Every finding on record at St Gerard's Community of Care

Based on observation, review of facility policy, and staff interview, the facility failed to ensure staff followed professional standards of practice for 3 of 3 residents (Residents #8, #16, and #23) observed for insulin preparation and administration. Failure to properly prime an insulin pen and administer insulin correctly may result in residents receiving an inaccurate dose of insulin.Findings include:Review of the facility policy titled, Insulin Pen occurred on 07/23/25. This policy, dated 04/09/23, stated, . Prime the insulin pen: i. Dial 2 units by turning the dose selector clockwise. ii. With the needle pointing up, push the plunger, and watch to see that at least one drop of insulin appears on the tip of the needle. If not, repeat until at least one drop appears.-Observation on 07/22/25 at 5:30 p.m. showed a nurse (#4) prepared Resident #16's insulin pen for administration. The nurse (#4) dialed the pen to 3 units and with the needle cap on, primed the pen with the needle pointed horizontally. The nurse primed the insulin pen with 3 units instead of 2 units and failed to remove the needle cap and hold the pen upward when priming. -Observation on 07/22/25 at 6:00 p.m. showed a nurse (#4) prepared Resident #23's insulin pen for administration. The nurse (#4) dialed the pen to 3 units and with the needle cap on, primed the pen with the needle pointed horizontally. The nurse primed the insulin pen with 3 units instead of 2 units and failed to remove the needle cap and hold the pen upward when priming. -Observation on 07/23/25 at 11:14 a.m. showed a medication aide (MA) (#6) prepared Resident #8's insulin pen for administration. The MA (#6) dialed the pen to 2 units and with the needle cap on, primed the pen with the needle pointed horizontally. The MA failed to remove the needle cap and hold the pen upward when priming. During an interview on 07/23/25 at 1:30 p.m., an administrative staff member (#5) stated she expected staff to prime an insulin pen with the cap off and the needle pointed upward.

Based on observation, record review, review of facility policy, and staff interview, the facility failed to follow standards of infection control and prevention for 2 of 8 sampled residents (Residents #8 and #15) and 1 supplemental resident (Resident #18) observed during cares. Failure to practice infection control standards related to enhanced barrier precautions (EBP) and hand hygiene has the potential to spread infection throughout the facility.Findings include: Review of the facility policy titled Enhanced Barrier Precautions occurred on 07/23/25. This policy, dated 04/08/24, stated, . Enhanced barrier precautions (EBP) refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and gloves use during high contact resident care activities. Initiation of Enhanced Barrier Precautions: An order for enhanced barrier precautions will be obtained for residents with any of the following: . indwelling medical devices (e.g., central lines, urinary catheters . Implementation of Enhanced Barrier Precautions: . PPE [personal protective equipment] for enhanced barrier precautions is only necessary when performing high-contact care activities . High-contact resident care activities include: . Providing hygiene . Changing briefs or assisting with toileting . device care or use: central lines, urinary catheters, feeding tubes, tracheostomy/ventilator tubes . Review of the facility Infectious Disease Control Manual occurred on 07/23/25. This manual, dated May 2007, page 28 stated, . j. Handwashing . when to wash your hands . 2. Should be first thing you do when you enter resident's room and, last thing you do before leaving. 7. After removing your gloves. 8. Before and after handling dressing, catheters, bedpans, specimens, and urinals. Between procedures on the same resident. 9. Before and after assisting residents with any personal needs. -Review of Resident #8's medical record occurred on all days of survey. A physician's order stated, Change ostomy [a surgically created opening in the abdomen, that allows waste to be diverted from its usual pathway] pouch twice weekly and as needed. The current care plan stated, . Staff will use enhanced barrier precautions during the following high-contact activities: . caring for or using an indwelling medical device: colostomy and catheter. -Observation on 07/21/25 at 3:36 p.m. showed a certified nurse aide (CNA) (#1) applied a gown and gloves to change Resident #8's colostomy bag. A nurse (#4) entered the room with additional supplies. The CNA (#1) removed the pouch and placed it in the garbage bag. The nurse (#4), without performing hand hygiene, applied gloves and assisted the CNA by wiping stool from the colostomy stoma (opening) with disposable wipes and placed them in the garbage bag. The CNA tied the garbage bag and gave it to the nurse who exited the room. The CNA (#1) removed the gown and gloves, performed hand hygiene, and exited the room. The nurse (#4) failed to apply a gown before assisting with colostomy cares. During an interview on 07/23/25 at 1:30 p.m., an administrative staff member (#5) stated she expected staff to apply PPE when providing cares to residents on EBP. Observation on 07/21/25 at 1:25 p.m. showed two CNA's (#1 and #3) completed hand hygiene and applied gloves. The CNAs transferred Resident #18 from the wheelchair to the bed using a mechanical sling lift. The CNA (#1) removed Resident #18's soiled brief, performed perineal care, removed the soiled gloves, applied a clean brief, and positioned Resident #18's pants. The CNA (#1) failed to perform hand hygiene after removing the soiled gloves and failed to apply new gloves before applying a clean brief. Observation on 07/22/24 at 3:40 p.m. showed a CNA (#2) assisted Resident #15 to the toilet. The resident voided and performed toileting hygiene. The CNA (#2) applied gloves, provided additional perineal care, removed the soiled gloves, and without performing hand hygiene, applied clean gloves, positioned Resident #15's brief and pants, and assisted Resident #15 to the recliner. The CNA (#2) failed to complete hand hygiene after removing the soiled gloves and before applying clean gloves and failed to offer hand hygiene to Resident #15. During an interview on 07/23/25 at 2:00 p.m., an administrative nurse (#5) stated she expected staff to perform hand hygiene after removing soiled gloves.

