then stepped into the hallway. He/She said the resident had a bowel movement, he/she began cleaning up the resident, and he/she assisted the resident to roll onto his/her left side. He/She said the resident began to slide off the left side of the bed. He/She said he/she attempted to prevent the resident from rolling off the bed from his/her position on the right side of the bed, but the resident fell to the floor. CNA said he/she knew the resident was a two person assist for transfers, but did not know it was two for all care. He/She said the resident appeared to raise up his/her hip to help him/her get the resident clean of feces. They were not attempting to transfer him/her or adjust him/her in bed at the time, so he/she did not think he/she needed another staff to assist. During an interview on 2/19/26 at 2:40 P.M., the DON said the resident requires two staff members to assist with all care, and the information is in the resident's care plan. He/She said CNA A should have waited to provide peri care for the resident until another staff member was positioned on the other side of the bed. He/She said LPN B would have been the second staff member assigned to assist CNA A with providing the resident's care.Complaint #2737823

40424 Based on observation, interviews, and record review facility staff failed to safely propel three residents (Resident #23, #263, and #5) in a wheelchair. Facility staff failed to safely store hazardous materials in a manner to prevent accidents in one shower room and one storage room. The facility census was 58. 1. Review of the facility's Wheelchair Mobility policy, dated 2023, showed staff were directed that if a resident needs to be propelled and does not generally move or propel the wheelchair on their own, proper foot positioning on wheelchair pedal will be maintained and provided. 2. Review of Resident #23's quarterly Minimum Data Set (MDS) a federally mandated assessment tool, dated 10/21/24, showed staff assessed the resident as follows: -Severe cognitive impairment; -Wheelchair dependent; -Diagnosis of Alzheimer. Observation on 02/04/25 at 11:30 A.M., showed an unknown staff propelled the resident on the 200 hall dinning area to the 300 hall living room. Observation showed the resident bilateral feet slid on the floor and his/her right wrist rubbed the wheelchair wheel. 3. Review of Resident #263's admission MDS dated [DATE] showed staff assessed the resident as follows: -Diagnosis of arthritis and Alzheimer's; -Impairment of both upper extremities; -Wheelchair dependent. Observation on 02/05/25 at 8:33 A.M., showed an unknown staff propelled the resident to the dining room. Observation showed the wheelchair did not have foot pedals and the resident lifted his/her feet. The staff member stopped in the hall and said to the resident he/she needed to find the resident's foot pedals before they continued. Observation showed another unknown staff person began to push the resident to the dining room. 4. Review of Resident #5's quarterly MDS, dated [DATE], showed staff assessed the resident as follows: -Severe cognitive impairment; -Wheelchair dependent; -Diagnosis of Alzheimer and dementia. Observation on 02/05/25 at 10:30 A.M., showed the Activity Director propelled the resident from the 200 hall dinning area towards the hallway without foot pedals on the wheelchair and both feet slid and bounced off the floor. During an interview on 02/05/25 at 10:31 A.M., the Activity Director said he/she should have gone and got the pedals for the wheelchair before pushing the resident. He/She said normally they lift their feet up when being pushed. 5. During an interview on 02/06/25 at 2:10 P.M., Licensed Practical Nurse (LPN) C said pushing a resident in a wheelchair without foot pedals could cause an injury. During an interview on 02/07/25 at 8:51 A.M., the Director of Nursing (DON) said staff should put foot pedals on a wheelchair prior to pushing a resident. This will prevent injuries or falls. During an interview on 02/07/25 at 11:08 A.M., the administrator said staff should make sure foot pedals are on a wheelchair before pushing a resident for safety. If a residents foot hit the floor it could cause injury. 5. Review of the facility's Chemical Usage and Storage policy, dated 01/01/20, showed all chemicals should be stored in a secure location when not in direct use, and should never be left out in the open where others may accidentally come into contact with it. 6. Observation on 02/05/25 at 9:40 A.M., showed the medical supply room on the 200 hall, unlocked. Observation showed an unlocked cabinet below the sink contained a bottle of odor control solution, two bottles of cleaning solution and one bottle of calcium, lime and rust remover with precautionary statements which indicated hazards. During an interview on 02/05/25 at 9:45 A.M., the maintenance director said no one had ever asked him/her to place a lock on the supply room door so he/she never thought about the risks of the cleaning chemicals. 7. Observation on 02/06/25 at 1:50 P.M., showed the 100 hallway shower room door open. Observation showed an unlocked storage cabinet with an open box of disposable razors. Observation showed multiple residents walked by the open shower room door. During an interview on 02/06/25 at 1:50 P.M., CNA A said shower room doors are to be locked when not in use. He/She said the 100 hall shower room and cabinets can not be locked. Residents could be harmed if they came into contact with chemicals. 8. During an interview on 02/06/25 at 2:01 P.M., CNA B said storage cabinets and showers are supposed to be locked to prevent injury to the residents. During an interview on 02/06/25 at 2:10 P.M., LPN C said showers and cabinets should be locked because anyone could get in. Chemicals could injure a resident. During an interview on 02/07/25 at 8:51 A.M., the DON said residents should not have access to chemicals or other hazardous materials. He/She said hazardous materials should be locked up to prevent resident injury. During an interview on 02/07/25 at 11:08 A.M., the administrator said residents should not have access to any hazardous materials due to the risk to their health. These materials should be in a locked cabinet or room. 47193

Based on observation, interview, and record review, facility staff failed to obtain orders for one resident's (Resident #22's) Continuous Positive Airway Pressure (CPAP), a non-invasive ventilation machine that involves the administration of air usually through the nose by an external device at a predetermined level of pressure, and failed to assess and document the resident's respiratory status and response to therapy. Facility census was 54. 1. Review of the policies provided by the facility showed they did not contain a policy for CPAP, or Bi-level positive airway pressure (Bipap), a non-invasive ventilation machine that is capable of generating two adjustable pressure levels use. 2. Review of Resident #22's Quarterly Minimum Data Set (MDS), a federally mandated assessment tool, dated 12/29/23 showed staff assessed the resident as: -Cognitively intact; -Did not reject care; -Required supervision and touch assist from one staff member for upper body dressing; -Uses non-invasive mechanical ventilator; -Did not receive respiratory therapy; -Diagnoses of heart failure, Parkinson's disease, asthma, respiratory failure, and acute respiratory failure with hypoxia (decreased oxygen to tissue). Review of the resident's care plan, dated 01/25/24, showed staff documented the resident diagnosis of Obstructive Sleep Apnea (OSA), apnea (breathless) syndromes due primarily to collapse of the upper airway during sleep and uses a CPAP/BiPAP. Resident will adhere to CPAP/BiPAP regimen. Review of the Physician's Order Summary (POS), dated March 2024, showed it did not contain an order for the use of a CPAP/BiPAP/Automatic self-adjusting positive airway pressure (APAP), a non-invasive ventilation machine that automatically adjusts the air pressure according to the patient's requirement at a particular time, settings or required respiratory assessments. Review of the nurse's notes, dated March 2024, showed staff documented: -03/1/24- Oxygen Saturation (oxygen in blood) 94 percent (%); -03/4/24- 91%; -03/5/24- 93%; -03/6/24- 94%; -03/8/24- 95%. Review showed it did not contain further documentation in regard to the resident's respiratory status including response to therapy. Observation on 03/6/24 at 1:32 P.M., showed the resident in his/her room with a CPAP/BiPAP on his/her bedside table. During an interview on 03/06/24 at 1:32 P.M., the resident said he/she uses the CPAP for sleep apnea and has used it for over [AGE] years. The resident said he/she can put the mask on but he/she needs help because the machine is sat on a table behind his/her bed, and he/she is not always able to reach it. During an interview on 03/07/24 at 11:25 A.M., Licensed Practical Nurse (LPN) O said he/she knows the resident wears a CPAP or oxygen at night. The LPN said he/she does not know much about the resident's CPAP because he/she does not work nights, but he/she thinks the resident applies the CPAP himself/herself. During an interview on 03/07/24 at 11:49 A.M., LPN O said he/she would expect a resident with a diagnosis of OSA to use CPAP. The LPN said the resident was admitted with his/her CPAP. The LPN said CPAP use should be listed on the resident's care plan and there should be a physician order for use. The LPN said if a resident is admitted with a CPAP staff should ensure there are physician orders for the settings, and for cleaning. The LPN said sometimes the settings are in the orders and other times staff have to call the physician for orders, or the company who supplies the machine. LPN O said the resident should have a physician order for his/her CPAP, and he/she does not. The LPN said he/she did not know why the resident did not have orders for his/her CPAP. LPN O said the nurse is responsible for obtaining orders, and if they did not see orders they should notify the Director of Nursing (DON) or someone else to figure out the next steps. The LPN said he/she would also expect CPAP settings in the care plan. The LPN said when the resident came back from the hospital staff listened to his lung sounds, but now they check his oxygen saturation every day. The LPN said staff does not complete a respiratory assessment everyday for the resident. During an interview on 03/14/24 at 1:33 P.M., the DON said the resident uses an APAP. The DON said the settings are not set by the staff but set remotely by the resident's pulmonologist's (physician specializing in lung function) office. The DON said there should be an order for the APAP on the resident's POS. The DON said there is currently not a daily respiratory assessment conducted on the resident, but one should be completed daily. The DON said the facility does not have a policy for CPAP/BiPAP/APAP use. During an interview on 03/15/24 at 10:58 A.M., Registered Medical Assistant (RMA) P, who works with the resident's pulmonologist, said the resident uses a CPAP set at 14. The RMA said the pulmonologist would expect the resident to have a physician's order for the CPAP and order should contain the settings. The RMA said the last linked report showed the resident used his/her CPAP on 03/14/24. The RMA said the resident has not been seen by their office since 2019.

Based on observation, interview, and record review, facility staff failed to maintain resident dignity for three dependent residents' (esidents #45, #32 and #35) when staff did not clean and maintain the residents fingernails. The facility census was 55. 1. Review of the facility's policy titled, Right to Dignity, undated, showed staff promote care for elders of the facility in a manner and in an environment that maintains and enhances each elder's dignity and respect in full-recognition of the elder's individuality. Elders will be groomed as they including nail care. Each elder will be provided with independence and dignity during all dining experiences regardless of the amount of assistance the elder requires. Review of the facility's policy titled, Activities of Daily Living (ADLs), dated 2023, showed the facility based on the resident's comprehensive assessment and consistent with resident's needs and choices, ensure a resident's abilities in ADLs do not deteriorate unless deterioration is unavoidable to include grooming. A resident who is unable to care out activities of daily living with receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene. 2. Review of Resident #45's Quarterly Minimum Data Set (MDS), a federally mandated assessment tool, dated 01/26/24, showed staff assessed the resident as follows: -Moderate cognitive impairment; -Rejection of care not exhibited; -Required set up assistance from staff member with eating; -Dependent on staff for personal hygiene and transfers; -Always incontinent of bowel and bladder; -Diagnosis of Stroke (damage to the brain from interruption of its blood supply). Review of the resident's care plan, dated 02/05/24, showed staff documented the resident required assistance from one staff member for personal hygiene and independent with eating. Observation on 03/05/24 at 11:35 A.M., showed the resident in bed in his/her room. Observation showed the resident's fingernails long with a built up black substances under then nail. Observation showed the resident rubbed his/her lips and eyes with his/her fingers. Observation on 03/05/24 at 12:26 P.M., showed the resident ate in bed in his/her room. Observation showed the resident fed himself/herself with long fingernails long with black a substances under them. Observations on 03/06/24 at 8:12 A.M., showed the resident fed himself/herself breakfast in bed. The resident's fingernails are long with a black substances built up under them. Observation on 03/06/24 at 1:24 P.M., showed the resident's fingernails long with a black substance built up under them. Observation on 03/07/24 at 8:20 A.M., showed the resident ate breakfast in bed. The resident touched his/her mouth with his/her fingers. The resident's fingernails are long with a built up black substance under them. Observation on 03/07/24 at 11:52 A.M., Certified Nursing Assistant (CNA) E sat the resident's lunch tray on the bedside table. Observation showed the resident's fingernails long with a built up black substance under them. Observation showed the resident picked up a piece of food from the table with his/her fingers and put it in his/her mouth. During an interview on 03/07/24 at 11:30 A.M., the resident said his/her fingernails are to long and they hurt his/her arm. The resident pointed to scratches on his/her arm. The resident said he/she want's his/her fingernails cut. During an interview on 03/07/24 at 11:57 A.M., CNA E said he/she served the resident breakfast and lunch. The CNA said he/she had not tried to clean the resident's fingernails. The CNA said he/she does not know why he/she did not check the resident's fingernails. During an interview on 03/07/24 at 12:01 P.M., Certified Medication Technician (CMT) F said the resident's fingernails need to be cleaned. The CMT said the resident just told him/her his/her nails are cutting his/her arms. The resident scratches a lot. 2. Review of Resident #32's Quarterly MDS, dated [DATE], showed staff assessed the resident as follows: -Severe cognitive impairment; -Rejection of care not exhibited; -Required moderate assistance from staff with eating; -Dependent on staff for personal hygiene and transfers; -Always incontinent of bowel and bladder; -Range of Motion (ROM) impairments on both sides of upper extremities; -Diagnosis of stroke. Review of the resident's care plan, dated 01/9/24, showed staff documented the resident requires assistance from one staff member for personal hygiene and independent with eating. Observation on 03/05/24 at 11:45 A.M., showed the resident sat at a table in the dining room. Observation showed the resident's fingernails long and have brown debris under them. Observation showed the resident picked up cornbread and fed himself/herself with his/her fingers. Observation on 03/06/24 at 1:33 P.M., showed the resident's fingernails long, jagged and full of a brown substance. Observation showed the resident rubbed his/her lips and eyes with his/her finger tips. Observation on 03/07/24 at 8:28 A.M., showed the resident fed himself/herself breakfast in the dining room. Observation showed the resident's fingernails are long and have built up brown debris under them. 3. Review of Resident #35's Quarterly MDS, dated [DATE], showed staff assessed the resident as follows: -Severe cognitive impairment; -Rejection of care not exhibited; -Required maximal assistance from staff with eating; -Dependent on staff members for personal hygiene and transfers; -Always incontinent of bowel and bladder; -Diagnosis of Dementia (persistent or progressive loss of intellectual functioning, especially impairment of memory and abstract thinking). Review of the resident's care plan, dated 02/17/24, showed staff documented the resident requires assistance from one staff member with eating and personal hygiene. Observation on 03/05/24 at 3:35 P.M., showed the resident's fingernails long, jagged, and with a brown substance built up under them. Observation on 03/06/24 at 1:36 P.M., showed the resident in bed. The resident's fingernails are long, jagged, and with built up brown substance under them. Observation on 03/07/24 at 8:47 A.M., showed the resident sat in his/her chair. The resident's fingernails are long, jagged and have brown debris under them. 4. During an interview on 03/07/24 at 11:57 A.M., CNA E said staff are supposed to clean resident fingernails when they are dirty. Staff should check resident's fingernails all the time. During an interview on 03/07/24 at 12:01 P.M., CMT F said he/she checks resident fingernails when he/she gives showers and when he/she sees they are dirty. The CMT said staff should check resident fingernails when providing care. The CMT said if a resident feeds themselves staff should ensure the residents' fingernails are cleaned prior to meals so the resident does not get bacteria in their mouth. During an interview on 03/07/24 at 12:05 P.M., Registered Nurse (RN) G said staff should check resident fingernails during all care. The RN said staff should check resident's fingernails before and after each meal. During an interview on 03/08/24 at 8:41 A.M., Director of Nursing (DON) said staff should check resident fingernails when they get the resident up in the morning or when care is provided. The DON said staff should trim resident fingernails as needed and on shower days. The DON if a resident feeds themselves, staff should check the residents' fingernails before food is served. The DON said a resident putting dirty nails in his/her mouth put them at risk for infection, and also a dignity issue. The DON said all residents should be offered hand hygiene before meals.

