Every finding on record at Stonebridge Hermann

Based on interview and record review, the facility staff failed to post accurate nurse staffing information, which included the total number of staff and the actual hours worked by both licensed and unlicensed nursing staff directly responsible for resident care per shift when staff included another employee from the assisted living facility to the total number of nursing staff working. The census was 70. 1.Review of the facility policies showed staff did not provide a policy for nurse staff posting.Review of the nurse staff posting sheets, dated 03/01/26 to 05/31/26, showed sheets contained the total number of licensed and unlicensed staff who provided care to both the skilled nursing facility and the attached assisted living facility. The census on the staff posting sheets reflected the number of residents in the Skilled Nursing facility.During an interview on 06/03/26 at 3:08 P.M., the Assistant Director of Nursing (ADON), said he/she was in charge of scheduling and staff postings. He/She said he/she was not aware he/she couldn't count the assisted living staff as skilled staff when counting the total amount of staff in the building. During an interview on 06/03/26 at 3:31 P.M., the Director of Nursing (DON) said he/she was not aware the number of staff could not include staff on the assisted living side during evenings and nights.During an interview on 06/04/2026 at 11:59 A.M., the administrator said the daily staff posting reflected all staff for the skilled nursing facility and the assisted living facility. He/she said the census on the daily staff posting reflected the number of residents in the skilled nursing facility. The administrator said his/her expectations are the ADON post accurate staffing sheets. He/She said the ADON is in charge of scheduling, and the DON was ultimately responsible. He/she said the staff on the assisted living facility do not provide direct care for the residents on skilled side.

Based on observation, interview and record review, facility staff failed to develop and implement complete policies and procedures for the inspection, testing and maintenance of the facility's water systems to inhibit the growth of waterborne pathogens and reduce the risk of an outbreak of Legionnaire's Disease (LD- a serious type of pneumonia (lung infection) caused by Legionella bacteria, which places all residents of the facility at risk of exposure which could lead to illness. Facility staff failed to implement an enhanced barrier precautions (EBP) system for one (Resident #33) of two sampled residents with wounds when facility staff failed to wear appropriate personal protective equipment (PPE) during high-contact care activities and place PPE in close proximity. The facility census was 56. 1. Review of the Centers for Medicare and Medicaid Services (CMS) Survey and Certification (S&C) letter 17-30, dated 06/02/17 and revised on 06/09/17, showed: -The bacterium Legionella can cause a serious type of pneumonia called LD in persons at risk. Those at risk include persons who are at least [AGE] years old, smokers, or those with underlying medical conditions such as chronic lung disease or immunosuppression. Outbreaks have been linked to poorly maintained water systems in buildings with large or complex water systems including hospitals and long-term care facilities. Transmission can occur via aerosols from devices such as shower heads, cooking towers, hot tubs, and decorative fountains; -Facilities must develop and adhere to policies and procedures that inhibit microbial growth in building water systems that reduce the risk of growth and spread of Legionella and other opportunistic pathogens in water; -CMS expects Medicare certified healthcare facilities to have water management policies and procedures to reduce the risk of growth and spread of Legionella and other opportunistic pathogens in building water systems. An industry standard calling for the development and implementation of water management programs in large or complex building water systems to reduce the risk of legionellosis was published in 2015 by American Society of Heating, Refrigerating, and Air Conditioning Engineers (ASHRAE). In 2016, the Centers for Disease Control and Prevention (CDC) and its partners developed a toolkit to facilitate implementation of this ASHRAE Standard (https://www.cdc.gov/legionella/maintenance/wmp-toolkit.html). Environmental, clinical, and epidemiological considerations for healthcare facilities are described in this toolkit; -Surveyors will review policies, procedures, and reports documenting water management implementation results to verify that facilities: -Conduct a facility risk assessment to identify where Legionella and other opportunistic waterborne pathogens (e.g. Pseudomonas, Acinetobacter, Burkholderia, Stenotrophomonas, nontuberculous mycobacteria, and fungi) could grow and spread in the facility water system; -Implement a water management program that considers the ASHRAE industry standard and the CDC toolkit, and includes control measures such as physical controls, temperature management, disinfectant level control, visual inspections, and environmental testing for pathogens; -Specify testing protocols and acceptable ranges for control measures, and document the results of testing and corrective actions taken when control limits are not maintained. Review of the facility's Water Management Program, showed the program did not contain policies related to water management. Review showed the program did not contain control measures or corrective actions. Review of the facility's water management documentation showed four water heaters were identified as temperature permissive areas where Legionella could grow. Review showed two of the four water heaters were identified as not