Based on observation, record review, review of facility policy, and family and staff interviews, the facility failed to ensure 3 of 3 supplemental residents (Resident #13, #19, and #23) with impaired cognition and unable to consent were free from resident to resident abuse. Failure to assess, care plan, and operationalize a plan/process may result in unwanted physical and/or sexual contact and may cause residents to experience fear, anxiety, and psychosocial harm. During the on-site recertification survey, the team consulted with the State Survey Agency (SSA) and determined an Immediate Jeopardy (IJ) situation existed on 06/09/24. The facility failed to assess, care plan, and operationalize a plan/process for; (1) a resident who seeks frequent close physical contact to do so safely and (2) cognitively impaired residents vulnerable to being the subject of unwanted physical and/or sexual contact, to ensure that all residents only had desired, safe contact with each other. The IJ was identified when a nurse's note in Resident #24's medical record, dated 06/09/24, identified he had kissed two female residents on the cheek (Resident #19 and #23). An observation on 06/12/24 at 3:07 p.m. showed Resident #24 seated on a chair beside Resident #13 who was sitting in a recliner chair facing forward. Resident #24 was sitting with his knees facing the side of Resident #13's chair. Resident #24 was leaning over the top of Resident #13 chest to chest with his left arm around Resident #13's right shoulder. Resident #24 was rubbing Resident #13's hair and the side of her face and they were holding hands. Resident #13 remained non-verbal throughout the observation. These findings placed the residents in immediate danger of fear, anxiety, or psychosocial harm in response to Resident #24's actions. * 06/12/24 at 7:20 p.m. - The survey team notified the administrator and director of nursing of the IJ situation, provided the IJ template, and requested a plan for removal of the immediate jeopardy. * 06/13/24 at 8:04 a.m. - The facility submitted a removal plan. * 06/13/24 at 1:00 p.m. - The survey team reviewed and accepted the facility's written plan for the removal of the IJ situation. The removal plan included the following: * Investigation of alleged resident to resident abuse completed including staff interviews. * Notification to the State Survey Agency. * Immediate constant observation of Resident #24. * Immediate education provided by the Director of Nursing (DON) or Assistant Director of Nursing (ADON) to all staff working on 06/12/24. All licensed nurses, certified nurse aides (CNAs), activity staff, social services and direct care staff not working on 06/12/24 will receive education prior to the start of their next shift. Education specifically focused on how to identify what constitutes resident to resident abuse or the potential of such abuse and the importance of implementing procedures to ensure the safety of the resident involved as well as the potential for all residents in the facility. * All staff assigned to healthcare academy (online training) regarding abuse to be completed within a week. * Will contact Great Plains Quality Innovation Network as a resource for education regarding this topic for Administrator, DON, Abuse Coordinator, and other leaders by 06/18/24. * To ensure compliance with this regulation is maintained, F600 will become part of the Quality Assurance program and completed by DON, ADON, or Abuse Coordinator. * Governing Board President and Secretary updated regarding most recent events and plan of correction. * 06/13/24 at 2:55 p.m. - The survey team verified the implementation of the removal plan as of 06/13/24 and removed the IJ. The deficient practice remained at an E scope and severity following the removal of the immediate jeopardy. Findings include: Review of the facility policy titled Abuse, Neglect and Exploitation Policy occurred on 06/13/24. This policy, dated June 2023, stated, . It is the policy of St. Gerard's Community of Care to provide protections for the health, welfare and rights of each resident . Assess, monitor, and develop appropriate plans of care for residents with needs and behaviors which may lead to conflict . Identify, correct, and intervene in situations in which abuse . is more likely to occur. Required to report . Sexual activity . where one of the resident's capacity to consent to sexual activity is unknown. Observation on 06/12/24 at 3:07 p.m. showed Resident #24 seated on a chair beside Resident #13 who was sitting in a recliner chair facing forward. Resident #24 was sitting with his knees facing the side of Resident #13's chair. Resident #24 was leaning over the top of Resident #13 chest to chest with his left arm around Resident #13's right shoulder. Resident #24 was rubbing Resident #13's hair and the side of her face and they were holding hands. Resident #13 remained non-verbal throughout the observation. During an interview on 06/12/24 at 3:08 p.m., the nurse (#3) stated, This happens everyday. If we try to take her away she gets mad. The nurse stated she was not aware if the facility notified the families of the situation and referred the surveyor to an administrative nurse. At 3:09 p.m., an administrative nurse (#2) stated, Yes, we contacted both family representative/guardians and they gave consent for hugging and holding hands. - Review of Resident #24's medical record occurred on June 12-13, 2024 and included a diagnosis of severe dementia. The quarterly Minimum Data Set (MDS), dated [DATE], identified a brief interview for mental status (BIMS) of 6, indicating severely impaired cognition. The care plan, dated 05/28/24, stated, . My wish to engage in consensual acts of hand holding, hugging, caressing each other, providing tenderness and comfort in the comfort of our public living area will be granted . Acts of tenderness will occur in the public common areas . My POA or representative will continue to approve of my desired relationship . Staff may redirect us if actions become inappropriate or if others in area provide concern. Resident #24's care plan failed to address interventions related to Resident #24 entering female residents' rooms. Resident #24's nurses' notes included the following: * 03/25/24 at 12:30 p.m., . Call placed to guardian [guardian's name] updates given that this resident and female resident have found comfort in each others companionship which at times leads to hugging and holding hands. Resident has gone into female residents [sic] room and is escorted out by staff at times to discontentment of both residents. Sought clearance from guardian on situation and states no concerns with same interactions and agrees resident does not have capacity for any further physical interactions. Will continue to allow contact in the form of holding hands and hugging, but will be mindful to prevent intimate physical relations. * 06/09/24 at 4:36 p.m. Resident was wandering into everyone's room this afternoon and trying to kiss different females multiple times. Resident does not listen even if the person asks him not to touch them. During an interview on 06/12/24 at 3:46 p.m., a nurse (#3) who witnessed the incidents on 06/09/24 stated Resident #24 kissed Resident #19 and Resident #23 on the cheek in a public area. The nurse stated, Usually he is just tapping people on the shoulders and most residents' do not like it when he does tap them on the shoulder. When the nurse (#3) told Resident #24 he could not kiss Resident #19, Resident #19 stated, He can do that. The nurse (#3) stated Resident #24's kiss elicited no response verbally or non-verbally from Resident #23. The nurse (#3) stated she immediately attempted to redirect Resident #24 who was difficult to redirect and just started talking about other things. The nurse verified she did not notify the DON, administrator, or abuse coordinator about the incident, stating, I didn't even think of it as abuse, but I should because I would not want my family member touched like that. - Review of Resident #13's medical record occurred on June 12-13, 2024 and included a diagnosis of dementia. The quarterly MDS, dated [DATE], identified moderately impaired cognition skills and may make poor decisions. The care plan stated, . My wish to engage in consensual acts of hand holding, hugging, caressing each other, providing tenderness and comfort in the comfort of our public living area will be granted. Acts of tenderness will occur in the public common areas . My POA or representative will continue to approve of my desired relationship . A nurses' note, dated, 03/25/24 at 12:31 p.m., stated, . Call placed to daughter [daughter's name] that this resident and a male resident have found comfort in each others companionship which at times leads to hugging and holding hands. Male resident has gone into residents [sic] room and is escorted out by staff at times to discontentment of both residents. Sought clearance from daughter on situation and states no concerns with same interactions and agrees resident does not have capacity for any further physical interactions. Will continue to allow contact in the form of holding hands and hugging, but will be mindful to prevent intimate physical relations. During an interview on 06/12/24 at 3:50 p.m., Resident #13's daughter (#2) stated, My sister and I do not want him [Resident #24] touching our mother. My sister has told the facility we do not want him [Resident #24] touching our mother. During an interview on 06/12/24 at 4:19 p.m., Resident #13's daughter and Power of Attorney (POA) (#1) stated, They [the facility] did contact me in March about the situation and at that time we were ok with hugging and holding hands. His [Resident #24's] behavior is progressing and we do not want him touching our mother. When my niece and I were visiting my mother one day in May that man [Resident #24] came into her room and my niece told him he needed to leave and he did. Then myself and my niece told staff we do not want him [Resident #24] in my mother's room or touching her. The surveyor asked daughter (#2) if her mother was cognitively intact, would she be ok with Resident #24's hugging, touching her face and holding hands and the daughter responded, Absolutely not. - Review of Resident #19's medical record occurred on June 12-13, 2024 and included a diagnosis of Alzheimer's disease. The quarterly MDS, dated [DATE], showed a brief interview for mental status (BIMS) score of 5, indicating severely impaired cognition. Resident #19's care plan, updated 08/14/23, failed to address the resident's wishes for engaging in physical contact with other residents. - Review of Resident #23's medical record occurred on June 12-13, 2024 and included a diagnosis of dementia. The admission MDS, dated [DATE], identified severely impaired cognition. Resident #23's care plan, updated 04/10/24, failed to address the resident's wishes for engaging in physical contact with other residents. During an interview on 06/12/24 at 4:07 p.m., four administrative staff members (Administrator, Director of Nursing, Assistant Director of Nursing and Abuse Coordinator) all stated they had not been notified of Resident #34's behaviors and they did not identify the actions as sexual abuse. Administrative staff (#10) stated all staff received abuse orientation upon hire and annually and staff are expected to report any abuse immediately to the administrator, DON, and ADON, who in return notify the state health department. The facility failed to have a system and policy and procedures in place for assessing all resident 's needs, desires, and usual preferences to determine how to care plan according to the assessment.