Based on observation, interview, and record review, the facility staff failed to ensure proper hand hygiene was performed during medication pass for four (Residents #13, #39, #29, and #46) out of nine sampled residents. The facility census was 49 residents. 1. Review of the facility's Handwashing Policy and Procedures, undated, showed the policy directed staff to wash hands in the following situations: -When coming on duty; -When hands are obviously dirty; -Between handling of individual residents; -Before and after touching one's face; -Before and after use of toilet; -Before and after eating; -After handling dressings, used sputum containers, soiled urinals, catheters and bedpans or being exposed to body fluids; -Before leaving work. Review of the facility's Medication Pass Policy, dated May 2012, showed the policy did not contain direction regarding hand hygiene during medication pass. 2. Observation on 1/11/23 at 3:39 P.M., showed Licensed Practical Nurse (LPN) B did not perform hand hygiene before or after he/she administered medications to Resident #13. 3. Observation on 1/11/23 at 3:45 P.M., showed LPN B did not perform hand hygiene before or after he/she administered medication to Resident #39. 4. Observation on 1/11/23 at 3:55 P.M., showed LPN B did not perform hand hygiene before or after he/she administered medication to Resident #46. 5. Observation on 1/11/23 at 4:03 P.M., showed LPN B did not perform hand hygiene before or after he/she administered medications to Resident # 29. During an interview on 1/13/23 at 9:21 A.M., LPN C said he/she would use hand sanitizer between every medication pass and would wash his/her hands with soap and water on every fifth administration. During an interview on 1/13/23 at 9:32 A.M., Certified Medication Tech (CMT) H said he/she used hand sanitizer between every resident and he/she would wash hands with soap and water after every two residents unless soiled. During an interview on 1/13/23 at 11:38 A.M., Registered Nurse (RN) A said hands should be sanitized between every two residents when passing medications and washed with soap and water after every two residents or when soiled. During an interview on 1/13/23 at 12:57 P.M., the Director of Nurses said hand sanitizer should be used prior to administering medicine, between each resident and when soiled. He/She said soap and water should be used after every fifth resident.

Based on observation, interviews, and record review, the facility staff failed to change gloves and perform hand hygiene as often as necessary, to cover trash cans when not in use, and to properly store open food to prevent cross contamination and outdated usage. This had the potential to affect all facility residents. The census was 49. 1. Review of the facility's Proper Hand Washing and Glove Use policy, dated 2020, showed: - All employees will wash hands upon entering the kitchen from any other location and between all tasks. Handwashing should occur at a minimum of every hour. - Employees will wash hands before and after handling foods, after touching any part of the uniform, face or hair; - Gloves are to be used whenever direct food contact is required; - Hands are washed before donning gloves and after removing gloves; - Gloves are changed any time hand washing would be required. This includes when leaving the kitchen for a break or to go to another location in the building; after handling potentially hazardous raw food; or if the gloves become contaminated by touching the face, hair, uniform, or other non-food contact surface, such as door handles and equipment; - When gloves must be changed, they are removed, handwashing procedure is followed, and a new pair of gloves is applied. Gloves are never placed on dirty hands; the procedure is always wash, glove, remove, rewash, and re-glove. Observation on 1/11/23 at 11:40 A.M., showed dietary aide (DA) K prepared resident lunch plates. DA K used his/her gloved hands to touch a bratwurst and place it on a resident plate. Further observation showed the DA touched serving utensils, resident plates, and a food cart. DA K used the same gloved hands to push the cart to the dining room, touching the door handles on both sides of the door. The DA returned to the kitchen, and he/she used the same gloved hands to prepare more resident lunch plates, and touched the bratwurst to place them on the plate. DA K did not change his/her gloves and wash his/her hands after he/she touched the bratwurst, the cart, and the door handles. Observation on 1/11/23 at 11:58 A.M., showed DA L prepared a grilled cheese sandwich for a resident's lunch. The DA took the pan to the dishwashing area, and he/she rinsed the pan with his/her gloved hands. He/She returned to the food preparation area, touched an ice cream container, resident bowl with gloved thumb on the food surface, lettuce, cheese, and nine resident drinks with gloved hands on the lip of the cups. The DA touched the front of his/her facemask with his/her gloved hand. He/She touched the doors to the freezer and the refrigerator, an ice cream container, and the lip of a glass. DA L did not change his/her gloves or wash his/her hands after he/she touched the dishwashing sink and his/her facemask. Observation on 1/11/23 at 12:20 P.M., showed Cook M entered the kitchen, washed his/her hands, adjusted his/her facemask with his/her bare hand to the front of his/her facemask, and the donned gloves. The cook used his/her gloved hand to rinse a dirty spoon, touch baking pans, parchment paper, and bacon slices. The cook also touched the refrigerator handles and sausage patties. He/She changed his/her gloves and used the gloved hands to touch various food related items while he/she prepared the resident's dinner meal. The cook opened a 15 pound package of hamburger and used his/her gloved hands to break up the hamburger log. Cook M did not change his/her gloves or wash his/her hands after he/she touched his/her facemask, the dirty spoon, the bacon, and the sausage. The cook did not wash his/her hands after he/she removed his/her gloves or before he/she put on new gloves. During an interview on 1/13/23 at 10:12 A.M., the dietary manager said it is expected dietary staff would change their gloves between food products and when changing tasks. She said staff are to wash their hands before they put on and when they take off gloves, when going from a dirty task to a clean task, after touching their face, and whenever they enter the kitchen. The dietary manager said the facility has a glove use and hand washing policy, and staff have been trained on the policy. She said it is expected staff would change gloves and wash hands as outlined in the policy. During an interview on 1/13/23 at 11:30 A.M., the administrator said the dietary manager is responsible to ensure dietary staff change gloves and wash their hands according to facility policy. She said the dietary staff have been trained on the policy. The administrator said it is expected staff would use gloves when preparing food, and they should change their gloves between different foods. She said dietary staff should wash their hands when they enter the kitchen, after touching their face, before and after glove use, and when moving from a dirty task to a clean task. 2. Review of the facility's Garbage and Rubbish Disposal policy, dated 2020, showed: - All containers will be provided with tight-fitting lids or covers, and will be leak-proof and water-proof; - All garbage and rubbish containing food waste are covered when not in immediate use so as to be inaccessible to vermin. Observation on 1/11/23 at 10:24 A.M., showed a trash can located in the dishwashing area uncovered and not in use. The trash can located next to the clean dish drying rack, and a crockpot on the drying rack near the trashcan visibly dirty with chunks of an unidentified substance. Observation also showed the dishwashing area did not contain a lid for the trash can. During an interview on 1/13/23 at 10:12 A.M., the dietary manager said trash cans should be covered at all times. She said the facility has a policy regarding trash cans, and staff have been trained on the policy. The dietary manager looked for the lid to the trash can in the dishwashing area, but she was unable to locate it. During an interview on 1/13/23 at 11:30 A.M., the administrator said it is expected the trash can would be covered at all times, unless staff are throwing something away. She said the dietary manager is responsible for ensuring the trash cans stay covered. 3. Review of the facility's Food Storage policy dated 2020, showed all food items will be labeled. The label must include the name of the food. Observation on 1/11/23 at 9:45 A.M., of the two door refrigerator, showed one open bag of a brown crumble substance not labeled. Observation on 1/11/23 at 10:45 A.M., of the three door freezer, showed: - Four open bags of breaded patties unlabeled; - One package labeled 14 slices with no other identifiers of contents; - Seven bags of chunked white substance unlabeled; - Two bags of meat patties unlabeled; - One bag of breaded nuggets unlabeled. During an interview on 1/13/23 at 10:12 A.M., the dietary manager said all food containers should be labeled with the contents before they are placed into storage. It is expected staff would label any food they see without a label. The dietary manager said the facility has a policy on food storage, and staff is trained on the policy. During an interview on 1/13/23 at 11:30 A.M., the administrator said it is expected all food containers would be labeled before they are placed into storage. She said the dietary manager is responsible for ensuring the food is identified and stored correctly. The administrator said the facility has a policy on food storage, and the dietary staff is trained on the policy.

Based on observation, interview, and record review, facility staff failed to provide safe mechanical lift transfer for two residents (Residents #35, and #46) in a manner to prevent accidents. The facility census was 49. 1. Review of the facility's Safe Lifting and Movement of Residents Policy, dated June 2019, showed staff were directed as follows: -Staff responsible for direct resident care will be trained in the use of mechanical lifting devices; -Staff will be observed for competency in using mechanical lifts and observed periodically for adherence to the policies and procedures regarding use of equipment and safe lifting techniques. 2. Review of Resident #35's quarterly review minimum data set (MDS) a federally mandated assessment tool dated, 12/8/22, showed staff assessed the resident as follows: -Severe cognitive impairment; -Totally dependent on two plus staff for assistance with transfers. Observation on 1/10/23 at 2:31 P.M., showed Licensed Practical Nurse (LPN) I and Nurse Assistant (NA) J transferred the resident from his/her bed to a wheelchair. LPN I pushed the mechanical lift under the resident's bed with the legs of the mechanical lift closed. The LPN and NA then connected the mechanical lift sling to the lift. The resident was lifted off the bed by the LPN while the NA supported the resident. LPN I then moved the resident away from the bed and turned the mechanical lift without opening the legs of the lift for stability. The resident was then lowered to the wheelchair with the NA supporting the resident without opening the legs of the mechanical lift. 3. Review of Resident #46's quarterly MDS, dated [DATE] showed facility staff assessed the resident as follows: -Unable to complete brief interview for mental status; -Totally dependent for transfers, locomotion and eating. Observation on 1/10/23 at 2:24 P.M., showed Certified Nursing Assistants (CNAs) D and E transferred the resident from a chair to his/her bed. The CNAs lifted the resident from his/her chair, rotated the mechanical lift 180 degrees and lowered the resident to his/her bed with the lift legs in the closed position. Observation on 1/12/23 at 8:50 A.M., showed CNA F and G transferred the resident from a chair to his/her bed. The CNAs lifted the resident from his/her bed, rotated the mechanical lift 90 degrees and lowered the resident to his/her bed with the lift legs in the closed position. During an interview on 1/13/23 at 8:26 A.M., CNA G said the resident is lifted with a two person assist. The mechanical lift sling is connected to the lift and the resident lifted and moved. The mechanical lift legs should be spread to the widest position for stability. During an interview on 1/12/23 at 8:55 A.M. CNA G said he/she had mechanical lift training around October of 2022. CNA G said the lift legs should be spread, because the lift gets wobbly if you don't spread the legs. CNA G said he/she did not spread the lift legs because the space is so small. 4. During an interview on 1/13/23 at 8:30 A.M., Registered Nurse (RN) A said during a Hoyer lift the resident should be secured by two staff during the transport. The mechanical lift legs should be at the widest position when moving the resident. During an interview on 1/13/23 at 8:42 A.M., CMT H said two staff are involved with a mechanical lift and transfer. The legs should be open during the lift for stability. During an interview on 1/13/23 at 8:44 A.M., the Administrator and the director of nursing said two staff assist during a mechanical lift. The lift pad is hooked to the lift with the wheels locked on the lift. While transferring the resident the legs of the lift should be at the widest position. 45564

Based on interview and record review, facility staff failed to provide notice to the Ombudsman (a resident advocate who provides support and assistance with problems and/or complaints regarding the facility) related to a transfer or discharge to a hospital, including the reason for the transfer for two residents (Resident #51 and #307). The facility census was 49. 1. Review of the facility policies provided showed staff did not provide a policy for resident transfers and discharges. Review of the facility's Discharge to Facility Check Off form, undated showed the form did not include direction to notify the ombudsman. Review of the Discharge to Home Check off form, undated showed the form did not include direction to notify the ombudsman. 2. Review of Resident # 51's Discharge Return Anticipated Minimum Data Sets (MDS), a federally mandated resident assessment, dated 10/19/22, showed staff documented they discharged the resident to a hospital. Review of the resident's medical record showed the record did not contain documentation the staff informed the ombudsman of a transfer and/or reason for the transfer. Review of the resident's Discharge Return Not Anticipated MDS, date 11/14/22, showed staff documented they discharged the resident home. Review of the resident's medical record showed the record did not contain documentation the staff informed the ombudsman of the discharge and/or reason for the discharge. 3. Review of Resident # 307's medical record showed staff documented they transferred the resident to a hospital on 1/6/22. Review of the resident's medical record showed the record did not contain documentation the staff informed the ombudsman of the transfer and/or reason for the transfer. 4. During an interview on 1/13/23 at 10:28 A.M., the Director of Nursing said he/she developed a check list for discharges and transfers and the checklist included notifying the ombudsman. He/She said the checklist serves as the policy and procedure. During an interview on 1/13/23 at 10:31 A.M., Social Services Director said he/she has not been notifying the ombudsman of transfers or discharges. He/She said she is now aware that he/she is required to do so and will be notifying the ombudsman of all transfers and discharges from now on.