having recirculating pumps. Review showed the monitoring procedure for water heaters was weekly temperature checks. Review showed weekly water temperature check log sheets did not contain an acceptable range for water temperatures. Review showed the plan did not include a temperature range or corrective actions to address out of range water temperatures. During an interview on 09/19/24 at 9:30 A.M., the maintenance director said he/she and housekeeping staff are responsible for cleaning water fixtures and running water faucets weekly. The maintenance director said he/she checks water temperatures weekly. The maintenance director said he/she did not flush the four large water heaters. The maintenance director said he/she was not aware of any water management policies. During an interview on 09/19/24 at 1:15 P.M., the administrator said he/she and the maintenance director were responsible for the water management program. The administrator said there were not policies or an overall plan related to water management. The administrator said he/she did not know two of four water heaters did not have recirculating pumps. The administrator said if water temperatures were not high enough, water should not be used until the issue was corrected. The administrator said there was no policy to identify correct water temperature range, but water should be between 105 and 120 degrees Fahrneheit. 2. Review of the facility's EBP policy, dated September 2022, showed: -EBP refer to the use of gown and gloves for use during high-contact resident care activities for residents known to be colonized or infected with a MDRO (Multi-drug resistant organism, bacteria resistant to antibiotics) as well as those that increased risk of MDRO acquisition (e.g., residents with wounds or indwelling medical devices); -Clear signage will be posted on the door or wall outside of the resident room indicating the type of precautions, required personal protective equipment (PPE), and the high-contact resident care activities that require use of gown and gloves; -An order for EBP will be obtained for residents with wounds and/or indwelling medical devices even if the resident is not known to be infected or colonized with a MDRO; -Make gowns and gloves available immediately outside the resident's room; -High-contact resident care activities include: dressing, bathing, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, device care or use (urinary catheters), and wound care (any skin opening that requires a dressing. 3. Review of Resident #33's Quarterly Minimum Data Set (MDS), a federally mandated assessment tool, dated 06/19/24, showed staff assessed the resident as: -Impaired Cognition; -One unhealed stage III pressure (full-thickness tissue loss) wound; -Received pressure ulcer care to include a non-surgical dressing to the feet; -Diagnosis of diabetes, anemia (low iron) and dementia. Review of the Physician Order Sheet (POS), dated September 2024, showed an order on 08/22/24 to cleanse the left heel wound with wound cleanser, cover with a petroleum dressing, and followed by a border gauze pad daily. Observation on 09/16/24 at 11:29 A.M., showed a sign on the resident's door said EBP, wear gloves and gown for the following high-contact resident care activities: dressing, bathing, transferring, changing linens, personal hygiene, changing briefs and assisting with toileting, device care, urinary catheter care, wound care - any skin opening requires a dressing. PPE was not located outside the resident room. Observation on 09/16/24 at 1:30 P.M., showed Nurse Aide (NA) I and NA E transfered the resident to the bed from the wheelchair. NA I and NA E did not wear a gown during the transfer. A sign was located on the resident's door EBP, wear gloves and gown for the following high-contact resident care activities: dressing, bathing, transferring, changing linens, personal hygiene, changing briefs and assisting with toileting, device care, urinary catheter care, wound care - any skin opening that requires a dressing. PPE not located outside the resident room. Observation on 09/17/24 at 09:41 A.M., showed Registered Nurse (RN) L and Licensed Practical Nurse (LPN) K provided wound care to the resident and did not wear a gown. A sign was located on the resident's door, EBP, wear gloves and gown for the following high-contact resident care activities: dressing, bathing, transferring, changing linens, personal hygiene, changing briefs and assisting with toileting, device care, urinary catheter care, wound care - any skin opening that requires a dressing. PPE not located outside the resident room. Observation on 09/18/24 at 08:11 A.M., showed a sign on the resident's door read: EBP, wear gloves and gown for the following high-contact resident care activities dressing, bathing, transferring, changing linens, personal hygiene, changing briefs and assisting with toileting, device care, urinary catheter care, wound care - any skin opening that requires a dressing. PPE not located outside the resident room. 4. During an interview on 09/16/24 at 1:30 P.M., NA E said he/she does not use a gown when transferring this resident because he/she does not have an infection. NA E said the resident recently had Coronavirus disease (COVID-19) (a contagious disease caused by the SARS-Cov-2 virus) and the sign just wasn't removed yet. He/She said he/she was educated on EBP but they only have to use a gown when a resident has a catheter. During an interview on 09/17/24 at 8:48 A.M., Nurse Aide (NA) I said staff do not use extra PPE when just transferring this resident. He/She said the resident does not need the extra PPE and there are not any residents in that room that require it. He/She said he/she was educated on EBP. During an interview on 09/17/24 at 9:41 A.M., RN L said EBP have not been implemented for all wounds