Based on observation, record review, review of facility policy, and family and staff interview, the facility failed investigate incidents of resident to resident abuse for 3 or 3 supplemental resident (Resident #13, #19, and #23) with impaired cognition and unable to consent. Failure to investigate incidents of abuse may result in unwanted physical and/or sexual contact and may cause residents to experience fear, anxiety, and psychosocial harm. During the on-site recertification survey, the team consulted with the State Survey Agency (SSA) and determined an Immediate Jeopardy (IJ) situation existed on 06/09/24. The facility failed to investigate resident to resident abuse. The IJ was identified when a nurse's note in Resident #24's medical record, dated 06/09/24, stated he had kissed two female residents on the cheek (Resident #19 and #23). An observation on 06/12/24 at 3:07 p.m. showed Resident #24 seated on a chair beside Resident #13 who was sitting in a recliner chair facing forward. Resident #24 was sitting with his knees facing the side of Resident #13's chair. Resident #24 was leaning over the top of Resident #13 chest to chest with his left arm around Resident #13's right shoulder. Resident #24 was rubbing Resident #13's hair and the side of her face and they were holding hands. Resident #13 remained non-verbal throughout the observation. These findings placed the residents in immediate danger of fear, anxiety, or psychosocial harm in response to Resident #24's actions. * 06/12/24 at 7:20 p.m. - The survey team notified the administrator and director of nursing of the IJ situation, provided the IJ template, and requested a plan for removal of the immediate jeopardy. * 06/13/24 at 8:04 a.m. - The facility submitted a removal plan. * 06/13/24 at 1:00 p.m. - The survey team reviewed and accepted the facility's written plan for the removal of the IJ situation. The removal plan included the following: * Investigation of alleged resident to resident abuse completed including staff interviews. * Notification to the State Survey Agency. * Immediate constant observation of Resident #24. * Immediate education provided by the Director of Nursing (DON) or Assistant Director of Nursing (ADON) to all staff working on 06/12/24. All licensed nurses, certified nurse aides (CNAs), activity staff, social services and direct care staff not working on 06/12/24 will receive education prior to the start of their next shift. The education specifically stated that all alleged abuse allegations of any kind will be investigated. The investigation will include interviews with all staff members and non-staff individuals involved. * All staff assigned to healthcare academy (online training) to be completed within a week. * Will contact Great Plains Quality Innovation Network as a resource for education regarding this topic for Administrator, DON, Abuse Coordinator, and other leaders by 06/18/24. * To ensure compliance with this regulation is maintained, F610 will become part of the QA [Quality Assurance] program and completed by DON, ADON, or Abuse Coordinator. * Governing Board President and Secretary updated regarding most recent events and plan of corrections. * 06/13/24 at 2:55 p.m. - The survey team verified the implementation of the removal plan as of 06/13/24 and the IJ removal. The deficient practice remained at an E scope and severity following the removal of the immediate jeopardy. Findings include: Review of the facility policy titled, Abuse, Neglect and Exploitation occurred on 06/13/24. This policy, dated June 2023, stated, To provide protections for the health, welfare and rights of each resident . that prohibit and prevent abuse . When suspicion of abuse . or reports of abuse . occur, an investigation is immediately warranted. Once the resident is immediately cared for and initial reporting has been shared between the charge nurse and DON an investigation will be conducted, and the administrator must be notified. Observation showed Resident #24 seated on a chair beside Resident #13 who was sitting in a recliner chair facing forward. Resident #24 was sitting with his knees facing the side of Resident #13's chair. Resident #24 was leaning over the top of Resident #13 chest to chest with his left arm around Resident #13's right shoulder. Resident #24 was rubbing Resident #13's hair and the side of her face and they were holding hands. Resident #13 remained non-verbal throughout the observation. During an interview on 06/12/24 at 3:08 p.m., the nurse (#3) stated, This happens everyday. If we try to take her away she gets mad. The nurse stated she was not aware if the facility notified the families of the situation and referred the surveyor to an administrative nurse. At 3:09 p.m., an administrative nurse (#2) stated, Yes, we contacted both family representative/guardians and they gave consent for hugging and holding hands. - Review of Resident #13's medical record occurred on June 12-13, 2024 and included a diagnosis of dementia. The quarterly Minimum Data Set (MDS), dated [DATE], identified moderately impaired cognition. A nurses' note, dated, 03/25/24 at 12:31 p.m., stated, . Call placed to daughter [daughter's name] that this resident and a male resident have found comfort in each others companionship which at times leads to hugging and holding hands. Will continue to allow contact in the form of holding hands and hugging, but will be mindful to prevent intimate physical relations. During an interview on 06/12/24 at 3:50 p.m., Resident #13's daughter (#2) stated, My sister and I do not want him [Resident #24] touching our mother. My sister has told the facility we do not want him [Resident #24] touching our mother. During an interview on 06/12/24 at 4:19 p.m., Resident #13's daughter and Power of Attorney (POA) (#1) stated, They [the facility] did contact me in March about the situation and at that time we were ok with hugging and holding hands. His [Resident #24's] behavior is progressing and we do not want him touching our mother. When my niece and I were visiting my mother one day in May that man [Resident #24] came into her room and my niece told him he needed to leave and he did. Then myself and my niece told staff we do not want him [Resident #24] in my mother's room or touching her. The surveyor asked daughter (#2) if her mother was cognitively intact, would she be ok with Resident #24's hugging, touching her face and holding hands and the daughter responded, Absolutely not. Resident #13's daughter and niece reported Resident #24's behaviors to a staff member in May and the staff member failed to identify Resident #24's actions as abuse, failed to report it to the administrator therefore, the facility didn't know abuse existed and failed to investigate. - Review of Resident #24's medical record occurred on June 12-13, 2024 and included a diagnosis of severe dementia. The quarterly Minimum Data Set (MDS), dated [DATE], identified a brief interview for mental status (BIMS) of 6, indicating severely impaired cognition. A nurse's note, dated 06/09/24 at 4:36 p.m., stated, . Resident was wandering into everyone's room this afternoon and trying to kiss different females multiple times. Resident does not listen even if the person asks him not to touch them. During an interview on 06/12/24 at 3:46 p.m., a nurse (#3) who witnessed the incidents on 06/09/24 stated Resident #24 kissed Resident #19 and Resident #23 on the cheek in a public area. The nurse stated, Usually he is just tapping people on the shoulders and most residents' do not like it when he does tap them on the shoulder. When the nurse (#3) told Resident #24 he could not kiss Resident #19, Resident #19 stated, He can do that. The nurse (#3) stated Resident #24's kiss elicited no response verbally or non-verbally from Resident #23. The nurse (#3) stated she immediately attempted to redirect Resident #24 who was difficult to redirect and just started talking about other things. The nurse verified she did not notify the DON, administrator, or abuse coordinator about the incident, stating, I didn't even think of it as abuse, but I should because I would not want my family member touched like that. Failure to report the observations does not allow the facility to investigate and protect these residents and all residents from the actions of Resident #24. - Review of Resident #19's medical record occurred on June 12-13, 2024 and included a diagnosis of Alzheimer's disease. The quarterly MDS, dated [DATE], identified a BIMS score of 5, indicating severely impaired cognition. - Review of Resident #23's medical record occurred on June 12-13, 2024 and included a diagnosis of dementia. The admission Minimum Data Set (MDS), dated [DATE], indicated severely impaired cognition. During an interview on 06/12/24 at 4:07 p.m., four administrative staff members (Administrator, Director of Nursing, Assistant Director of Nursing and abuse coordinator) all stated they had not been notified of Resident #24's behaviors therefore did not investigate any of his actions as abuse and did not report them to the SSA.

Based on review of facility policy, record review, and staff interview, the facility failed to protect all residents in the facility (31 of 31 residents) by failing to screen unlicensed employees prior to employment. Failure to screen unlicensed employees placed all residents at risk for abuse, neglect, exploitation, and misappropriation of resident property. Findings included: Review of the facility policy titled Abuse, Neglect, and Exploitation occurred on 06/13/24. This policy, revised June 2023, stated, It is the policy of the facility to provide protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. A. Screening 1. Potential employees will be screened for a history of abuse, neglect, exploitation, or misappropriation of resident property. a. Background, reference, and credentials' checks shall be conducted on potential employees, contracted temporary staff, students affiliated with academic institutions, volunteers, and consultants. b. Screenings will be conducted by the facility itself, third-part agency or academic institution. Review of the facility's 802 Centers for Medicare and Medicaid Services (CMS) Matrix showed 31 residents resided in the facility on the first day of survey, 06/11/24. During an interview on 6/13/2024, at 11:50 a.m., the administrator stated the facility did not conduct criminal history checks on unlicensed employees or new hires. Instead, employees are asked on the application form if they have been convicted of any felonies, and the facility relies on their honesty. The administrator stated the facility would run all unlicensed employees through the nurse aide registry. The administrator acknowledged that without a license, the facility cannot verify if an individual had a conviction that would disqualify them from employment. She stated the facility's process for conducting background and criminal history checks on unlicensed employees and new hires needed improvement. She said the facility is in a small-town setting; therefore, the facility also depends on community word-of-mouth to identify any criminal activity or convictions of employees or new hires. The administrator stated there is no system in place to screen non-licensed staff to ensure they have not been found guilty of abuse, neglect, exploitation, misappropriation of property, or mistreatment by a court of law.