Based on observation, interview, and record review, the facility staff failed to use appropriate infection control procedures to prevent or reduce the risk of spreading bacteria including COVID-19, when staff failed to separate two residents who tested negative for COVID-19 (Residents #2 and #4) from their roommates who tested positive for COVID-19 (Residents #1 and #3). The facility census was 52. The administrator was notified on 05/25/22 at 1:30 P.M. of an Immediate Jeopardy (IJ) which began on 05/18/22. The IJ was removed on 05/26/22, as confirmed by surveyor onsite verification. 1. Review of the Centers for Disease Control and Prevention's (CDC) Interim Infection Prevention and Control Recommendations to Prevent [CONDITION(S)]-CoV-2 Spread in Nursing Homes, updated 02/02/22, showed: -Older adults living in congregate settings are at high risk of being affected by respiratory and other pathogens, such as [CONDITION(S)]-CoV-2 (the pathogen that causes COVID-19 infection); -Even as nursing homes resume normal practices, they must sustain core infection prevention and control (IPC) practices and remain vigilant for [CONDITION(S)]-CoV-2 infection among residents and health care personnel (HCP) in order to prevent spread and protect residents and HCP from severe infections, hospitalization s, and death; -Identify space in the facility that could be dedicated to monitor and care for residents with confirmed [CONDITION(S)]-CoV-2 infection; -The location of the COVID-19 care unit should ideally be physically separated from other rooms or units housing residents without confirmed [CONDITION(S)]-CoV-2 infection. This could be a dedicated floor, unit, or wing in the facility or a group of rooms at the end of the unit that will be used to cohort residents with [CONDITION(S)]-CoV-2 infection; -Ideally, a resident with suspected [CONDITION(S)]-CoV-2 infection should be moved to a single-person room with a private bathroom while test results are pending; -If limited single rooms are available, or if numerous residents are simultaneously identified to have known [CONDITION(S)]-CoV-2 exposures or symptoms concerning for COVID-19, residents should remain in their current location pending return of test results; -Residents should only be placed in a COVID-19 care unit if they have confirmed [CONDITION(S)]-CoV-2 infection. -Roommates of residents with [CONDITION(S)]-CoV-2 infection should be managed as described in Section: Manage Residents who have had Close Contact with Someone with [CONDITION(S)]-CoV-2 Infection. Manage Residents who had Close Contact with Someone with [CONDITION(S)]-CoV-2 Infection -Residents who are not up to date with all recommended COVID-19 vaccine doses and who have had close contact with someone with [CONDITION(S)]-CoV-2 infection should be placed in quarantine after their exposure, even if [CONDITION(S)] testing is negative. HCP caring for them should use full PPE (gowns, gloves, eye protection, and N95 or higher-level respirator). -Residents who are up to date with all recommended COVID-19 vaccine doses and residents who have recovered from [CONDITION(S)]-CoV-2 infection in the prior 90 days who have had close contact with someone with [CONDITION(S)]-CoV-2 infection should wear source control and be tested as described in the testing section. In general, these residents do not need to be quarantined, restricted to their room, or cared for by HCP using the full PPE recommended for the care of a resident with [CONDITION(S)]-CoV-2 infection unless they develop symptoms of COVID-19, are diagnosed with [CONDITION(S)]-CoV-2 infection, or the facility is directed to do so by the jurisdiction's public health authority. Quarantine might also be considered if the resident is moderately to severely immunocompromised. Review of the CDC Infection Control for Nursing Homes, Recommended Infection Prevention and Control (IPC) practices when caring for a patient with suspected or confirmed [CONDITION(S)]-CoV-2 infection, updated 02/02/22, showed: -The IPC recommendations described below also apply to patients with symptoms of COVID-19 (even before results of diagnostic testing) and asymptomatic patients who have met the criteria for empiric Transmission-Based Precautions (quarantine) based on close contact with someone with [CONDITION(S)]-CoV-2 infection. However, these patients should NOT be cohorted with patients with confirmed [CONDITION(S)]-CoV-2 infection unless they are confirmed to have [CONDITION(S)]-CoV-2 infection through testing; -Place a patient with suspected or confirmed [CONDITION(S)]-CoV-2 infection in a single-person room. The door should be kept closed (if safe to do so). The patient should have a dedicated bathroom; -Only patients with the same respiratory pathogen should be housed in the same room. Review of the facility's Infection Control Policy, dated 01/01/21, showed: -This facility will facilitate safe care of all residents and staff with known or suspected communicable disease by establishing and maintaining an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infection. This policy applies to all staff members from all departments of this facility, residents residing in the facility, visitors of facility, volunteers of facility, contracted and vendors of facility. The Infection Prevention and Control Program will follow accepted national standards and is based on facility assessment and includes prevention, identification, reporting, investigation and controlling infections and communicable disease for all residents, staff, volunteers, visitors and other individuals providing services under contractual arrangement. -Residents with known or suspected communicable diseases will be placed in the appropriate, least restrictive type of isolation precautions consistent with Center for Disease Center recommendations and guidelines and with the order of the primary care physician or physician extender. -Nursing personnel may initiate the least restrictive isolation precautions for residents whose infections disease(s) are detected by laboratory results including residents with positive cultures for resistive microorganisms. -Isolation Precautions - Airborne Precautions - Airborne precautions will be used for residents with known or suspected to be infected with microorganisms transmitted by airborne droplet nuclei. PRIVATE ROOM - necessary for all residents with Airborne Precautions *If a private room is not available, place the resident in a room with a resident with an infection of the same microorganism with no other infection (cohorting); *If cohorting is not achievable, consult the Medical Director and local county health infection control practitioners for direction. -Droplet Precautions will be used for residents known or suspected to be infected with microorganisms transmitted by droplets than can be generated by the resident during coughing, sneezing, talking or during performance of cough-inducing procedures. Droplet Precautions include: PRIVATE ROOM-Necessary for all residents in this category. *If a private room is not available, place the resident in a room with a resident who has an infection of the same microorganism unless otherwise recommended, but with no other infection (cohorting); *When cohorting is not achievable, maintain spatial separation of greater than 3 feet between the infected resident and other residents and visitors and keep curtain pulled between residents. -Contact Precautions will be used for specified residents known or suspected to be infected or colonized with microorganisms than can be transmitted by direct contact with the resident (and or skin-to-skin contact that occurs when performing resident-care activities that require touching the resident's skin) or indirect contact (touching) with environmental surfaces or resident care items in the resident's environment. PRIVATE ROOM - Necessary for all residents in this category. *When private room not available place resident in room with an residents with infection or who is colonized with the same microorganism but with no other infections (Cohorting); *If cohorting is not achievable, consultation with the resident's Primary Care Physician is necessary to determine appropriate placement. Review of the facility's Cohort Guidance for Pandemics policy, undated, showed: Pandemic precautions are a combination of Standard Precautions, Airborne Precautions, and Contact Precautions. Isolate symptomatic residents as soon as possible. Set up a separate, well-ventilated triage areas, place residents with suspected or confirmed COVID-19 in private rooms with the door closed and with private bathrooms (if possible). Review of the facility's Room Roster, undated, showed the roster listed Resident #1 and Resident #2 in the same room. Review showed, under the COVID + column, the roster listed a date of 05/18/22 next to Resident #1. Review of Resident #1's progress notes, dated 05/18/22 at 11:30 P.M., showed Licensed Practical Nurse (LPN) A documented the resident presented with a temperature of 100.2, a red face, his/her skin was hot to touch, and his/her oxygen saturation measured 88 to 89 percent on room air. The LPN documented he/she tested the resident for COVID-19 using a rapid test which resulted in positive results. The LPN documented the resident was placed on contact and droplet isolation precautions and he/she updated the resident's physician. Review of Resident #1's progress notes, dated 05/20/22 at 1:30 P.M., showed LPN B documented the resident was sent to the hospital at approximately 1:30 P.M. due to lethargy, wheezing and an oxygen saturation level of 84 percent on five liters of oxygen. Review of Resident #1's progress notes, dated 05/18/22 through 05/20/22, showed the records did not contain documentation to show staff separated the resident from his/her roommate prior to the resident being hospitalized approximately 38 hours after the resident tested positive for COVID-19 or that staff notified the facility's medical director the resident remained in the room with his/her roommate who tested negative for COVID-19. Review of Resident #2's medical records, showed the resident listed as his/her own responsible party and the resident refused vaccinations for COVID-19. Review of Resident #2's progress notes, dated 05/18/22, showed LPN A documented he/she updated the resident on his/her roommate's condition and COVID-19 positive result. The LPN documented he/she tested the resident for COVID-19 with negative results and the resident did not have symptoms. The LPN documented he/she educated the resident on droplet precautions and the resident requested to remain in the room. The LPN documented he/she informed the resident that he/she would be isolated as well, the resident agreed, and he/she pulled the privacy curtain between the residents. Review of Resident #2's progress notes, showed on 05/19/22 at 7:50 P.M., LPN C documented the resident's family member called the facility and was upset because the resident had not been moved to another room. The LPN documented the resident was asked if he/she wanted to be moved to a different room and the resident stated I am not moving. The LPN documented he/she explained to the resident's family member the resident had already been exposed and it was not their policy to move the resident. The LPN documented the resident's family said they were going to call the resident and tell him/her to move to another room and the LPN explained to the family member that it may not be an option to move the resident due to the facility having more positive cases and the resident was already exposed. Review of Resident #2's progress notes, dated 05/18/22 though 05/20/22, showed the records did not contain documentation to show staff separated the resident from his/her roommate prior to his/her roommate being hospitalized or that staff notified the facility's medical director the resident remained in the room with his/her roommate who tested positive for COVID-19. During an interview on 05/21/22 at 10:45 A.M., the Director of Nursing (DON) said staff tested Resident #1 for COVID-19 on 05/18/22, because the resident became symptomatic that day with a wet cough, fever and lethargy. The resident tested positive. Staff also tested Resident #2, who did not have symptoms, and the resident tested negative the same day. The DON said they did not have any private rooms left and since Resident #2 was presumed positive, he/she remained in the room with Resident #1 on isolation precautions. The DON said staff did talk to Resident #2 about moving to a different room, but the resident said he/she did not want to leave the room and said staff needed to move Resident #1. When asked why staff did not place two residents who had tested positive for COVID-19 into the same room to create another room for the resident the DON said, I don't have an answer for that. The DON said the residents (Resident #1 and #2) remained in the room together with the privacy curtain pulled and staff used as much infection control as they could when they provided care to the residents. The DON said the residents remained in the room together until they sent Resident #1 to the hospital around lunch time on 05/20/22, because the resident had trouble breathing and a low oxygen saturation level. During an interview on 05/21/22 at 12:25 P.M., the DON said as he/she understood it, per CDC and the Centers for Medicare and Medicaid services (CMS) guidelines, residents on isolation for COVID-19 should be moved to a private room, but if a private room was not available then they remain in place with a barrier and they are encouraged to wear masks. During an interview on 05/21/22 at 3:17 P.M., the DON said they should have moved the positive residents in with other positive residents when no private rooms were available, but it had been a crazy week and he/she just did not think to do that. During an interview on 05/21/22 at 3:30 P.M., Resident #2 said he/she did not often leave his/her room to prevent getting sick and he/she did not want to be in the same room with his/her roommate after he/she tested positive. The resident said staff did not offer him/her the opportunity to move to another room and when staff told him/her that his/her roommate tested positive for COVID-19, staff told him/her that he/she was stuck in the room too. During a telephone interview on 05/24/22 at 9:00 A.M., the facility's medical director said the facility staff had made him/her aware multiple residents tested positive for COVID-19, but staff did not notify him/her that Resident #1 and Resident #2 were together in the same room after Resident #1 tested positive until after the department's investigation began on 05/21/22. The medical director said if a resident with a roommate tests positive for COVID-19, staff should also test the roommate and if the roommate tests negative, staff should separate the residents. The medical director said ideally staff should place residents on isolation in private rooms, but if no private rooms are available, it would be ideal to place like residents together. The medical director said staff should follow the CDC guidelines related to COVID-19. During a telephone interview on 05/24/22 at 10:12 A.M., LPN C said he/she worked the day shift on 05/19/22. The LPN said night shift staff tested Resident #1 for COVID-19 before shift change and they reported to the day shift that he/she tested positive and they asked Resident #2 if he/she wanted to move and he/she said that he/she did not want to move. The LPN said after report, he/she went into the residents' room with Certified Nursing Assistant (CNA) D to provide care to Resident #1 and while in the room he/she asked Resident #2 if he/she wanted to go to another room if they could find a place for him/her and the resident said he/she did not want to move. The LPN said if a resident who tests positive for COVID-19 has a roommate who tests negative, the facility's policy is to separate the residents, but they did not have a private room for the resident to move to at the time. The LPN said he/she did not know why they did not move Resident #1 into a room with another COVID-19 positive resident. During a telephone interview on 05/24/22 at 12:12 P.M., CNA D said if a resident tests positive for COVID-19 and they share the same room with a resident who tests negative, staff are to ask the resident who tested negative if they want to move. The CNA said if the resident who tested negative does not want to move, then the resident is isolated in the room with the resident who tested positive, they pull the privacy curtain and staff wear PPE when in the room caring for the residents. The CNA said he/she worked the day shift on 05/19/22 and night shift staff reported Resident #1 tested positive during the night shift and Resident #2 tested negative. The CNA said while he/she and LPN C provided care to Resident #1 with the privacy curtain drawn on 05/19/22, the LPN asked Resident #2 if he/she wanted to be moved and the resident refused. The CNA said Resident #1 and Resident #2 remained in the room together during his/her shift. During a telephone interview on 05/24/22 at 10:43 A.M., LPN B said Resident #1 and Resident #2 were in the same room together during his/her shift on 05/20/22 until he/she sent Resident #1 to the hospital. The LPN said Resident #1 had tested positive for COVID-19 before his/her shift. The LPN said he/she asked Resident #2 at the beginning of his/her shift if the resident wanted to move and the resident said he/she liked his/her room and did not want to move. The LPN said if a resident who tests positive for COVID-19 has a roommate who tests negative, the facility's policy is to move the positive resident to a private room for isolation and to quarantine the negative resident. The LPN said they did not have a private room to move the resident to and since his/her roommate refused to move they were kept isolated in the same room. The LPN said he/she did not know why they did not move Resident #1 into a room with another COVID-19 positive resident. During a telephone interview on 05/24/22 at 3:03 P.M., LPN A said he/she was the charge nurse for the night shift on 05/18/22. The LPN said Resident #1 was having trouble breathing and had a fever, so he/she tested the resident for COVID-19 and the resident tested positive. The LPN said he/she told Resident #2 that Resident #1 had tested positive and he/she needed to test him/her too. The LPN said Resident #2 tested negative and the resident became concerned. The LPN said he/she told the resident they needed to move him/her out of the room and the resident declined. The LPN said the facility policy would be to separate the residents, but if they refuse to be moved then they pull the curtain between the resident and keep them on isolation. 2. Review of the facility's Room Roster, undated, showed the roster listed Resident #3 and Resident #4 in the same room. Review showed, under the COVID + column, the roster listed a date of 05/19/22 next to Resident #3. Review of Resident #3's progress notes, dated 05/19/22 at 12:32 P.M., showed staff documented they notified the resident's family the resident had COVID-19 and had been placed on isolation precautions. Review of Resident #3's progress notes, dated 05/19/22 through 05/21/22, showed the records did not contain documentation to show staff separated Resident #3 and Resident #4 or that staff notified the facility's medical director that Resident #4 remained in the room with his/her roommate who tested positive for COVID-19. Review of Resident #4's medical records showed the resident was not his/her own responsible party and had a designated representative. Review showed the resident was vaccinated for COVID-19 on 01/15/21, 02/12/21, and 11/14/21. Review of Resident #4's progress notes, dated 05/19/22, showed staff documented they notified the resident's family that the resident's roommate tested positive for COVID-19 and was quarantined to his/her room. Review of Resident #4's progress notes, dated 05/19/22 through 05/21/22, showed staff did not document they separated the resident from his/her roommate or that staff notified the facility's medical director that the resident remained in the room with his/her roommate who tested positive for COVID-19. During an interview on 05/21/22 at 10:45 A.M., the Director of Nursing (DON) said Resident #3 tested positive for COVID-19 on 05/19/22 and remained in the same room with Resident #4 who tested negative. The DON said the residents were isolated in the same room, because they did not have any private rooms to move the resident to. When asked why staff did not place two residents who had tested positive for COVID-19 in the same room to create another room for the resident, the DON said I don't have an answer for that. During an interview on 05/21/22 at 12:25 P.M., the DON said as he/she understood it, per CDC and the Centers for Medicare and Medicaid services (CMS) guidelines, residents on isolation for COVID-19 should be moved to a private room, but if a private room is not available then they remain in place with a barrier and they are encouraged to wear masks. Observation on 5/21/22 at 3:00 P.M., showed Resident #3 and Resident #4 in the same room with the privacy curtain drawn. During an interview on 05/21/22 at 3:17 P.M., the DON said there was room for improvement in the facility's management of COVID-19 positive residents and they should have moved the positive residents in with other positive residents when no private rooms were available, but it had been a crazy week and he/she just did not think to do that. During an interview on 05/21/22 at 3:45 P.M., Resident #4 said staff did not ask him/her if he/she wanted to change rooms when his/her roommate tested positive for COVID-19. During a telephone interview on 05/24/22 at 9:00 A.M., the facility's medical director said the facility staff had made him/her aware of multiple residents testing positive for COVID-19, but staff did not notify him/her about Resident #3 and Resident #4 being together in the same room after Resident #3 tested positive. The medical director said if a resident with a roommate tests positive for COIVD-19, staff should also test the roommate and if the roommate tests negative, staff should separate the residents. The medical director said ideally staff should place residents on isolation in private rooms, but if no private rooms are available, it would be ideal to place like residents together. The medical director said staff should follow the CDC guidelines related to COVID-19. During a telephone interview on 05/24/22 at 10:43 A.M., LPN B said Resident #3 and Resident #4 were in the same room together during his/her shift on 05/20/22 and Resident #3 had tested positive for COVID-19 before his/her shift. The LPN said he/she asked Resident #4 that morning if he/she wanted to move and the resident said he/she was not moving, because it was his/her room and he/she was there first. The LPN said Resident #3 had dementia and was only oriented to him/herself so they did not ask him/her about moving. The LPN said if a resident who tests positive for COVID-19 has a roommate who tests negative, the facility's policy is to move the positive resident to a private room for isolation and to quarantine the negative resident. The LPN said they did not have a private room to move the resident to and since his/her roommate refused to move they were kept isolated in the same room. The LPN said he/she did not know why they did not move Resident #3 into a room with another COVID-19 positive resident. During a telephone interview on 05/24/22 at 12:25 P.M., Resident #4's responsible party (RP) said the facility staff called him/her on 05/19/22 to notify him/her the resident's roommate had tested positive for COVID-19 and the resident was being quarantined in the same room with his/her roommate, because they did not have a private room available. The RP said he/she would have preferred the resident not be in the same room with a positive resident, but the staff did not ask him/her if he/she wanted the resident moved and they did not make it seem as if that was an option, because they said they did not have a room available. The RP said while the resident had dementia, he/she was still able to let staff know what he/she wants and needs. The RP said he/she did not believe the resident would have declined being moved if staff offered, because when he/she came to visit the resident on 05/20/22, the resident wanted to know why he/she had to stay in his/her room and kept saying that he/she wanted out of there. 3. During a telephone interview on 05/24/22 at 9:08 A.M., the administrator said he/she knew residents who tested positive for COVID-19 were in rooms with residents who tested negative. He/she had discussed the situation with the facility's medical director and the medical director said to leave the residents where they were. The administrator said the medical director was made aware of the status of roommates with each positive report. The administrator said they would normally separate the positive and negative residents, but they did not have any private rooms available to move the residents to, so they followed their policy of pulling the privacy curtain in the room, keeping the residents three feet apart from one another and staff using a different set of PPE to care for the residents when in the room. The administrator said the other COVID-19 positive residents in private rooms in the front of the building were admitted to the facility into private rooms so they did not have any semi-private rooms available to cohort positive residents together. He/she did not apply for a waiver to use other rooms in the facility not normally used for resident care to be able to cohort the residents. He/she did not consider moving Resident #1 and Resident #3 together when Resident #3 tested positive the next day. Additionally, the administrator said staff asked both Resident #2 and Resident #4 if they wanted to move and the residents refused so he/she felt they were honoring their rights. NOTE: At the time of the survey, the violation was determined to be at the immediate jeopardy level J. Based on observation, interview and record review completed during the onsite visit, it was determined the facility had implemented corrective action to remove the IJ violation at the time. A final revisit will be conducted to determine if the facility is in substantial compliance with participation requirements. At the time of exit, the severity of the deficiency was lowered to the D level. This statement does not denote that the facility has complied with State law (Section 198.026.1 RSMo.) requiring that prompt remedial action to be taken to address Class I violation(s). MO 432

Based on interview and record review, the facility failed to ensure notice of discharge/transfer contained all of the required information for nine out of 15 sampled residents with a facility initiated discharge or transfer (Residents #7, #13, #23, #26, #37, #40, #51, #57, and #60). The census was 57. 1. Review of the facility's Transfer of Care to EMS for Stabilization/Transport of Acutely Ill or Potentially Dangerous Elders, not dated, showed it did not address the transfer/discharge notices for the resident/responsible party. Review of the facility's Bed Hold Policy, not dated, also showed it did not address the transfer/discharge notices for the resident/responsible party. 2. Review of the facility's Discharge/Transfer notice, showed it did not contain the following information: - A statement of the resident's appeal rights; - Information for the Office of the State of Long-Term Care Ombudsman; - Information of the agency responsible for the protection and advocacy of individuals with a mental disorder. 3. Review of Resident #7's medical record, showed the following: - A facility initiated discharge on 7/24/19 and on 9/25/19; - Additional review showed the record did not contain a discharge/transfer notice with the required information. 4. Review of Resident #13's medical record, showed the following: - A facility initiated discharge on 9/11/19; - Additional review showed the record did not contain a discharge/transfer notice with the required information. 5. Review of Resident #23's medical record, showed the following: - A facility initiated discharge on 12/14/19; - Additional review showed the record did not contain a discharge/transfer notice with the required information. 6. Review of Resident #26's medical record, showed the following: - A facility initiated discharge on 12/5/19; - Additional review showed the record did not contain a discharge/transfer notice with the required information. 7. Review of Resident #37's medical record, showed the following: - A facility initiated discharge on 11/5/19; - Additional review showed the record did not contain a discharge/transfer notice with the required information. 8. Review of Resident #40's medical record, showed the following: - A facility initiated discharge on 1/7/20; - Additional review showed the record did not contain a discharge/transfer notice with the required information. 9. Review of Resident #51's medical record, showed the following: - A facility initiated discharge on 11/10/19; - Additional review showed the record did not contain a discharge/transfer notice with the required information. 10. Review of Resident #57's medical record, showed the following: - A facility initiated discharge on 12/25/19; - Additional review showed the record did not contain a discharge/transfer notice with the required information. 11. Review of Resident #60's medical record, showed the following: - A facility initiated discharge on 1/4/20; - Additional review showed the record did not contain a discharge/transfer notice with the required information. 12. During an interview on 1/10/20 at 10:28 [NAME]M., the Social Service Designee (SSD) said she does not complete any paperwork for the emergency transfers. That paperwork is completed by the nurses. 13. During an interview on 1/10/20 at 10:29 [NAME]M., the Assistant Director of Nursing (ADON) said the nursing staff complete a discharge/transfer letter for the resident/responsible party, a bedhold notice, and a discharge summary when a resident discharged /transferred. At 11:00 [NAME]M., the Director of Nursing (DON) and the ADON said the nursing staff completes a discharge/transfer letter which contains the date, place, reason, and bedhold information when residents are discharged /transferred from the facility for emergency care. A discharge summary is also added to the resident's medical record. They were not aware the letter should contain the ombudsman information or information for the agency responsible for the protection and advocacy of individuals with a mental disorder. 14. During an interview on 1/10/20 at 2:20 P.M., the Administrator said she would expect all the required information to be included in the discharge and transfer notice. The administrator said she would expect both the ombudsman information, and mental health advocacy information to be included in the notices.