Based on observation, record review, review of facility policy, and family and staff interview, the facility failed to report incidents of resident to resident abuse to the Administrator and State Survey Agency (SSA) for 3 of 3 supplemental residents (Resident #13, #19, and #23) with cognitive impairments and unable to consent. Failure to report incidents of abuse may result in unwanted physical and/or sexual contact and may cause residents to experience fear, anxiety, and psychosocial harm. Findings include: Review of the facility policy titled, Abuse, Neglect and Exploitation Policy occurred on 06/13/24. This policy, dated June 2023 stated, . It is the policy of St. Gerard's Community of Care to provide protections for the health, welfare and rights of each resident . A. Any staff witnessing or possessing reliable knowledge of any act, or suspect act, involving . abuse . must notify their department supervisor immediately. Observation on 06/12/24 at 3:07 p.m. showed Resident #24 seated on a chair beside Resident #13 who was sitting in a recliner chair facing forward. Resident #24 was sitting with his knees facing the side of Resident #13's chair. Resident #24 was leaning over the top of Resident #13 chest to chest with his left arm around Resident #13's right shoulder. Resident #24 was rubbing Resident #13's hair and the side of her face and they were holding hands. Resident #13 remained non-verbal throughout the observation. During an interview on 06/12/24 at 3:08 p.m., the nurse (#3) stated, This happens everyday. If we try to take her away she gets mad. The nurse stated she was not aware if the facility notified the families of the situation and referred the surveyor to an administrative nurse. At 3:09 p.m., an administrative nurse (#2) stated, Yes, we contacted both family representative/guardians and they gave consent for hugging and holding hands. - Review of Resident #13's medical record occurred on June 12-13, 2024 and included a diagnosis of dementia. The quarterly Minimum Data Set (MDS), dated [DATE], identified moderately impaired cognition and poor daily decision making skills. A nurses' note, dated, 03/25/24 at 12:31 p.m., stated, . Call placed to daughter [daughter's name] that this resident and a male resident have found comfort in each others companionship which at times leads to hugging and holding hands. Will continue to allow contact in the form of holding hands and hugging, but will be mindful to prevent intimate physical relations. During an interview on 06/12/24 at 3:50 p.m., Resident #13's daughter (#2) stated, My sister and I do not want him [Resident #24] touching our mother. My sister has told the facility we do not want him [Resident #24] touching our mother. During an interview on 06/12/24 at 4:19 p.m., Resident #13's daughter and Power of Attorney (POA) (#1) stated, They [the facility] did contact me in March about the situation and at that time we were ok with hugging and holding hands. His [Resident #24's] behavior is progressing and we do not want him touching our mother. When my niece and I were visiting my mother one day in May that man [Resident #24] came into her room and my niece told him he needed to leave and he did. Then myself and my niece told staff we do not want him [Resident #24] in my mother's room or touching her. The surveyor asked daughter (#2) about her mother's cognition and if she would be ok with Resident #24's hugging, touching her face and holding hands and the daughter responded, Absolutely not. The staff member who Resident #13's daughter and niece reported the incident to in May failed to identify this as abuse and failed to report this to the administrator. - Review of Resident #24's medical record occurred on June 12-13, 2024 and included a diagnosis of severe dementia. The quarterly MDS, dated [DATE], identified a brief interview for mental status (BIMS) of 6, indicating severely impaired cognition. A nurses' note, dated 06/09/24 at 4:36 p.m., stated, . Resident was wandering into everyone's room this afternoon and trying to kiss different females multiple times. Resident does not listen even if the person asks him not to touch them. During an interview on 06/12/24 at 3:46 p.m., a nurse (#3) who witnessed the incidents on 06/09/24 stated Resident #24 kissed Resident #19 and Resident #23 on the cheek in a public area. The nurse stated, Usually he is just tapping people on the shoulders and most residents do not like it when he does tap them on the shoulder. When the nurse (#3) told Resident #24 he could not kiss Resident #19, Resident #19 stated, He can do that. The nurse (#3) stated Resident #24's kiss elicited no response verbally or non-verbally from Resident #23. The nurse (#3) stated she immediately attempted to redirect Resident #24 who was difficult to redirect and just started talking about other things. The nurse verified she did not notify the DON, administrator, or abuse coordinator about the incident, stating, I didn't even think of it as abuse, but I should because I would not want my family member touched like that. - Review of Resident #19's medical record occurred on June 12-13, 2024 and included a diagnosis of Alzheimer's disease. The quarterly Minimum Data Set (MDS), dated [DATE], identified a brief interview for mental status (BIMS) of 5, indicating severely impaired cognition. - Review of Resident #23's medical record occurred on June 12-13, 2024 and included a diagnosis of dementia. The admission MDS, dated [DATE], identified severely impaired cognition. During an interview on 06/12/24 at 4:07 p.m., four administrative staff members (Administrator, Director of Nursing, Assistant Director of Nursing ,and Abuse Coordinator) stated they had not been notified of Resident #24's behaviors and staff are expected to report any abuse immediately to the administrator, DON, and ADON, who notify the SSA. The facility lacked evidence the above incidents (06/09/24 and 06/12/24) were reported to the administrator and the SSA.

Based on observation, record review, review of facility policy, and staff interview, the facility failed to review and revise care plans to reflect residents' current status for 2 of 3 sampled residents (Resident #4 and #10). Failure to update care plans limited staffs' ability to communicate needs and ensure continuity of care. Findings include: Review of the facility policy titled Nursing Care Plans occurred on 06/13/24. This policy, dated November 2017, stated, . POLICY: A person centered plan of care shall be developed . Evaluation of approaches and goals shall be charted on care plans by the nurse doing the monthly charting for the resident. - Review of Resident #4's medical record occurred on all days of survey and included diagnoses of traumatic brain disorder and epilepsy. The current care plan stated, . No water in room . The significant change Minimum Data Set (MDS), dated [DATE], identified a brief interview for mental status (BIMS) score of 15, indicating cognitively intact. Observation on 06/11/24 at 10:57 a.m. showed no water cup in Resident #4's room. When asked why he doesn't have a water cup in his room, the resident stated, When I finish drinking the water they take the cup and then bring some [water] back to me later. Observation on 06/12/24 at 8:37 a.m. showed no water cup in Resident #4's room. When the resident asked for water a certified nurse aide (CNA) (#9) stated, You already had your water. During an interview on 06/12/24 at 11:32 a.m., Resident #4 stated he has to request water when he wants it and the staff have not told him why he cannot have a water cup in his room. During an interview on 06/12/24 at 11:44 a.m., when asked why Resident #4 has to ask for water instead of water being available for him in his room at all times, a licensed nurse (#3) stated, We can't give him excessive amounts of water due to his medications, specifically lithium. He has an obsessive-compulsive disorder and would drink large amounts if it is left in his room. There are very specific times he requests water. There is no specific amount of water he can have. During an interview on 06/12/24 at 11:49 a.m., when asked about Resident #4's care plan stating no water in room, an administrative nurse (#2) stated, There are very specific times that he [Resident #4] requests and receives water. Resident #4's care plan failed to address specific times to provide the resident with water/fluids and reason why he is not able to have a water cup in his room. - Review of Resident #10's medical record occurred on all days of survey and included a diagnosis of osteoarthritis. The current care plan stated, . I will transfer with . EZ stand [sit-to-stand mechanical lift] with 1x [1 staff assist] assist . I am at risk to fall . The physician's orders included, . Transfer: EZ stand 1x assist with buttocks and leg strap . Observation on 06/11/24 at 3:08 p.m. showed a CNA (#8) transferred Resident #10 from the wheelchair to the bathroom using the EZ stand lift without using the buttocks sling and leg strap. Resident #10's care plan failed to include use of the leg strap and buttocks sling with the EZ stand lift transfers. During an interview on 06/12/24 at 2:41 p.m., an administrative nurse (#1) stated she expected care plans to be individualized.