Based on observation, interviews, and record review, the facility failed to post, in a form and manner accessible to the residents, a list of names, addresses, and phone numbers of the State survey agency, the Long Term Care Ombudsman, and the hotline information. The census was 57. 1. Observations on 1/7/20 at 1:58 P.M., 1/8/20 at 8:30 [NAME]M., 1/9/20 at 9:26 [NAME]M., and 1/10/20 at 10:30 [NAME]M. showed a frame, measuring approximately 8 inches by 7 inches, hung on the wall near the front entrance to the facility. The frame hung at a height greater approximately 5 feet and 5 inches above the floor. The information in the frame did not contain the address or email of the hotline or state agency. The information did not contain any information regarding the ombudsman. 2. During an interview on 1/10/20 at 10:36 [NAME]M., Housekeeping G said the hotline number is posted at the nurses station and probably in the administrators office. The state agency and ombudsman information is probably posted in the same places. He/She had not seen the information posted anywhere else in the facility. 3. During an interview on 1/10/20 at 10:39 [NAME]M., CNA F said the hotline number is posted at the nurses station and is in the admission packet for the residents. The State agency information is also at the nurses station. She has not seen it anywhere else, but she thinks it may be posted in the employee break room. 4. During an interview on 1/10/20 at 10:42 [NAME]M., LPN [NAME] said the hotline number and the State agency information is found in the staff handbook and at the nurses station. It may also be on a poster in the staff break room. She is not aware of the information posted in any other location in the facility. 5. During an interview on 1/10/20 at 11:05 [NAME]M., Resident #31 said he/she knew they could call the hotline if they want, but did not know where the hotline number or any information is posted within the facility. The resident said he/she was not sure who the ombudsmen is, nor did they know where to find the phone number. 6. During an interview on 1/10/20 at 11:20 [NAME]M., Resident #44 said he/she is aware they can call in a complaint to the state but is not sure where the information is posted. The resident said he/she did not know who the ombudsmen is or to contact them 7. During an interview on 1/10/20 at 11:25 [NAME]M , the Social Service Designee (SSD) said the hotline information, the State agency information, and ombudsman information is listed in the resident admission packet on pages 12-13. The information is posted in her office, but her office is not easily accessible to the residents. She locks her door when she is not in there, because they have private resident information in there. The information is posted near the entrance door in a picture frame. The SSD said she is 5 feet 3 inches tall, and the frame is over her head. Residents would not be able to read the sign in that location, especially residents who sit in wheelchairs. The sign did not contain the ombudsman information. The sign also did not contain the addresses or emails for the hotline and State survey agency. She was not aware that information was required to be posted. Observation with the SSD throughout the facility showed the information was not posted in any other location. 8. During an interview on 1/10/20 at 2:24 P.M., the Administrator said she would expect the required posting to contain the addresses, and phone numbers of the State survey agency, the Long Term Care Ombudsman, and the hotline information. The administrator said, the frame with the hotline number posted was a little high for residents to see. The administrator said the ombudsman information should be posted. 9. During in an interview on 1/10/20 at 3:30 P.M., Resident #39 said he/she they would assume the hotline information is posted up front by the entrance, as that is where it is in most facilities. The resident said he/she knows who the ombudsman is but can't remember her name. He/she said they do not know the ombudsman's contact information and have not seen it posted anywhere.

Based on observation, interview, and record review the facility staff failed to follow physicians orders, and report a change of condition for one resident (Resident #20), and failed to follow the physician's orders [REDACTED].#15, and #20) which could have resulted in fluid overload or dehydration. The facility census was 66. 1. Review of Resident #20's significant change in status assessment (SCSA) Minimum Data Set (MDS), a federally mandated assessment tool, dated [DATE], showed staff assessed the resident as follows: -Moderate cognitive impairment: -[DIAGNOSES REDACTED]. -Requires extensive assistance of a more staff member for eating; -Requires extensive assistance of two or more staff members for bed mobility, dressing, toilet use, and hygiene; -Dependent on two or more staff members for transfers, and bathing; -Limitations in functional range of motion in upper and lower extremities; -Always incontinent of bowel and bladder; -No symptoms of shortness of breath; -Weight 167 pounds (lbs.); -Weight loss, not on physician prescribed weight loss regimen; -Unstageable pressure ulcer; -Antidepressant, anticoagulant (blood thinners), antibiotics, and a diuretic (medication to remove excess water) medications administered daily; -Oxygen therapy; -Hospice. Review of the resident's chest X-ray, dated [DATE], showed the physician documented: -The heart is normal in size and configuration; -Lung are clear without mass, infiltrate, congestion, or effusion; -No acute cardiopulmonary disease seen. Review of the resident's care plan, dated [DATE], shows it directs staff: -The resident has a [DIAGNOSES REDACTED]. -Goal to remain comfortable, and with dignity; -Changes in health, condition, medications and treatments will be discussed between facility and hospice staff; -Resident has a chronic history of embolism/[MEDICAL CONDITION] (blood clots) of both lower extremities; -Administer anticoagulant medication as prescribed; -Monitor and report immediately if the resident complains of pain in his/her extremities, extremities are cold, numb, cyanotic (purple or blue in color), or difficulty breathing. The care plan did not contain direction to the staff on oxygen use, monitoring of respiratory status, or increased [MEDICAL CONDITION]. Review of the resident's weight summary, dated [DATE]-[DATE], showed the staff documented: -[DATE] 158 lbs.; -[DATE] 157.2 lbs.; -[DATE] 161.4 lbs. (a 4.2 lbs. weight gain). Review of the resident's Physician order [REDACTED]. -Resident may wear oxygen per nasal cannula, ,[DATE] liters/minute (L) as needed for shortness of breath; -[MEDICATION NAME] Solution 0XXX,[DATE].5 (3) milligrams (mg)/3 milliliters (ml), every eight hours as needed for congestion; -[MEDICATION NAME] (medication to thin mucous) ER (extended release) 600 mg every 12 hours as needed for congestion; -[MEDICATION NAME] liquid 100 mg/5 ml, give 200 mg as needed for cough, may have four times daily; -[MEDICATION NAME] 40 mg, every morning for [MEDICAL CONDITION]; -Xarelto (medication for thinning the blood) 20 mg every evening for history of blood clot. Observation on [DATE], at 11:37 A.M., showed the resident in his/her room in his/her chair. Additional observation showed the resident with [MEDICAL CONDITION] (swelling of the tissue) in his/her hands, and legs. Further observation showed an oxygen concentrator with new tubing sealed in the bag and a medication nebulizer machine on top of it in the corner. Observation showed the equipment not in use. Observation on [DATE], at 10:09 A.M., showed the resident in his/her bed. The resident's breathing was labored, he/she used accessory muscles (abdominal and chest muscles) to breath, respirations occurred 24 times in one minute, the resident's shoulders rose with each breath, and the resident had a productive cough. The resident said I don't feel good. Additional observation showed an oxygen concentrator beside the resident's curtain with new tubing sealed in the bag and a medication nebulizer machine on top of it in the corner. Further observation showed the equipment not in use. Observation on [DATE], at 12:04 P.M., showed licensed practical nurse (LPN) K and certified nurse assistant (CNA) H provided wound care to the resident. Additional observation showed the resident short of breath, audibly congested, and moisture movement with breath could be heard from across the room. Further observation showed the resident has [MEDICAL CONDITION] in his/her lower extremities. CNA H told LPN K, the resident has a concentrator from when he/she was sick. Observation showed the nurse left the room and did not place the oxygen on the resident as ordered. Observation on [DATE], at 12:10 P.M., showed LPN K listened to the resident's chest and said you have rattles on exhale, I am going to call and see if I can get a x-ray. The resident said he/she did not feel well and did not want to get up for lunch. Additional observation showed an oxygen concentrator beside the resident's curtain with new tubing sealed in the bag and a medication nebulizer machine on top of it in the corner. Staff did not apply oxygen on the resident as ordered. Observation on [DATE], at 12:29 P.M., showed the resident with labored breathing. The resident said, I do not feel good, taking a breath between each word. Additional observation showed an oxygen concentrator beside the resident's curtain with new tubing sealed in the bag and a medication nebulizer machine on top of it in the corner. Further observation showed the equipment was not in use. Observation on [DATE], at 1:56 P.M., showed the resident with labored breathing and short of breath. Additional observation showed an oxygen concentrator beside the resident's curtain with new tubing sealed in the bag and a medication nebulizer machine on top of it in the corner. Further observation showed the equipment was not in use. Observation on [DATE], at 3:28 P.M., showed the resident with labored breathing and short of breath. Additional observation showed an oxygen concentrator beside the resident's curtain with new tubing sealed in the bag and a medication nebulizer machine on top of it in the corner. Further observation showed the equipment is not in use. Review of the resident's record for [DATE] showed staff did not document any to show they assessed the resident's respiratory status, temperature, respirations per minute, or oxygen saturation. Review of the resident's Medication Administration Record [REDACTED]. Review of the resident's nurses notes, dated [DATE], showed staff did not document an assessment of the resident's respiratory status, notification of the physician, notification of hospice, or document any interventions for the resident's respiratory distress. Observation on [DATE], at 8:46 A.M., showed the resident with audible congestion, and his/her breathing could be heard from the hall. Additional observation showed the resident short of breath, his/her face swollen and red, and unable to speak. When DHSS staff asked the resident if he/she was having trouble breathing the resident shook his/her head yes. Additional observation showed an oxygen concentrator beside the resident's curtain with new tubing sealed in the bag and a medication nebulizer machine on top of it in the corner. Further observation showed the equipment is not in use. During an interview on [DATE], at 8:48 A.M., the director of nursing (DON) said he/she had just been with the resident and went to get him/her mints from his/her office for the resident's cough. He/She said he/she did not know the resident has been short of breath since yesterday. The DON said he/she did not know the resident has PRN (as needed) orders for [MEDICATION NAME], duo neb (a medication inhaled to help with shortness of breath), and oxygen. During an interview on [DATE], at 10:30 A.M., the DON said he/she did not know why the nurse did not administer the resident's PRN medications or treatments yesterday. He/She said staff did not pass on the resident's respiratory distress in report. The DON said the resident had a temperature and worsened respiratory distress this morning. The DON said staff administered a breathing treatment, [MEDICATION NAME], and oxygen and the resident is feeling much better now. Observation at [DATE], at 11:00 A.M., showed the resident up in his/her chair with his/her eyes closed and did not show distress. During an interview on [DATE], at 11:31 A.M., LPN K said he/she wrote a note to the doctor and got an order for [REDACTED]. He/She said he/she did not because there was so much going on. The LPN said he/she did not notify hospice yesterday. He/She said the resident's temperature this morning was 99.3, He/She said staff administered the nebulizer treatment, applied the resident's PRN order for oxygen and administered the [MEDICATION NAME]. The nurse said the PRNs did seem to help and the resident was able to get up for breakfast. He/She said he/she notified hospice this morning. Review of the resident's chest X-ray, dated [DATE], showed the physician documented: -Comparison to chest X-ray [DATE]; -The cardiac silhouette is enlarged; -There are prominent bilateral interstitial lung markings; -This is consistent with [MEDICAL CONDITIONS]; -Opacities are present in the left lung base; -These may be due to atelectasis (collapsed lung) or pneumonia; -The exam is overall worse compared with the prior X-ray. During an interview on [DATE], at 10:14 A.M., the resident said he/she was so short of breath the other day, he/she could not talk much without coughing. He/She said he/she couldn't breathe well for over 24 hours, and he/she was so scared, and I could barely talk to tell anyone and when I tried I would just cough. He/She said the staff did not tell him/her what the X-ray showed, and he/she said he/she still feels bad, but at least he/she can breathe. He/She said the medications and oxygen helped. During an interview on [DATE], at 4:35 P.M., LPN M said he/she worked the night shift of [DATE]. He/She said it was passed on in report the resident sounded mucousy, but his/her lungs were clear. He/She said the day shift staff sent a fax requesting a chest X-ray. He/She said he/she usually gives the resident a pain pill, and he/she doesn't remember the resident reporting issues with breathing. He/She did not know if the day nurse gave the resident any of his/her PRN medications or treatments for breathing issues, or what his/her vital signs were. He/She said she/she did not assess the resident's breathing status. 2. Review of Resident #15's quarterly MDS, dated [DATE], showed the staff documented as follows: -Severe cognitive impairment; -[DIAGNOSES REDACTED]. -Administration of a diuretic medication five days out of seven days. Review of the resident's physician's orders [REDACTED]. -Daily weights to monitor for weight gain related to [MEDICAL CONDITION]; -Administer [MEDICATION NAME] 40 mg on Monday, Wednesday, and Fridays; -[MEDICATION NAME] (a diuretic medication) 2.5 mg daily. Review of the resident's care plan, last revised [DATE], directs the staff to: -Monitor weights closely related to fluid overload; -Full code (perform CPR if his/her heart stops); -Monitor for weight fluctuations, [MEDICAL CONDITION], and problems breathing; Review of the resident's weight summary, dated [DATE]-[DATE], showed staff documented: -[DATE], 113.6 lbs.; -[DATE] a 3.4 lbs. gain in one day; -[DATE] the resident's weight at 123.6, with a 5.6 lbs. weight gain in one day; -[DATE] a 6.3 lbs. loss; -[DATE] the resident's weight at 111.2 lbs, an additional 6.8 lbs. loss; -[DATE] a 8 lbs. gain in one day; -[DATE] a 3.2 lbs gain in one day; -[DATE] a 2.8 lbs. weight loss in one day; -[DATE] a 5.4 lbs. weight gain in one day; -[DATE] the resident's weight at 130.4, with a 5.1 lbs. weight gain in one day; -[DATE] a 4 lbs. weight gain in one day; -[DATE] the resident's weight at 133.2 (a 19.6 lbs. weight gain since [DATE]). Review of the resident's nurses notes, dated [DATE]-[DATE], showed it did not contain staff documentation of assessment for respiratory status, [MEDICAL CONDITION], or physician notification of weight fluctuations. Review of the resident's nurses notes, dated [DATE], showed staff documented the physician notified of resident's recent weight gain, [MEDICAL CONDITION] in the resident's bilateral lower extremities and face as requested by the family member. Review of the resident's nurses notes, dated [DATE], showed the staff documented the physician notified the staff the resident's cardiac test show significant increase in heart pressure, [MEDICAL CONDITION] hypertension, and right side pressure overload. Additional review showed the physician recommended adjustment to the resident's diuretic, cardio physician consult, or heart surgery. During an interview on [DATE], at 11:24 A.M., the resident's family member said the resident's legs are really swollen. He/She said if staff do not watch his/her [MEDICAL CONDITION] the resident gets sores and fluid will come out of his/her legs, which caused [MEDICAL CONDITION] last month. He/She said the resident was admitted to the hospital in September. He/She said he/she reported something was wrong with the resident, and the doctor would not come in and look at him/her. He/She said he/she had to have the staff get the paperwork ready and take the resident to the hospital himself/herself, and the staff told him/her they noticed the change, but they didn't do anything. 3. Review of Resident #25's quarterly MDS, dated [DATE], showed staff documented as follows: -Severe cognitive impairment; -[DIAGNOSES REDACTED]. -Administration of a diuretic medication every day. Review of the resident's physician's orders [REDACTED]. -Daily weights to monitor for weight gain related to [MEDICAL CONDITION], call physician if two to three or five pounds in a week; -Administer [MEDICATION NAME] 20 mg as needed for fluid retention based on daily weights; -Administer [MEDICATION NAME] 40 mg daily. Review of the resident's care plan, last revised [DATE], shows it directs the staff to: -Weight daily before breakfast and PRN; -Monitor for weight gains and [MEDICAL CONDITION] and inform my Physician of changes whether gain or loss; -Monitor weights closely related to fluid overload; -Monitor for signs of dehydration. Review of the resident's weight summary, dated [DATE]-[DATE], showed staff documented: -[DATE], 114.1 lbs.; -[DATE], 120.1, 3.6 lbs. gain in one day, 6 lbs gain in ten days; -[DATE], 2.8 lbs. weight gain in one day; -[DATE], 3.6 lbs. weight loss in one day; -[DATE], 2.8 lbs. weight loss in one day; -[DATE], 2.7 lbs. weight gain in one day; -[DATE], 2.8 lbs. weight gain in one day; -[DATE], 4.8 lbs. weight loss in one day; -[DATE], 2.3 lbs. weight gain in one day; -[DATE], 7.1 lbs. weight loss in one day, -[DATE], 4.1 lbs. weight gain in one day; -[DATE], 2.2 lbs. weight loss in one day. Review of the resident's Medication Administration Record [REDACTED]. Review of the resident's nurses notes, dated [DATE]-[DATE], showed it did not contain staff documentation of assessment for respiratory status, [MEDICAL CONDITION], signs and symptoms of dehydration, or physician notification of the resident's weight fluctuations. During an interview on [DATE], at 9:14 A.M., the DON said the resident has not had [MEDICAL CONDITION] or fluid overload like a cough. He/She said the resident has had those orders since he/she came in and if the weight varies he/she should have been reweighed. He/She said the nurses probably did not call the physician or give the PRN [MEDICATION NAME] as ordered because the resident was not symptomatic. The DON said facility staff usually does not monitor [MEDICAL CONDITION] over a month, unless they have an acute exacerbation. 4. During an interview on [DATE], at 9:22 A.M., registered nurse (RN) F said there are several resident's with daily weights for [MEDICAL CONDITION]. He/She said staff are expected to monitor the residents' weights, [MEDICAL CONDITION], and look at how they are clinically. He/She said staff are expected to report to the physician if a resident has more than 5 lbs in a week for their weight gain. The RN said if a resident's physician ordered PRN [MEDICATION NAME], and the resident gains ,[DATE] lbs. in a day or 5 lbs. in a week, then staff are expected to follow the physician's orders [REDACTED]. He/She said staff are expected to notify the physician according to the orders, and with any change in condition, and document the notification in the nurses notes. He/She said he/she did not know why the physician was not notified with the resident's changes, or why the PRN medications were not administered. During an interview on [DATE], at 9:14 A.M., the DON said staff are expected to follow physicians orders, notify the physician with change of condition, assess residents with fluctuations in their weights and document the findings. He/She said the staff usually do not monitor [MEDICAL CONDITION] over a month, unless they have an acute exacerbation.

Based on interview and record review, facility staff failed to ensure that as needed (PRN) [MEDICAL CONDITION] medication orders were limited to 14 days unless a specific duration and clinical rationale were provided for resident's (Resident #4, #7, and #52). The facility census was 66. 1. Review of the facility's [MEDICAL CONDITION] Medication Use Policy, dated 3/01/18 showed: Each resident's drug regimen must be free from unnecessary drugs, which are defined as drugs that are used in excessive doses, for an excessive duration, without adequate indication, without adequate monitoring for it's use, or in the presence of adverse consequences which indicate the dosage should be reduced or discontinued. 2. Review of Resident #4's Minimum Data Set (MDS), a federally mandated assessment tool, dated 7/6/18, showed staff documented: -Mild Cognitive Impairment; -No behaviors; -Limited assistance transfer; -Locomotion on unit supervision. -Alzheimer/dementia Review of the resident's care plan, dated 10/23/18, showed staff documented the resident may have behaviors due to Dementia. Additionally, staff are directed to assist the resident to feel safe and at home. Staff are to help the resident back to the residents's room if he/she is disturbing other residents. The care plan directs staff to monitor side effects like muscle weakness and to regularly assess the resident. Additionally, the Pharmacist is directed to review medications. Review of the resident's physician's orders [REDACTED]. Additional review showed the order did not have an end date. Review of the resident's Pharmacist Medication Regimen Review, dated 4/20/18-9/30/18, showed it did not contain requests for physician intervention. Review of the resident's medical record showed it did not contain recommendations for a gradual dose reduction (GDR) for the [MEDICATION NAME]. Review of the resident's Behavior Monitoring showed staff did not document the resident exhibited behaviors. 2. Review of Resident #7's annual MDS, dated [DATE], showed staff documented: -Cognitively intact; -Resident is without signs and symptoms of [MEDICAL CONDITION], depression, hallucinations, delusions, or behaviors; -Resident has not had vomiting in the last seven days; -Antianxiety and antidepressant medications administered every day. Review of the resident's care plan, last revised 7/24/18, showed it directs the staff as follows: -Resident has moments of outburst cursing, and acting out; -Reassure the resident he/she is safe and staff are here to help; -Do not argue or try to reason with the resident, this will usually make things worse, or confuse the resident; -Keep the resident's daily routine; -Separate the resident from the situation and take the resident to his/her room to cool down. -A pharmacist reviews the resident's antidepressant and antianxiety medication for possible recommendations to the resident's physician to reduce, change, or eliminate [MEDICAL CONDITION] medications; -Administer the medications as ordered by the physician. Review of the resident's physician's orders [REDACTED]. Additional review showed the order did not include a stop date. Review of the resident's Pharmacy Consultant Note, dated 8/31/18, showed the pharmacist recommended the physician consider placing a stop date, preferably 14 days on the [MEDICATION NAME] 0.25 mg twice a day PRN. Review showed the physician responded on 9/6/18 with, yes, place 14 day duration on PRN [MEDICATION NAME] from the date this order is received back into the nursing home signed. Additional review showed the document did not include documentation to show staff carried through the order. Review of the resident's Medication Administration Record [REDACTED].M. Additional review showed the documentation did not include why the resident received the medication, or interventions attempted prior to the administration of the PRN antianxiety medication. During an interview on 10/25/18 at 3:00 P.M., the director of nursing (DON) said the pharmacy consultant recommended the 14 day stop date and the physician agreed, but it did not get carried through to the order; the medication does not have a stop date. He/She said the charge nurse is expected to carry through new orders from the pharmacy recommendations. 3. Review of Resident # 52's MDS, dated [DATE], showed staff assessed the resident as: -Cognitively intact; -Diagnoses; [MEDICAL CONDITION], Anxiety Disorder, Diabetes Mellitus, [MEDICAL CONDITIONS]; -No behaviors; -Received an antianxiety medication five days out of the seven day look back period. Review of resident's POS, dated 8/18/18 to 9/18/18, showed the resident with an order for [REDACTED]. Review of the resident's medical record showed it did not contain a specific duration or clinical rationale provided by the physician for continuation of the as needed medication for longer than the allotted 14 day period. Review of the resident's Pharmacy Consultant Note, dated 8/31/18, showed the pharmacist recommended a 14 day stop date for the [MEDICATION NAME]. 4. During an interview on 10/25/18, the DON said he/she did not know the physician needed to document a clinical justification to extend a PRN past 14 days or it still required a stop date to be reevaluated. He/She said he/she thought the pharmacist and the physician took care of the PRN medications.

Based on observation, interview and record review, facility staff failed to store food in a manner to protect against potential contamination and the use of out-dated food items. Facility staff failed to date open food items, store food items in appropriate air-tight containers and store resident personal food items separate from the facility food supply in one of two unit refrigerator/freezer units. Facility staff also failed to maintain the unit refrigerator in a clean sanitary condition. The facility census was 66. 1. Review of the facility's Use and Storage of Personal Foods Brought In By Residents/Resident Representatives Policy, undated, showed: -The facility requires all food items be stored in manner using appropriate sanitation and temperature requirements for said food item; -Food items brought to the facility by residents, family members or other visitors will be clearly labeled with the elder's name, contents and date of storage; -If the elder does not have a personal refrigerator in the bedroom, personal food may be stored in a unit refrigerator specifically designated for elder food stuffs. Any food brought in from outside the facility must be labeled with the elder's name, date and bedroom number and will be held in the unit refrigerator for up to 24-hours; -Foods are considered perishable after a sealed container has been opened. 2. Observation on 10/23/18 at 11:19 A.M., showed the refrigerator/freezer unit, in the rear kitchenette by resident room [ROOM NUMBER], with an excess of food debris and dried sticky multi-colored substance on the shelves and in the rubber seals. Further observation showed the following inside the unit: *Freezer: -a four pound plastic whipped margarine container which contained ice cream dated 9-29; -an opened and undated box of glazed doughnuts with contents exposed to air; -two opened and undated bags of bagels. *Refrigerator: -an opened 46 ounce (oz.) container of prune juice marked 9/12; -an opened 46 oz. container of grape juice marked 10/2 with an excess of dried juice on the exterior of the container; -an opened and undated 46 oz. container grape juice; -an opened and undated 46 oz. container of pineapple juice; -an opened and undated 46 oz. container of cranberry juice cocktail; -an opened and undated 46 oz. container of apple juice; -an opened and undated bag of bagels with contents exposed to the air; -multiple open soda cans, covered cups of various beverages, and various opened packages of food items without names or dates stored on the shelves with facility food items. During an interview on 10/23/18 at 12:13 P.M., the Dietary Manager (DM) said the dietary aide assigned to the kitchenette is responsible for monitoring and cleaning the freezer/refrigerator. The DM said he/she would not consider the unit to be clean and staff should wipe up any spills as they happen. The DM said all opened food items should be sealed, labeled and dated. The DM said opened containers of juices should be discarded if not used within one week and commercial containers made for other foods should not be reused. The DM said the drinks and various opened food packages in the refrigerator belonged to residents and he/she did not know that resident personal foods had to be stored separate from facility foods in the unit refrigerators. The DM said he/she frequently monitors the food storage in the kitchen, but did not frequently monitor the food storage in the units in the kitchenettes.