Based on observation, record review, review of facility policy, review of manufacturer's instructions, review of facility investigation reports, and staff interview, the facility failed to provide adequate assistance for 2 of 2 sampled residents (Resident #3 and #10) observed during a sit-to-stand mechanical lift transfer and failed to complete an investigation for 1 of 1 sampled resident (Resident #4) with a history of falls and a fracture. Failure to ensure proper use of the stand lift, including use of the seat and leg strap, and failure complete a fall investigation, including intervention to alleviate falls, placed the residents at risk of experiencing pain/discomfort and/or possible accidents with/without injury. Findings include: Review of the facility policy titled RESIDENT INCIDENT FOLLOWUP REPORT occurred on 06/13/24. This policy, dated March 2016, stated, . To review the individual incident reports and state the corrective action taken . 1. The DON [director of nursing] or charge nurse will review each incident report within 24 hours of the occurrence. 2. After reviewing the incident report, the nurse is responsible for completing the Resident incident report concerning that incident. Review of the facility policy titled EZ WAY STAND AID occurred on 06/13/24. This policy, dated December 2021, stated, . The EZ Way Stand Aid will be used as a resident transferring device for those residents who have adequate arm strength to pull themselves upward and enough leg strength to support their own weight. The manufacturer's instructions for the EZ Way Seat Strap stated, . Applying the seat strap: Stand behind the patient, and using the hand control, press the UP button to raise the patient slightly off the surface. Tighten the harness buckle. 7. Slide the seat strap under the patient's buttocks. - Review of Resident #3's medical record occurred on all days of survey and included diagnoses of muscle weakness and arthritis. The current care plan stated, . I am at risk to fall . I will utilize the EZ Stand with seat strap and 1 assist for transfers. Observation on 06/11/24 at 10:03 a.m. showed a certified nurse aide (CNA) (#12) transferred Resident #3 from the wheelchair to the toilet using the EZ way stand lift. As the CNA began to raise the resident, the resident failed to hold onto the handles. The CNA stated, I better use the butt sling [seat strap]. The CNA then utilized the seat strap. The resident, unable to bear weight, hung from the chest harness in a semi-seated position. The harness straps pulled upward into Resident #3's axillae and caused the shoulders to raise to ear level with the elbows extended horizontally. Observation on 06/12/24 at 10:04 a.m. showed a CNA (#7) transferred Resident #3 from the wheelchair to the bathroom using the EZ way stand lift with the seat strap positioned above the resident's buttocks rather than under the buttocks. The resident could not lift his upper body enough to hold onto the handle bars and grabbed onto another part of the lift directly in front of him. The CNA placed the resident's hands on the handle bars. His hands immediately fell off and the resident grabbed the part of the lift in front him. The resident, unable to bear weight, hung from the chest harness in a semi-seated position. The harness straps pulled upward into Resident #3's axillae and caused the shoulders raised to ear level with the elbows extended horizontally. During an interview on 06/12/24 at 11:36 a.m., a licensed nurse (#3) stated, I know he [Resident #3] hangs there, but there is no way we could get the hoyer [full body lift] into the bathroom. - Review of Resident #10's medical record occurred on all days of survey and included diagnoses of dementia and osteoarthritis. The current care plan stated, . I will transfer . EZ stand with 1x [one staff] assist. I am at risk to fall . The medical record included the following physicians order, Transfer: EZ stand 1x assist with butt [buttocks] and leg strap . Observation on 06/11/24 at 3:08 p.m. showed a CNA (#8) transferred Resident #10 from the wheelchair to the toilet using the EZ way stand lift and failed to apply the seat/buttocks and leg straps. - Review of Resident #4's medical record occurred on all days of survey and included a diagnosis of hemiplegia (one-sided weakness or paralysis). The current care plan stated, . I am at risk to fall . monitor my falls for any pattern. The medical record showed Resident #4 experienced seven falls between 03/31/24 to 05/31/24, one with a major injury. Resident #4 progress notes included the following: * 05/09/2024 at 9:45 p.m. Res [resident] chair alarm was sounding, Staff entered room to find res on the floor. this [sic] nurse entered room to find res lying on his left side with his backside facing the dresser in his room. TV [television] had ended up on the floor behind res unplugged and cord under his left leg. no injuries noted at this time, ROM [range of motion] WNL [within normal limits] for resident. Will continue to monitor. * 05/10/2024 at 6:27 a.m. Res started to c/o [complain of] left elbow pain during the night. No swelling noted, tender to touch just above the elbow. Tylenol given at 2AM [2:00 a.m.] with some relief noted at the time. Res currently c/o pain again, will have med aid give another dose of Tylenol. * 5/10/2024 at 7:48 a.m. updates to [nurse practitioner] provided on fall with pain complaints. Decision that resident will go for clinic appt [appointment] . today at 2pm for x-ray and seen by . * 05/10/2024 at 4:28 p.m. Resident returned from appointment with . x-ray showed a fractured left ulna [bone in forearm] proximal-non displaced. The investigation related to the above fall and fracture stated, . [Resident #4] with no additional injury. He has been noted to fluctuate in his physical abilities. He is working with therapy regarding his positioning in chair. We will work with therapists to determine best method for transfers at this time. During an interview on 06/12/24 at 2:41 p.m., an administrative nurse (#1) confirmed staff failed to complete the investigation including a corrective action plan related to Resident #4's falls and failed to update the care plan since 2020.

Based on observation, record review, review of facility policy, and staff interview, the facility failed to ensure an effective infection prevention and control program for a safe, sanitary, and comfortable environment and to help prevent the development and transmission of infections for 2 of 3 sampled residents (Resident #10 and #18) observed during care and 1 of 2 certified nurse aides (CNAs) reviewed for handwashing (CNA #4). Failure to removed soiled gloves and perform hand hygiene after incontinence cares and failure to disinfect multi-use equipment may result in exposure of infections to residents, staff, and visitors. Findings included: Review of the facility policy titled Infectious Disease Control Manual occurred on 06/12/24. This undated policy stated, General Aseptic Technique section: ii. 10 key times to wash your hands 2.) Should be first thing you do when you enter the resident room and the last thing you do before leaving. 4.) Between resident contacts. 5.) Before and after tending to any personal needs or contact with your face, or mouth (sneezing, blowing your nose, combing your hair, using the toilet, before and after you smoke). 7.) After removing our gloves. 8.) Before and after handling dressings, catheters, bedpans, specimens, and urinals. Between procedures on the same resident. 9.) Before and after assisting residents with any personal needs. - Observation on 06/11/24 at 10:08 a.m. showed the CNA (#4) left Resident #11's room after transferring her to a wheelchair using a sit-to-stand lift. The CNA (#4) failed to clean or disinfect the lift after using it with Resident #11 and taking it to Resident #18's room. Observation on 06/11/24 at 10:11 a.m. showed the CNA (#4) applied gloves and transferred Resident #18 from the bed to the toilet using the sit-to-stand lift just used for Resident #11's transfer. The CNA removed Resident #18's pants and brief, sat the resident on the toilet, and removed her gloves. The CNA (#4) failed to sanitize her hand and touched the resident's blanket and sheets and straightened the bed cover. The CNA (#4) sat on Resident #18's bed until the resident finished using the toilet. The CNA applied gloves and provided perineal cares for the resident. While still wearing the soiled gloves, the CNA retrieved a clean brief, placed it on the resident, pulled up the resident's pants, and used the sit-to-stand lift to transfer Resident #18 into her wheelchair. The (CNA) #4 removed her gloves, placed the oxygen tubing into the resident's nose, flushed the toilet, disposed of the soiled brief in the trash can, and then washed her hands. During an interview with CNA (#4) on 6/11/24 at 2:38 p.m., she confirmed she did not wash her hands or change her gloves appropriately while providing care to Resident #18. She acknowledged that she should have washed her hands after removing her gloves and before touching clean items with dirty hands or gloves. During an interview with an the DON on 6/12/24 at 10:30 a.m., she stated staff were to wash their hands before they initiated care for a resident, after, and after gloves were removed. The DON said the staff should clean and disinfect the sit-to-stand lift between each resident to prevent the spread of infection. 40489 - Observation on 06/11/24 at 3:08 p.m. showed a CNA (#8) assisted Resident #10 to the bathroom using the sit-to-stand lift. After assisting the resident, the CNA exited the resident's room without disinfecting the lift. During interview on 6/13/24 at 9:17 a.m., the CNA (#8) stated she used the sit-to-stand lift to transfer residents, but does not clean or disinfect the lift between uses. She added housekeeping handles the cleaning, as her routine involves using the lift to assist residents and then placing it at the end of the hall for others to use.

Based on record review, review of professional reference, and staff interview, the facility failed to complete Minimum Data Set (MDS) assessments that accurately reflected the resident's status for 3 of 12 sampled residents (Resident #7, #8, and #26). Failure to correctly code MDS assessments may affect the development of an accurate care plan and impact resident care. Findings include: The Long-Term Care Facility RAI User's Manual, revised October 2019, pages N-6 and N-7, stated, . Coding Instructions . N0410E, Anticoagulant (e.g., warfarin, heparin, or low- molecular weight heparin): Record the number of days an anticoagulant medication was received by the resident at any time during the 7-day look-back period (or since admission/entry or reentry if less than 7 days). Do not code antiplatelet medications such as aspirin/extended release, dipyridamole, or clopidogrel here. N0410H, Opioid: Record the number of days an opioid medication was received by the resident at any time during the 7-day look-back period (or since admission/entry or reentry if less than 7 days). SECTION N: Medications - Review of Resident #7's medical record occurred on all days of survey. The Medicare 5 day Prospective Payment System (PPS) MDS, dated [DATE], identified the resident received an anticoagulant on 7 of 7 days. Resident #7's medication administration record (MAR) identified Resident #7 received Plavix (an antiplatelet) daily during the look back period. - Review of Resident #8's medical record occurred on all days of survey. The quarterly MDS, dated [DATE], identified the resident did not receive an opioid during the 7 day look back period. Resident #8's MAR identified Resident #8 received Tramadol (an opioid) daily during the look back period. - Review of Resident #26's medical record occurred on all days of survey. The admission MDS, dated [DATE], identified the resident received an anticoagulant on 6 of 7 days. Resident #26's MAR identified Resident #26 received Plavix (an antiplatelet) daily during the look back period. During interviews on the morning and afternoon of 07/19/23, an administrative nurse (#1) confirmed staff should not code Plavix as an anticoagulant and should have coded Tramadol as an opioid. 46963