Based on interview and record review, facility staff failed to implement infection control policies and procedures when staff failed to screen three of seven sampled new hired employees (Dietary Aide (DA) C, DA D, and Housekeeper E) for [MEDICAL CONDITION] in accordance applicable state and federal guidelines. The facility staff also failed to date and cover oxygen tubing to prevent contaminants for three residents (Resident #13, #44, and #52), and failed to adequately cleanse glucometers in a way to prevent contaminates from spreading infection for four resident's (Resident #36, #38, #52, and #263). The facility census was 66. 1. Review of Missouri state regulations 19 CSR 20-20.100 ([MEDICAL CONDITION] testing for residents and workers in long-term care facilities) showed: -Employees and volunteers who work ten or more hours per week are required to obtain a Mantoux PPD two-step [MEDICATION NAME] skin test (TST) within one month prior to starting employment in the facility. If the initial test is zero to nine millimeters (mm), the second test should be given as soon as possible within three weeks after employment begins, unless documentation is provided indicating a Mantoux PPD test in the past and at least one subsequent annual test within the past two years. -It is the responsibility of the facility to maintain documentation of each employee's or volunteer's [MEDICATION NAME] status. -All skin test results are to be documented in millimeters (mm) of induration. 2. Review of the facility's [MEDICAL CONDITION] Control policy, undated, showed Every facility should have a [MEDICAL CONDITION] surveillance program that included the following procedures: -Initial Examination. Provide a [MEDICATION NAME] skin test (Mantoux, 5 [MEDICATION NAME] units (TU) of purified protein derivative (PPD)) to all employees during pre-employment procedures, unless a previous reaction greater than or equal to 10 mm is documented. If the initial skin test result is 0-9 mm, a second test should be given at least one week and no more than three weeks after the first test. The results of the second test should be used as the baseline in determining treatment and follow-up of these employees. The two-step test regimen is optional for employees with a history of negative skin tests within the last two years. 3. Review of DA C's personnel records showed a hire date of 09/05/18. Further review showed the records contained documentation of a one-step TST administered on 09/03/18 in which staff documented the results of the TST on 09/05/18 as negative. Review showed the records did not contain documentation of a two-step TST or documentation of the results of the TST administered in mm as required. 4. Review of DA D's personnel records showed a hire date of 09/10/18. Further review showed the records contained documentation of a one-step TST administered on 09/08/18 in which staff documented the results of the TST on 09/10/18 as negative. Review showed the records did not contain documentation of a two-step TST or documentation of the results of the TST administered in mm as required. 5. Review of Housekeeper E's personnel records showed a hire date of 09/19/18. Further review showed the records contained documentation of a one-step TST administered on 04/18/18 and another one-step TST administered on 10/01/18 in which staff documented the results of the TST 10/14/18 (13 days after administration) as negative. Review showed the records did not contain documentation of a two-step TST or documentation of the results of the prior TST's administered in mm as required. 6. During an interview on 10/23/18 at 4:30 P.M., the administrator said the staff development coordinator (SDC) is responsible for the completion of all the new hire paperwork which includes TB testing. The administrator said TB testing should be documented for all employees and he/she did not know why the employees did not have complete documentation of TB testing in their files. 7. During an interview on 10/24/18 at 11:15 A.M., the SDC said he/she became responsible for the completion of screenings for new employees in (MONTH) (YEAR). The SDC said new employees should be given a TST before orientation and he/she then a paper slip at the time clock, usually two weeks later, for as a reminder for the employees to get their second TST. The SDC said until a new employee has completed the testing, he/she folds their testing record in half in the binder to track completion. The SDC said he/she tries to look at the binder every few days to ensure all testing is completed, but he/she missed that DA C, DA D and Housekeeper E did not get their second TST. The SDC also said he/she did not know TST results were to be documented in millimeters of induration. 8. Review of the facility's oxygen administration general infection control guidelines, directs facility staff to: -Store all cannulas and nebulizer masks in a plastic bag when not in use. -Disposable cannulas, nebulizer masks and tubing will be changed and dated on the night shift. -Change cannula and tubing weekly. Store masks, med traps, tubing and cannulas in a labeled plastic bag when not in use. 9. Observation on 10/23/18, at 11:25 A.M., showed Resident #13's medication nebulizer mask on the resident's bed uncovered. Staff did not place the mask in a plastic bag when the resident did not use it. 10. Observation on 10/23/18, at 11:37 A.M., showed Resident #44's nasal cannula oxygen tubing hung off the resident's oxygen concentrator unbagged, and a medication nebulizer mask on a bedside table with a hat on top of the mask, not covered. 11. Observation on 10/23/18, at 2:15 P.M., showed Resident # 52's oxygen tubing undated. Observation on 10/24/18, at 1:14 P.M., showed the resident's oxygen tubing undated and lay uncovered on top of the oxygen concentrator. Observation on 10/25/18, at 9:45 A.M., showed the resident undated oxygen nasal cannula lay on the floor. Observation on 10/26/18, at 9:38 A.M., showed the resident's oxygen tubing undated. 12. Observation on 10/24/18, at 9:28 A.M., showed Resident #263's nebulizer mask and tubing uncovered and undated, inside a drawer of the bedside table. 13. Review of the facility's policy and procedure for disinfecting glucometers, revised 7/30/15, showed the facility staff are directed to disinfect the glucometer between each resident use: 1. Sanitize hands and put on clean gloves. 2. Clean meter with Super Sani wipe #1 and discard. 3. Wrap meter in Super Sani wipe #2 to disinfect and allow surface to stay wet for 2 minutes with the meter facing downward to avoid moisture in the port. 4. After the 2 minute wet time, discard Super Sani wipe and place disinfected glucose meter on a clean barrier surface (paper towel) to air dry. 5. When finished, wrap the disinfected meter in a clean paper towel. 14. Observation on 10/24/18, at 11:21 A.M., showed LPN L did not allow the glucometer time to air dry after sanitizing with sani-wipes between Resident #263, Resident #38, Resident #52, and Resident #36. 15. Observation on 10/25/18, at 11:44 A.M., showed RN A did not allow the glucometer time to air dry after sanitizing with sani-wipes between Resident #36 and Resident #52. 16. During an interview on 10/24/18, at 11:21 A.M., LPN L said he/she did not need to air dry the glucometer after he/she wiped it with sani-wipes because the glucometers are dry by the time he/she does the next glucose check. He/she dries the glucometer with a paper towel if it was still wet.

Based on observation, interview and record review the facility failed to ensure the resident's call lights were answered in a timely manner. The facility's census was 66. 1. Review of the facility's Call Light History, dated 10/19/18 at 7:00 A.M.-10/22/18 at 7:00 A.M., showed a resident pushed their call light 61 times and the report says announced nine times, response required but not received, this alert was never responded to. Review of the report showed some of the residents called multiple times when their call light said the alert was never responded to on the report. 2. Observation on 10/24/18, at 10:25 A.M., showed Resident #14 in the bathroom. Additional observation showed the resident repeatedly knocked on the door, and asked is anyone out there. Resident #43's family member asked the resident in the bathroom if he/she pulled the call light. He/She said, yes a long time ago. During an interview on 10/24/18, at 10:25 P.M., Resident #43's family member said Resident #14 knocked on the door at least 15 minutes. Observation on 10/24/18, at 10:32 A.M., showed Resident #14 opened the door to the bathroom and said excuse me loudly. Additional observation showed three staff walked by the resident's room, but did not assist the resident. Observation on 10/24/18, at 10:40 A.M., showed staff entered the bathroom to assist Resident #14. During an interview on 10/24/18, at 10:44 A.M., Resident #14 said he/she does not know why the bathroom call light takes so long to get help. He/She said he/she was in the bathroom for at least 30 minutes, and he/she gets uncomfortable sitting on the toilet that long. During an interview on 10/24/18, at 11:00 A.M., certified nurse assistant (CNA) H said he/she did not get a page for the resident's call light until 10:15 A.M., and he/she and another staff member were taking care of the resident across the hall. 3. During an interview on 10/23/18, 12:56 P.M., Resident #13's family member said the resident called him/her on the phone three separate times to ask him/her to call staff to help the resident off of the toilet. He/she said the resident sat on the toilet for over 45 minutes each of those times. The resident's family member said his/her mom has to wait a long time to get help to go the bathroom in the evenings and on the weekends. 4. During the group interview on 10/24/18 at 1:09 P.M., resident said sometimes staff do not respond quickly to call lights because they are understaffed. 5. Review of the Resident #32 's Minimum Data Set (MDS), a federally mandated assessment tool required to be completed by facility staff for care planning, dated 8/17/18, showed there resident as: -Minimal cognitive impairment; -Extensive assistance one person for transfer; -Walk in room activity occurred one or two times; -Extensive assistance on toileting. During an interview on 10/24/18 at 1:38 PM., the resident said he/she layed in bed for hours after pushing the call light. The resident said he/she feels there is not enough staff and sometimes staff will come, but then say they will be back later because they have another emergency. 6. During an interview on 10/26/18, at 9:09 A. M., Certified Medical Technician (CMT) J, said sometimes the pagers don't work correctly. During an interview on 10/26/18, at 9:16 A.M., the Maintenance Director (MD) said the first three call light pages are sent to CNAs, the next three pages go to the CNAs and Nurses, the next three pages go to CNAs, Nurses, ADON, DON, and ADM. The pages will go to all pagers in the building one time after that. All pages go off at 3 minute intervals. If the call light is not answered, then it registers as unanswered. He/she said the pager system does not have anything to do with whether the facility wifi is working. He/she added that some of the staff do not like the pager system. During an interview on 10/26/18 at 10:29 A.M., CNA H said if the batteries go dead calls might be missed. During an interview on 10/26/18, at 11:00 A.M., the administrator said the call light report is hard to read. He/She said it does not show the number of times a resident pushes their call light, just the number of alerts to the pager before the call light is manually reset in the room. He/She said staff have to hold the button in the room to show it is answered. He/She said there is no way to tell a resident's call light is on when staff walk by the room, unless staff have a pager. During an interview on 10/26/18, at 3:11 P.M., the activity director (AD) said resident council members say staff do not answer the call lights fast enough. During an interview on 10/26/18, at 3:18 P.M., CNA O said sometimes the residents say they called and staff do not get a page. He/She said the resident's call light in room [ROOM NUMBER] had issues recently and staff stopped by a lot to check on the resident because we didn't think the call light was working. He/She said sometimes staff do not get the page until the second or third alert. He/She said if there are call light issues, it is reported to the MD and he/she comes in and it seems to fix it. He/She said the facility has issues with the call lights frequently. During an interview on 10/26/18, at 3:21 P.M., CNA P said sometimes the call light page makes it and sometimes it does not. He/She said residents say they called, and sometimes he/she did not get the page. During an interview on 10/26/18, at 3:45 P. M, the director of nursing (DON) said that the call light report shows call lights go unanswered, but he/she has talked to residents and sometimes they say it takes a long time for their call light to be answered. He/She said he/she is unable to confirm there are call lights that are unanswered. During an interview on 11/1/18, at 4:35 P.M., licensed practical nurse (LPN) Q said the residents said there are issues with the call lights. He/She said the residents say it has been on for an hour but it just alerted the staff's pagers. The LPN said the staff have issues with the pagers and the CNA's said the light is on but it didn't come through to the pagers. He/She said if the call light isn't working, staff switch it out and try to rectify the situation, then let the MD know. The nurse said on his/her shift, it seems like there are issues about once a week. He/She said it is hard with the new system because there is not a visual light or anything to tell the light is on, and some of the staff cannot read the pagers and have to go to the desk to figure out what is going on, which is not efficient.

Based on observation, interview, and record review, facility staff failed to maintain residents' dignity by not properly covering urinary catheter bags for three residents (Residents #19, #40 and #44). The facility census was 66. 1. Review of Resident #19's Minimum Data Set (MDS), a federally mandated assessment tool, dated 7/27/18, showed staff assessed the resident as follows: -Moderate cognitive impairment; -Indwelling catheter (tube inserted into the bladder to drain urine); -Extensive two person assistance. Review of the resident's care plan dated 10/17/17, showed staff are directed to cover the resident's catheter bag with a privacy cover. Observation on 10/23/18 at 2:16 P.M., showed the resident in bed. Further observation showed the bottom of his/her catheter bag exposed and full of urine. Observation on 10/24/18 at 11:00 A.M., showed the resident in bed. Further observation showed the bottom of his/her catheter bag exposed and full of urine. Observation on 10/25/18 at 12:28 P.M., showed the resident in bed with the door open. Further observation showed the bottom of his/her catheter bag exposed. 2. Observation on 10/23/18 at 12:36 P.M., showed Resident #40 in his/her wheelchair in the dining room. Additional observation showed his/her urinary drainage bag contained urine, uncovered under his/her chair. 3. Observation on 10/23/18 at 11:53 A.M., showed Resident #44 in his/her wheelchair in the dining room. Additional observation showed urine leaked out of the urinary drainage bag and pooled under his/her chair. 4. During and interview on 10/25/18 at 3:15 P.M., CNA I said residents with catheter bags should have privacy bags to completely cover them. During and interview on 10/25/18 at 3:20 P.M., Director of Nursing (DON) said catheter bags should be completely covered for privacy, but there is no way to do so with the current supplied privacy bags.

Based on interview and record review, facility staff failed to implement the facility's abuse and neglect policies and procedures when facility staff failed to conduct a check of the Nurse Aide Registry (a registry used to verify federal indicators for abuse, neglect, and misappropriation of property) for five of seven sampled employees (Registered Nurse (RN) A, Licensed Practical Nurse (LPN) B, Dietary Aide (DA) C, DA D, and Housekeeper E) prior to employment. The facility census was 66. 1. Review of the facility's Abuse, Neglect and Exploitation Policy, dated (MONTH) (YEAR), showed The names of all potential employees will be checked against the list maintained by the State of persons who may not be eligible for employment within a long-term care facility. CNA registry checked on all new hires and print copy for employee file prior to employment date and according to state law. 2. Review of Registered Nurse (RN) A's personnel records showed a hire dated of 04/16/18. Further review showed the records did not contain documentation of a check of the Nurse Aide Registry as required. 3. Review of Licensed Practical Nurse (LPN) B's personnel records showed a hire dated of 01/25/18. Further review showed the records did not contain documentation of a check of the Nurse Aide Registry as required. 4. Review of Dietary Aide (DA) C's personnel records showed a hire date of 09/05/18. Further review showed the records did not contain documentation of a check of the Nurse Aide Registry as required. 5. Review of DA D's personnel records showed a hire date of 09/10/18. Further review showed the records did not contain documentation of a check of the Nurse Aide Registry as required. 6. Review of Housekeeper E's personnel records showed a hire date of 09/19/18. Further review showed the records did not contain documentation of a check of the Nurse Aide Registry as required. 7. During an interview on 10/23/18 at 4:30 P.M., the administrator said the staff development coordinator (SDC) is responsible for the completion of all the new hire paperwork which includes the background screening checks. The administrator said the Nurse Aide Registry should be checked for all new employees prior to hire and he/she did not know why the employees did not have a check of the Nurse Aide Registry in their files. 8. During an interview on 10/24/18 at 11:15 A.M., the SDC said he/she became responsible for the completion of criminal background checks and screenings for new employees in (MONTH) (YEAR). The SDC said once a new employee accepts the position and completes all the necessary paperwork, he/she checks the Nurse Aide Registry for a federal indicator for abuse or neglect. The SDC said the facility uses a computer program to identify what paperwork needs to be completed for each employee and track its completion. The SDC said, while he/she knew of the requirement to check the Nurse Aide Registry for all employees, he/she did not check the registry for the five employees because the computer system does not prompt him/her to check that registry for employees who are not nurse aides.