Based on observation, review of facility policy, and staff interview, the facility failed to ensure each resident received adequate supervision and assistive devices to prevent accidents for 4 of 4 residents (Resident #9, #13, #14, and #377) observed being transported in a wheelchair with his/her feet dragging on the floor. Failure to utilize foot pedals on a wheelchair during transport has the potential to result in falls and/or injury. Findings include: Review of the facility policy Transporting Residents in Wheelchairs occurred on 05/11/22. This policy, dated February 1995, stated, . To transfer the resident to the wheelchair, the escort should: . 4. Adjust footrests and leg supports. During the trip, the escort should: . 5. Check the chair frequently to make sure that wheels are free and that the resident's feet are secure on the footrests, (if need footrests). Observations during survey included the following: * 05/09/22 11:45 a.m. - Staff member (#7) transported Resident #14 by wheelchair from the nurses' station to the dining room without utilizing foot pedals. The resident's feet/slippers made a sliding sound on the floor during transport. * 05/10/22 8:30 a.m. - Staff member (#7) transported Resident #14 by wheelchair from the nurses' station to the dining room without utilizing foot pedals. The resident's feet/slippers made a sliding sound on the floor during transport. * 05/10/22 8:45 a.m. - Staff member (#5) transported Resident #377 by wheelchair from the nurses' station to the resident's room and back to the nurses' station area without utilizing foot pedals. The resident's feet/shoes made a sliding sound on the floor during transport. * 05/10/22 8:49 a.m. - Staff member (#5) transported Resident #9 by wheelchair down the hall to the nurses' station without utilizing foot pedals. The resident's feet/shoes made a sliding sound on the floor during transport. * 05/10/22 11:18 a.m. - Staff member (#5) transported Resident #13 by wheelchair down the hall to the resident's room and back down the hall without utilizing foot pedals. The resident's feet/shoes made a sliding sound on the floor during transport. * 05/10/22 5:15 p.m. - Staff member (#6) transported Resident #14 and Resident #377 by wheelchair down the hall to the dining room without utilizing foot pedals. The residents' slippers/shoes made a sliding sound on the floor during transport. During an interview on 05/11/22 at 2:15 p.m., two administrative staff members (#1 and #2) agreed staff should utilize wheelchair foot pedals while transporting residents when feet are sliding on the floor.

Based on observation, record review, review of facility policy, review of professional reference, and staff interview, the facility failed to ensure respiratory care consistent with professional standards of practice for 2 of 2 residents observed with portable oxygen (O2) tanks (Resident #23 and #377). Failure to ensure residents receive oxygen as ordered may result in respiratory complications, and failure to transport oxygen in a safe manner may result in accident hazards. Findings include: Kozier & Erb's Fundamentals of Nursing, Concepts, Process and Practice, 11th Edition eText, 2021, Pearson, Boston, Massachusetts, page 1292, stated, . Oxygen cylinders need to be handled and stored with caution and strapped securely in wheeled transport devices or stands to prevent possible falls and outlet breakages. Review of the facility's policy and procedure title Oxygen Therapy occurred on 05/11/22. This policy, revised February 2016, stated, Oxygen is administered to residents who need it, consistent with professional standards of practice, the comprehensive person-centered care plans, and the residents' goals and preferences. 1. Oxygen is administered under orders of a physician . Staff shall document the initial and ongoing assessment of the resident's condition warranting oxygen and the response to oxygen therapy . 5. The resident's care plan shall identify the interventions for oxygen therapy, based upon the resident's assessment and orders. 7. Staff shall monitor for complications associated with the use of oxygen and take precautions to prevent them. - Review of Resident #23's medical record occurred on all days of survey. Current physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Observation on 05/10/22 at 5:20 p.m. showed Resident #23 in his wheelchair with an oxygen cylinder delivering oxygen via nasal cannula. The gauge on the cylinder showed the oxygen tank was empty. A medication aide (#5) confirmed the tank as empty. The medication aide brought a new cylinder from the storage closet but failed to secure it in a carrier/cart during transport. After switching the oxygen cylinders, the medication aide carried the used cylinder back to the storage closet and failed to secure it in a carrier/cart. - Observation on 05/10/22 at 8:35 a.m. showed Resident #377 seated in his wheelchair near the nurses' station wearing a nasal cannula and tubing for O2 therapy. A portable oxygen tank located on the back of the wheelchair showed the oxygen regulator set at 2 liters (L). The tank's regulator arrow pointed to empty. During this time a staff nurse (#4) verified the oxygen tank as empty. Review of Resident #377's medical record occurred on 05/11/22. A Physician Readmission Order Sheet, dated 05/05/22, stated, . Diagnosis: [MEDICAL RECORD OR PHYSICIAN ORDER] . CHF [congestive heart failure] . 2L O2 via NC [nasal cannula]. The current care plan failed to address the resident's use of oxygen. During an interview on 05/11/22 at 11:28 a.m., an administrative nurse (#2) stated staff should transport oxygen in a cart or carrier and check cylinders to ensure they are full.

Based on observation, record review, review of facility policy, and staff interview, the facility failed to provide treatment and care in accordance with professional standards for 2 of 13 sampled residents (Resident #18 and #23). Failure to consistently implement interventions for dressing changes (Resident #18) and skin breakdown (Resident #23) may result in worsening skin conditions or infection. Findings include: - Observation on 05/09/22 at 4:44 p.m. showed two certified nursing assistants (CNAs) (#9 and #12) checked and changed Resident #23 in bed. The resident was incontinent of urine and stool. Observation showed the resident's peri-rectal area was reddened and excoriated. The CNA (#9) stated, it's pretty red and applied [MEDICATION(S)] (a skin protectant) cream to the area. Observation on 05/10/22 at 9:00 a.m. showed two CNAs (#10 and #11) checked and changed Resident #23 after transferring him to bed. The resident's peri-rectal area remained reddened/excoriated, and a CNA (#11) applied triple antibiotic ointment to the area. Observation on 05/11/22 at 9:02 a.m. showed two CNAs (#8 and #12) checked and changed Resident #23 after transferring him to bed. A nurse (#7) entered the room and gave the CNAs [MEDICATION(S)] cream, stating, I heard his [bottom] was kind of red. The nurse then left the room without observing the area. A CNA (#8) stated to Resident #23, Your bottom looks sore, I'm going to put some cream on it, and applied [MEDICATION(S)]. Review of Resident #23's care plan, CNA Kardex, physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of facility policy titled Documentation of Wound Treatments occurred on 05/10/22. This policy, dated 12/04/20, stated, . If no treatment is due, an indication on the status of the dressing shall be documented each shift (i.e., clean, dry, intact,) . - Observation on 05/10/22 at 9:23 a.m. showed a loose, undated, 4x4 gauze dressing on Resident #18's right lower back over a drainage tube catheter. A nurse (#4) pulled the loose gauze over the drain sponge and catheter and secured the dressing with the same tape. The dressing lacked a date. When asked about an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The dressing is changed with the [MEDICATION(S)] [a tube placed in the chest to remove fluid] drain procedure. Review of Resident #18's medical record occurred on all days of survey. The record lacked a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 05/11/22 at 10:00 a.m. a staff nurse (#3) stated, The dressing is only changed when the [MEDICATION(S)] drain system is used, and the catheter system kit contains the dressing.

Based on observation, record review, review of facility policy, and staff interview, the facility failed to follow professional standards of practice for 1 of 2 residents (Resident #18) observed during administration of eye drops. Failure to ensure nursing staff followed physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings include: Review of the facility's policy titled Medication Errors occurred on 05/10/22. This undated policy stated, . The greatest prevention of error is to follow procedures for medication administration as instructed during training. Review of the facility's Performance Criteria For Medication Administration occurred on 05/10/22. This undated educational tool stated, . 12. SAFELY administer the correct medication according to the 'Six Rights' . the right dose . by the right route. Observation on 05/09/22 at 3:50 p.m. showed a medication aide (MA) (#5) administered one drop of [MEDICATION(S)] (antibiotic) eye drop into both eyes of Resident #18. The prescription label indicated one drop of [MEDICATION(S)] to right eye 4 times daily. Review of Resident #18's medical record occurred on 05/10/22. A medical provider's order, dated 05/07/22, stated, . [MEDICATION(S)] - 1 drop R [right] eye QID [4 times daily] - conjunctvitis [sic] . During an interview on 05/10/22 at 4:15 p.m., an administrative nurse (#2) agreed the MA failed to follow the medical provider's order.

Based on observation, record review, review of facility policy, and staff interview, the facility failed to offer fluids to 6 of 12 sampled residents (Residents #3, #5, #22, #24, #25, and #27) and 2 supplemental residents (Residents #11 and #12) during cares. Failure to offer fluids with cares may result in dehydration, constipation, and urinary tract infections (UTI's). Findings include: Review of the facility policy titled Hydration occurred on 03/10/21. This policy, dated November 2017, stated, . Nursing and CNAs (certified nursing assistants) . encourage resident to drink every time you see them . Offer appropriate assistance as needed if resident cannot drink without help . - Review of Resident #3's medical record occurred on all days of survey and included the [DIAGNOSES REDACTED]. Observation on 03/08/21 at 3:06 p.m. showed two CNAs (#3 and #6) failed to offer fluids to Resident #3 after assisting her to the bathroom and transferring her to the recliner. Observation showed a pitcher of water located on the bed side table but not within the resident's reach. - Review of Resident #5's medical record occurred on all days of survey and included the [DIAGNOSES REDACTED]. Observation on 03/08/21 at 2:46 p.m. showed two CNAs (#3 and #6) failed to offer fluids to Resident #5 after assisting her from the wheelchair to the bed. Observation on 03/09/21 at 12:52 p.m. showed two CNAs (#4 and #5) failed to offer fluids to Resident #5 after assisting her from the wheelchair to the bed. - Review of Resident #11's medical record on 03/09/21 and included the [DIAGNOSES REDACTED]. I am at risk for dehydration due to hx (history) of poor intake . Observation on 03/08/21 at 4:21 p.m. showed a CNA (#6) failed to offer fluids to Resident #11 after assisting her from the bed to the wheelchair. - Review of Resident #12's medical record occurred on 03/09/21 and included the [DIAGNOSES REDACTED]. Observation on 03/08/21 at 2:44 p.m. showed a CNA (#6) failed to offer fluids to Resident #12 after offering the resident assistance with using the bathroom. - Review of Resident #22's medical record occurred on all days of survey and included the [DIAGNOSES REDACTED]. Observation on 03/08/21 at 3:50 p.m. showed two CNAs (#10 and #11) failed to offer fluids to Resident #22 after assisting her from the bed to the wheelchair. Observation on 03/09/21 at 1:58 p.m. showed two CNAs (#4 and #5) failed to offer fluids to Resident #22 after assisting her from the wheelchair to the bed. - Review of Resident #24's medical record occurred on all days of survey and included the [DIAGNOSES REDACTED]. Observation on 03/08/21 at 2:44 p.m. showed a CNA (#6) failed to offer Resident #24 fluids after offering assistance with the bathroom. Observation on 03/09/21 at 11:38 a.m. showed two CNAs (#8 and #9) failed to offer Resident #24 fluids after assisting him to use the bathroom. - Review of Resident #25's medical record occurred on all days of survey. The current care plan stated, . I have short term memory impairment . Observation on 03/08/21 at 3:05 p.m. showed a CNA (#6) failed to offer Resident #25 fluids after offering assistance with the bathroom. - Review of Resident #27's medical record occurred on all days of survey. The current care plan stated, . I am at risk for dehydration related to my medication use of a diuretic . Offer me fluids between meals. I need help with my ADLs (activities of daily living), my balance is not so great, I have left sided weakness related to history of TBI ([MEDICAL CONDITION]) . I transfer with 1 assist and cane . Observation on 03/09/21 at 3:56 p.m. showed a CNA (#7) assisted Resident #27 from his bed to the bathroom. Upon completion of cares, the CNA assisted Resident #27 to sit in a chair. Observation showed a water mug on the dresser next to the TV, but not within the resident's reach. The CNA failed to offer/encourage fluids during this observation. During an interview on 03/10/21 at 12:26 p.m., an administrative nurse (#1) stated staff should offer fluids to residents with each interaction.

Based on observation, record review, facility policy, and staff interview the facility failed to provide adequate supervision and assistive devices necessary to prevent accidents for 1 of 4 sampled residents (Resident #28) and 1 supplemental resident (Resident #11) observed during transfers. Failure to use a gait belt during transfers placed the residents at risk of accidents and injury. Findings include: Review of facility policy titled Gait Belt occurred on 03/10/21. This undated policy stated, . PURPOSE OF GAIT BELT: 1. Provide increased security for the resident and staff. POLICY: A gait belt is to be used during ambulation or movement of residents who need the security . - Review of Resident #11's medical record occurred on 03/09/21 and included [DIAGNOSES REDACTED]. A quarterly Minimum Data Set (MDS), dated [DATE], identified extensive assist for transfers and two or more falls with no injury. During an observation on 03/08/21 at 4:21 p.m. a certified nurse aide (CNA) (#6) transferred Resident #11 from the bed to the wheelchair. During the transfer the CNA placed her arm under Resident #11's right axilla and assisted the resident to stand. The CNA failed to utilize a gait belt during the transfer. - Review of Resident #28's medical record occurred on all days of survey and included a [DIAGNOSES REDACTED]. An annual MDS, dated [DATE], identified extensive assist for transfers and one fall with no injury. During an observation on 03/08/21 at 4:09 p.m. a CNA (#6) transferred Resident #28 from the bed to the wheelchair. During the transfer the CNA placed her arm under Resident #28's right axilla and assisted the resident to stand. The CNA failed to use a gait belt during the transfer. During an interview on 03/10/21 at 12:30 p.m., an administrative nurse (#1) stated she expected staff to use a gait belt when assisting residents to stand.

Based on observations, interviews, and record reviews, the facility failed to ensure that staff was performing proper hand hygiene to prevent transmittable diseases. Specifically, the staff did not use the correct sequence for washing hands, and staff was touching resident's food trays in multiple residents' rooms without performing hand hygiene (HH). Findings include: 1. On 6/23/20 at 12:19 PM, observation of Certified Nurse Aide 1 (CNA1) revealed CNA1 approach a sink on the East hall, CNA1 using her left hand dispensed soap into the left hand (without rinsing hands first), with right-hand turned faucet on, and then began soaping hands first. After CNA1 dried her hands, when asked about the sequence of soaping before rinsing hands, CNA1 replied, I was a little distracted. Above the sink was signage that had the correct series for washing hands. On 6/23/20 at 12:50 PM, in an interview with the IPC-Nurse (infection control preventionist), when shared observation of the incorrect sequence, IPC-Nurse states she does monitors hand hygiene, and her goal is 95% compliance. Review of policy title Hand Hygiene effective 3/09/2020, subsection title, Policy Explanation and Compliance Guidelines: number five subsection Hand hygiene techniques when using soap and water: a. Wet hands with water. b. Apply enough soap to cover all hand surfaces. c. Rub hands together vigorously for at least 20 seconds, covering all surfaces of the hands and fingers. d. Rinse hands with water. e. Dry thoroughly with a single-use towel. f. Use towel to turn off the faucet. On 6/23/20 at 1:10 PM, in an interview with the Nursing Home Administrator (NHA) shared observations of CNA1 washing hands, NHA replied what is wrong with using soap first. Explained to NHA what best practices for the prevention of transmittable diseases are to rinse hands before using soap, and illustrated that the facility policy and signage align with best practices. The NHA acknowledged. 2. On 6/23/20 at 12:30 PM, Dietary Aide 1 (DA1) was observed picking up lunch trays from residents' rooms, exiting the room, and discarding left food items from the plate and disposing of food items in a bucket on top of the cart (out in the hall) while wearing gloves. Then DA1 submerses the towel into a bucket of liquid and enters the resident room and proceeds to clean the bedside table, where the tray was, manipulating resident's personal items to clean the surface of the bedside table. Then DA1 exits the room, again without hand hygiene and wearing the same gloves, then returns the towel into the bucket, he then enters into another resident's room, no hand hygiene, and wearing the same gloves. DA1 repeats the sequence from the resident's room, as described earlier. Observed the DA1 continue to enter into another resident room, but was stopped by this surveyor. On 6/23/20 at 12:38 PM, in an interview with DA1, when shared observations, DA1 states, Yea, I probably should have changed them (gloves) later states he usually keeps gloves in his pocket. The IPC-Nurse approached and shared observations. When asked what her expectation of staff upon entry and exiting residents' rooms, the IPC-Nurse states, she would expect staff to wash hands, change gloves, and hand hygiene between changing gloves. When informed IPC-Nurse, there are no gloves on the food cart; the IPC-Nurse then points to the end of the hall (approximately 20 feet) where the box of gloves was. Record review of Hand Hygiene policy effective 3/9/2020, subtitle number six, Additional Considerations section b reads, The use of gloves does not replace hand washing. Under title page, Hand Hygiene reads in pertinent part, Hand hygiene continues to be the primary means of preventing the transmission of infection. The following is a list of some situations that require hand hygiene (even if gloves are used): Before and after eating or handling food (handwashing with soap and water); On 6/23/20 at 1:12 PM, in an interview with the NHA, when shared observations of DA1, the NHA verbally acknowledged.