Based on observation and interview, facility staff failed to ensure residents' environment remained free of accident hazards for three residents (Residents #50, 54 and 52 ) when the thresholds of their rooms were raised. The facility census was 66. 1. Review of Resident # 52's quarterly Minimum Data Set (MDS), a federally mandated assessment tool, dated 9/21/18, showed staff assessed the resident as: -Cognitively intact; -Requires extensive assistance of two staff members for bed mobility, personal hygiene, bathing, toilet use, and transferring; -Required extensive assistance of one staff member for walking, dressing, and locomotion on and off unit; -Uses a wheelchair. Review of the resident nurses' notes dated 6/02/18, showed staff documented they found a bleeding toe on the resident's right foot. Review of the resident nurses' notes dated 6/09/18, showed staff documented a toenail on the resident's left foot was torn off and bleeding. During an interview on 10/26/18, at 9:38 A.M., the resident, said his/her toenail on right the foot was torn off when it got caught on the threshold of the doorway. He/She said this occurred when a CNA propelled him/her in a wheelchair without foot rests. Additionally, the resident said, another time after that, his/her toenail on the left foot, came off when it hit the door frame of the bathroom when staff propelled him/her to the bathroom without foot rests. 2. Review of Resident #50's quarterly MDS, dated [DATE], showed staff assessed the resident as follows: -Severe cognitive impairment -Extensive one person assists for transfers -Walking in corridor supervision -Walking in room supervision Observation on 10/23/18 at 2:25 P.M., showed the resident attempted to leave his/her room. He/She picked up his/her walker to clear the floor trim at his/her door and instead running the leading edge of the walker into the trim, the resident wavered and then made another attempt. The resident was not supervised at this time. 3. Review of Resident #54's MDS, showed staff assessed the resident as follows: -Mild cognitive impairment -Extensive one person transfer -Walking in room activity occurred one or two times -Walking in corridor activity occurred one or two times Observation on 10/25/18 at 11:27 A.M., showed the resident attempted to roll his/her wheelchair into his/her room. Additional observation showed the resident could not do so without grabbing the doorframe to pull the chair over the threshold. 4. During an Interview on (needs a date) at 11:17 A.M., Residents #28 and Resident #36 said they are unable to pull themselves over the threshold, especially when they are tired. (Both residents reside in the same room.) 5. Observation on 10/26/18, at 11:01 A.M., showed Resident #53 walked in the hall toward his/her room. Additional observation showed the resident approach the threshold of his/her room, lift his/her walker over the threshold and sit his/her walker on the other side of the raised threshold. Further observation showed as the resident walked over the threshold, his/her toe caught on the raised threshold. During an interview on 10/26/18, at 11:03 P.M., the resident said, I have to lift my walker to go over the threshold because it will stop you. 6. During an interview on 10/26/18 at 11:06 A.M., Resident #38, said he/she has trouble getting his/her wheelchair over the rubber threshold in his/her room doorway. 7. During an interview on 10/26/18 at 11:07 A.M., Resident #13 said he/she has to pull himself/herself through the doorway by putting his/her hands on the door frame and pulling hard to get over the threshold. He/She said he/she couldn't get out of his/her room until he/she figured it out, and some days he/she still needs help. 8. Observation on 10/26/18 at 11:09 A.M., showed the flooring in the facility is made of a laminate simulated wood with a rubber threshold between the doorway and hall, raised to approximately a half of an inch. 9. During an interview on 10/26/18 at 11:13 A.M., Resident #23 said he/she has problems going into the bathroom and the hallway because of the raised threshold. He/She said, it is hard to get your walker over it. 10. During an interview on 10/26/18 at 11:24 A.M., Resident #15's family member said he/she helps several residents get over the hump into their rooms in their wheelchairs because many of them cannot push their wheelchairs over the hump. 11. During an interview on 10/25/18 at 11:10 A.M., the Maintenance Director (MD) said he/she is aware the flooring threshold is too tall and may cause a problem. He /she said he/she is looking into a solution. During an interview on 10/25/18 at 11:01 A.M., CNA G said he/she sees residents have trouble getting their walkers or wheelchairs over the bumps or uneven spots in the flooring. During an interview on 10/26/18 at 11:12 A.M., RN F said he/she sees residents have trouble pushing themselves in and out of their rooms and request assistance to get over the transition threshold. During an interview on 10/26/18 at 11:21 A.M., CNA G said he/she has problems getting wheelchairs over the thresholds in room doorways. During an interview on 10/26/18, at 11:30 A.M., CMT J said he/she has had some trouble getting wheelchairs over the bump in the doorways and will have to turn the wheelchair a little to get over them. During an interview on 10/26/18 at 11:34 A.M., the MD said the flooring was replaced in (YEAR). During an interview on 10/26/18, at 11:38 A.M., licensed practical nurse (LPN) M said some residents have problems getting over the hump between the hall and their room. He/She said there are about five resident's who can't get over the threshold and we have to help them or they get stuck. During an interview on 10/26/18 at 11:41 A.M., certified nurse assistant (CNA) R said Resident #16, Resident #25, and Resident #56 get stuck on the thresholds when they enter their rooms. During an interview on 10/26/18, at 11:53 A.M., CNA S said the resident's wheelchairs get hung up on the thresholds and we have to help them over it. He/She said the floors were redone last year and it has been an issue since then.

Based on observation, interview, and record review, facility staff failed to properly propel three residents (Residents #34, #35, #36) in wheelchairs in a manner to prevent accidents. Facility staff also failed to ensure the residents' environment remained free of accident hazards when they failed to lock medication/treatment cart when not in use, failed to ensure razors were not accessible to residents, and failed to ensure hazardous items were not accessible to two residents (Resident #36 and # 45). The facility census was 68. 1. Review of the facility's Wheelchair Mobility Policy, dated 2017, showed staff are directed: -Avoid pushing the elder's wheelchair without asking permission from the elder; -If resident wants staff to propel them and is able to hold legs up for short distance, staff can slowly propel and assist resident with mobility as requested; -If resident needs to be propelled and does not generally move or propel the wheelchair on their own, pedals will be maintained and provided; -If the elder cannot safely propel the wheelchair, staff will provide proper seating, positioning and staff assisted wheelchair mobility. 2. Review of Resident #34's minimum data set (MDS), a federally mandated assessment tool, dated 10/13/17, showed staff assessed the resident as follows: -Moderate cognitive impairment; -Required extensive assistance with bed mobility and transfers; -Required limited assistance with locomotion on and off unit. Observation on 12/21/17 at 11:22 A.M., showed Licensed Practical Nurse (LPN) D propelled the resident in his/her wheelchair without foot rests. Further observation showed the resident's feet slid on the floor. 3. Review of Resident #35's MDS, dated [DATE], showed staff assessed the resident as follows: -None to mild mental impairment; -Required extensive assistance with bed mobility and transfers; -Required supervision with locomotion on and off unit. Observation on 12/20/17 at 10:17 A.M., showed the Administrator propelled the resident in his/her wheelchair without foot rests. Further observation showed the resident's feet slid on the floor. 4. Review of Resident #36's MDS, dated [DATE], showed staff assessed the resident as follows: -Moderate cognitive impairment; -Required extensive assistance with bed mobility, transfers, locomotion on and off unit. Review of the resident's care plan updated 12/12/17, showed staff are directed: -Please encourage the resident to elevate legs sitting; -Attempt to prevent injury from falls; -One staff member to assist resident to the dining room, uses a wheelchair for mobility; -Make sure resident is in a comfortable position while in wheelchair and in bed. Observation on 12/21/17 at 09:13 A.M., showed Certified Nursing Assistant (CNA) E propelled the resident in his/her wheelchair without foot rests. Further observation showed the resident's feet slid on the floor. Observation on 12/21/17 at 11:24 A.M., showed Physical Therapy Assistant (PTA) F propelled the resident in his/her wheelchair without foot rests. Further observation showed the resident's feet slid on the floor. During an interview on 12/21/17 at 11:25 A.M., PTA F said he/she should check the resident's positioning in their chair and make sure they are able to hold their feet up before he/she propels them. If the resident's feet drag or slide on the floor he/she should stop and get foot rests. He/She has not had any in-services about propelling residents since he/she started in August. 5. During an interview on 12/21/17 at 1:10 P.M., The Staff Development Coordinator (SDC) said staff are expected to always place foot pedals on the wheelchair if they propel a resident in his/her wheelchair. 6. During an interview on 12/22/17 at 08:23 A.M., the MDS Coordinator said staff are expected to propel residents in wheelchairs with foot pedals attached for sure, because the resident's legs could get caught and cause injuries. He/She also said there are plenty of foot pedals available for staff to use. 7. During an interview on 12/22/17 at 08:24 A.M., CNA H said staff should put foot pedals on a wheelchair before they propel a resident because their feet could get caught and they could fall forward out of the chair. 8. During an interview on 12/22/17 at 08:32 A.M., Nursing Assistant (NA) G said residents should have foot pedals in place, should be comfortable, and the brakes should be off before staff propel them in wheelchairs. 9. During an interview on 12/22/17 at 09:15 A.M., the Director of Nursing (DON) said it is okay for staff to have the resident hold his/her feet up when they propel the resident in a wheelchair. He/She said if the resident is unable to pick his/her feet up, staff are expected to place foot pedals on the wheelchair. 10. Review of the facility's Medication Storage Policy, dated 8/24/16, showed staff are directed: -Medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier; -The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications; -Medication rooms, carts, and medication supplies are locked or attended by persons with authorized access. 11. Observation on 12/21/17 at 06:40 A.M., showed the medication/treatment cart parked on Memory Lane hallway, located on the Alzheimer's unit, unlocked and unattended. Further observation showed the top drawer with boxes of lancets (small needles used to prick the skin to obtain a blood sample), vials of insulin (injectable medication used to treat high blood sugar), nail clippers, and one [MEDICATION NAME] emergency kit (injectable medication used to treat severely low blood sugar). Observation showed the second drawer with insulin syringes, and various ointments. Further observation showed the bottom drawer with one bottle of dandruff shampoo, various creams/ointments, and a container of micro-kill+ sanitizing wipes with a warning label to keep out of reach of children. Further observation showed a confused resident with clothes in his/her hands asking how and when he/she can get to St. Louis ambulated past the cart in the hallway. Staff did not ensure the residents' environment remained free from accident hazards, and did not ensure hazardous items were not accessible to residents. Observation on 12/21/17 at 06:45 A.M., showed the medication/treatment cart parked on Memory Lane hallway unlocked and unattended. Additional observation showed a certified nurse assistant (CNA) and the Social Services Director (SSD) walked back and forth in the hallway and did not lock the cart. Observation on 12/21/17 at 06:47 A.M., showed the medication/treatment cart parked on Memory Lane hallway unlocked and unattended. Staff did not ensure the residents' environment remained free from accident hazards, and did not ensure hazardous items were not accessible to residents. During an interview on 12/21/17 at 1:10 P.M., The Staff Development Coordinator (SDC) said staff are expected to keep the medication/treatment carts locked at all times when left unattended. 12. Review of Resident #36's MDS, dated [DATE], showed staff assessed the resident as follows: -Moderate cognitive impairment; -[DIAGNOSES REDACTED]. -Required extensive assistance with bed mobility, eating, and personal hygiene; Review of the resident's care plan, updated 12/12/17, showed staff are directed: -Required assistance of one staff with personal hygiene; -Resident participating in therapy for activities of daily living (ADL) management and cognition. Observation on 12/20/17 at 12:15 P.M., showed an unattended aerosol can of shaving cream on the resident's bedside table, with a warning label to keep out of reach of children. Staff did not ensure hazardous items were not accessible to the resident. 13. Review of Resident #45's MDS, dated [DATE], showed staff assessed the resident as follows: -Moderate cognitive impairment; -[DIAGNOSES REDACTED]. -Used wheelchair for mobility; -Required staff supervision with eating and mobility. Observation on 12/21/17 at 11:00 A.M., showed the resident sat in his/her wheelchair in his/her room next to the nightstand. Further observation showed a tube of antifungal cream with a warning label to keep out of reach of children, on the nightstand. Observation on 12/21/17 at 11:01 A.M., showed another tube of antifungal cream with a warning label to keep out of reach of children, on the bedside table in the resident's room. Staff did not ensure hazardous items were not accessible to the resident. 14. During an interview on 12/21/17 at 1:10 P.M., the Staff Development Coordinator (SDC) said staff are expected to keep tubes of ointments/creams or mouthwash locked away when not in use, and it is not safe to leave those items unattended on a resident's bedside table, particularly on the Alzheimer's unit. 15. During an interview on 12/22/17 at 08:23 A.M., the MDS coordinator said he/she expects staff to keep the treatment carts locked at all times when left unattended. He/she said creams and ointments should be labeled, and particularly on the Alzheimer's unit, they should be locked away in containers for resident safety. 16. During an interview on 12/22/17 at 08:25 A.M., CNA H said treatment ointments and creams in rooms of residents with altered mental status should be stored on the treatment cart, at the nurses station, or in staff pockets because residents could eat them. 17. During an interview on 12/22/17 at 08:34 A.M., NA G said treatment ointments and creams should not be left out due to contamination and because residents with an altered mental status may not know what they are and try to use them incorrectly or eat them. 18. During an interview on 12/22/17 at 09:15 A.M., the DON said staff are expected to lock medication/treatment carts when left unattended. Staff who work on the Alzheimer's unit, are expected to store creams/ointments, or mouthwash behind a locked cabinet in the resident's room to prevent harm to the residents. 19. Observation on 12/20/17 at 2:23 P.M., showed the 100 hall spa room open and unattended. Observation showed a drawer in the spa room contained three bags of razors. Observation on 12/21/17 at 5:46 A.M., showed the 100 hall spa room open and unattended and a drawer in the spa room contained three bags of razors. Observation on 12/21/17 at 10:56 A.M., showed the 100 hall spa room continued to be open and unattended and a drawer contained three bags of razors. During an interview on 12/21/17 at 1:09 P.M., the Staff Development Coordinator said staff are expected to keep razors in the supply room or locked in a treatment cart. The Staff Development Coordinator said he/she was not sure if razors should be kept in the spa rooms. During an interview on 12/22/17 at 08:22 A.M., CNA H said razors should be put away in the spa room because it would be dangerous if a resident got a hold of them. During an interview on 12/22/17 at 08:31 A.M., NA G said razors should not be left in the spa because residents could get in there and shave themselves. Razors should be put away in the cabinets. During an interview on 12/22/17 at 9:15 A.M., the DON said staff should store sharps and razors behind a locked cabinet.