Based on observation, interviews, and record reviews, the facility failed to develop a comprehensive resident-centered care plan consistent with measurable interventions for one (Resident 48) of the two residents looked at for care planning. Specifically, the facility failed to identify a medical focus that requires interventions to sustain life on the care plan. This failure places the resident at risk for not having their needs met. Findings include: Resident 48 was admitted on [DATE]. The resident's [DIAGNOSES REDACTED]. On 6/23/20 at 12:00 PM, Resident 48 was observed asleep in bed with [MEDICAL CONDITION] (Continuous Positive Airway Pressure) with O2 (Oxygen) tubing connected to the [MEDICAL CONDITION] tubing and the O2 concentrator set at 2L/M (Liters per Minute) of oxygen. Record review of Resident 48's Care Plan Goal reads, I will be able to participate in my cares while ambulating with extensive assist throughout facility next 3 months. Status is Active, Review date 8/31/2020, Start date 4/5/2018. Under subsection intervention reads, I will utilize oxygen as ordered attached to my [MEDICAL CONDITION] at bed rest as I allow. Status reads Active; Role(S) reads, Nursing, Nursing Assistant, Start Date reads 2/19/2019. In reviewing the comprehensive 39 pages of Resident 48's Care Plan, no goal/focus is listed for Resident 48's [DIAGNOSES REDACTED]. Record Review of the policy entitled Nursing Care Plans, Revised 11/17, subsection of the policy reads, A person-centered plan of care shall be developed within 14 days of admission by an interdisciplinary team. Number three reads, Areas to be discussed and addressed in the care plan are Dietary, Bowel and Bladder, Medical, Social, Emotional, and Activities. Number four reads, Problems in these areas are discussed along with approaches and goals. Record review of the policy entitled Oxygen Therapy revised on 2/1/2016. Under subsection Policy reads in pertinent part, Oxygen is administered to residents who need it, consistent with professional standards of practice, the comprehensive person-centered care plans, and the resident's goals and preferences. Subsection titled, Policy Explanation and Compliance Guidelines Number two reads, Personnel authorized to initiate oxygen therapy include physicians, RN's, LPNs, and respiratory therapists. Number five reads, The resident's care plan shall identify the interventions for oxygen therapy, based upon the resident's assessment and orders. On 6/23/2020 at 2:00 PM, in an interview with the Assistant Director of Nursing (ADON), when shared Resident 48's care plan states roles for assuring the [MEDICAL CONDITION] and oxygen are attached to the resident is to be done by nursing assistant, the ADON says it is her expectation that nursing supervised the placement of the [MEDICAL CONDITION] after the nursing assistant applies it to the resident. When asked does Resident 48 have oxygen attached to the [MEDICAL CONDITION]; the ADON replied, Yes. When shared, the facility policy states authorize personnel for oxygen initiation, or placement, excludes nursing assistants from applying oxygen. The ADON acknowledged. When the ADON/NHA (Nursing Home Administrator) was asked why [MEDICAL CONDITION] was not a focus on the care plan, the ADON states there is a care plan for activities and everything. When asked for a comprehensive care plan addressing measurable interventions for Resident 48's Sleep Apnea [DIAGNOSES REDACTED].

Based on observation, resident interview, review of facility water temperature logs, and staff interview, the facility failed to maintain acceptable hot water temperatures for 5 of 5 random residents' rooms (room [ROOM NUMBER]S, #103S, #108S, #103E, and #102N) observed for water temperature. Failure to ensure acceptable hot water temperatures has the potential for burn injuries to residents, visitors, and staff. Findings include: Upon request, the facility failed to provide a policy regarding water temperatures. Observation on 05/13/19 showed the following water temperatures in resident bathrooms: 4:47 p.m. - room [ROOM NUMBER]S 143 degrees Fahrenheit (F) 4:49 p.m. - room [ROOM NUMBER]E 136.4 degrees F 4:51 p.m. - room [ROOM NUMBER]S 142.8 degrees F 4:53 p.m. - room [ROOM NUMBER]N 131.3 degrees F 4:55 p.m. - room [ROOM NUMBER]S 140 degrees F - An interview with administrative staff members (#1 and #2) regarding the hot water temperatures occurred on 05/13/19 at 5:15 p.m. The staff members (#1 and #2) stated they were not aware of the high temperature, had no reports of resident burns, and would notify maintenance staff immediately regarding the water temperatures. During an interview on 05/13/19 at 5:20 p.m., a certified nursing assistant (CNA) (#10) stated the water temperatures are up and down, every day varies and every room varies, and she turns the cold water on so it is not so hot. During an interview on 05/13/19 at 5:32 p.m., a CNA (#5) stated, I noticed today the water was hot and one time this winter it was hot. I just add cold water. During an interview on 05/13/19 at 5:36 p.m., Resident A stated the water was really hot but he had not gotten burned. When asked if he reported the hot water, he stated oh they (staff) know, they are working on it. During an interview on 05/13/19 at 5:47 p.m a maintenance staff member (#9) stated he checked the water temperatures every morning, today the temperature measured 113 degrees F. He explained he had changed the water system today from the large boiler to a smaller boiler due to the change of season and at 3:00 p.m. it measured 114 degrees F. He agreed the present water temperature showed over 140 degrees. Review of the Maintenance Departments QA (Quality Assurance) Daily Check List from (MONTH) (YEAR) to (MONTH) 2019 identified monthly temperatures between 108 - 112 degrees F. Review of a maintenance notebook identified staff documented water temperatures two to three times per month, with temperatures ranging from 108 - 112 degrees F. The facility failed to maintain acceptable water temperatures after making a water system change.

Based on observation, review of facility policy, and staff interview, the facility failed to ensure staff followed appropriate infection control practices for 2 of 2 sampled residents (Resident #28 and #179) observed during pressure ulcer dressing changes, and 1 of 8 sampled residents (Resident #12) observed during toileting/personal cares. Failure to follow appropriate infection control practices may result in the spread of infection to other residents, staff, and visitors. Findings include: Review of the facility policy titled, Hand Hygiene occurred on 05/16/19. This undated policy stated, Hand hygiene continues to be the primary means of preventing the transmission of infection. The following is a list of some situations that require hand washing with soap and water: . Before and after assisting a resident with toileting, . cleansing/wiping perineal area . Review of the facility policy titled, Perineal Care After Urinary or Fecal Incontinence occurred on 05/16/19. This policy, dated (MONTH) 2010, stated, . Procedure with Resident Using the Bathroom: . 3. Put on disposable gloves . 5. When resident is finished, cleanse peri-area . 7. Remove and discard gloves . 8. Pull up pad/brief and adjust clothing 9. Assist resident to safe position/area 10. Wash your hands. - Observation of personal cares occurred on 05/13/19 at 3:36 p.m. Two certified nursing assistants (CNAs) (#5 and #8) assisted Resident #12 to a standing position from the toilet after the resident voided and had a small bowel movement. One CNA (#8) donned gloves and provided perineal cares, removed her gloves and assisted the other CNA (#5) with transferring the resident to the wheelchair. The CNA (#8) removed her gloves, repositioned the resident in her chair, applied wheelchair pedals, and combed the resident's hair. The CNA (#8) performed hand hygiene with an alcohol-based hand rub in the hallway as he/she wheeled the resident to the lounge area. The CNA (#8) failed to perform hand hygiene after performing perineal cares and prior to performing other tasks. - Observation on 05/14/19 at 9:59 a.m. showed a licensed nurse (#6) performed hand hygiene, donned gloves, sprayed two gauze pads with wound cleanser, removed Resident #28's pressure ulcer dressing to the left heel, and cleansed the area with a gauze pad. Without changing gloves or performing hand hygiene, the nurse (#6) removed the right heel pressure ulcer dressing, obtained the other gauze pad and cleansed the right heel. The nurse (#6) failed to change gloves and perform hand hygiene after cleansing the left heel and prior to removing the right heel dressing. - Observation on 05/15/19 at 9:09 a.m. showed a licensed nurse (#7) performed hand hygiene, donned gloves, and removed Resident #179's dressing from his left foot. The nurse (#7) removed his/her gloves and without performing hand hygiene donned gloves and applied the antibiotic ointment to the open area. During an interview on 05/16/19 at 9:30 a.m. a nurse manager (#2) stated she expected staff to remove gloves and perform hand hygiene after removing a dressing from a pressure ulcer before continuing with further wound care.