yet, just residents with catheters. He/She said that if the resident has a draining wound, EBP would be implemented. The resident does not have a draining wound and does not need EBP at this time. During an interview on 09/18/24 at 8:21 A.M., the Infection Preventionist (IP) said he/she was aware the regulation was in effect but wanted to start slowly to get the staff used to it before implementing fully. An in-service has been conducted by the facility, the health department and the Quality Improvement Program of Missouri (QIPMO) nurse regarding EBP and should include the use of signs and PPE outside of the resident rooms. During an interview on 09/19/24 at 8:30 A.M., LPN K said residents with wounds and catheters should have EBP used during care because they are higher risk of having bacteria introduced through the staff. Staff are instructed to use gowns and gloves. He/She said the process was started last month and was just using the extra precautions on those with catheters and not wounds until this week. He/She said PPE should be located outside the resident rooms for easier access. During an interview on 09/19/24 at 10:31 A.M., the DON said EBP has been fully implemented now and should be performed, as the sign says, during high-contact care activities. During an interview on 09/19/24 at 10:57 A.M., the Administrator said there should be a sign on the door and PPE outside the door for residents on EBP. He/She said EBP was put into place for residents with MDRO and anyone with catheters and should include the use of gown and gloves. He/She said that the Infection Control Assessment and Research (ICAR) team came to the facility and did an infection control survey and education and was instructed it was ok to start the process slowly. The administrator said the facility then had a COVID outbreak which delayed everything. He/She said he/she knew the regulation was in effect and had no other good reason it was not implemented. He/She said he/she just read the regulation at the end of July.

Based on interview and record review, the facility staff failed to ensure six Nurse Aide's ((NA) NA A, NA B, NA C, NA D, NA E, and NA F) of eight completed the nurse aide training program within four months of his/her employment in the facility. The census was 56. 1. Review of the facility's policies showed the facility did not provide a policy for NA qualifications. 2. Review of NA D's personnel file showed a hire date of 04/06/22. Review showed the NA file did not contain documentation the NA completed the required nurse aide training program. During an interview on 09/17/24 at 1:04 P.M., the administrator said this employee is 96% done with his/her classes. He/She said he/she is behind because he/she tried out another unit for three and half weeks before returning to nursing care. 3. Review of NA F's personnel file showed a hire date of 06/12/23. Review showed the NA file did not contain documentation the NA completed the required nurse aide training program. During an interview on 09/17/24 at 1:04 P.M., the administrator said the employee is on step 93 of 120 steps of the on-line program. He/She said he/she is not sure why it has taken the NA over the required 120 day times frame to complete the classes. 4. Review of NA E's personnel file showed a hire date of 11/20/23. Review showed the NA file did not contain documentation the NA completed the required nurse aide training program. During an interview on 09/17/24 at 1:04 P.M., the administrator said the employee is behind because he/she wanted to try out a different area for two weeks before returning to nursing work. 5. Review of NA C's personnel file showed a hire date of 01/18/24. Review showed the NA file did not contain documentation the NA completed the required nurse aide training program. During an interview on 09/17/24 at 1:04 P.M., the administrator said the NA is done with the on-line classes and is waiting for his/her test to be scheduled. He/She said he/she had just finished the classes on-line. 6. Review of NA A's personnel file showed a hire date of 02/21/24. Review showed the NA file did not contain documentation the NA completed the required nurse aide training program. During an interview on 09/17/24 at 1:04 P.M., the administrator said the NA was hired as a NA then wasn't sure if he/she wanted to be in nursing and tried out a different area. He/She said they have since decided they do want to do nursing and are currently on step 85 of 120 on their on-line classes. 7. Review of NA B's personnel file showed a hire date of 04/05/24. Review showed the NA file did not contain documentation the NA completed the required nurse aide training program. During an interview on 09/17/24 at 1:04 P.M., the administrator said he/she is not sure where this employee is at in the program, but they are enrolled in it. He/She said he/she sets the employees up with the on-line program upon hire and he/she gets weekly reports for where they are at in the program. He/She is reponsible for monitoring where they are at in the program and responsible for ensuring they complete the program on time. He/She said the employees work at their own pace and that is sometimes harder to mange compared to when emploees were taught in the class room. He/She does not know why this employee has not completed the program. 8. During an interview on 09/17/24 at 10:26 A.M., the clinical supervisor said the administrator signs them up for the classes, ensures they have completed the program in the four months and keeps track of where they are in the program. During an interview on 09/17/24 at 1:04 P.M., the administrator said he/she is responsible for ensuring the new hires nurse aides complete the nurse aide training. He/She is aware new hires need to complete the nurse aide training within the 120 days from hire. He/She said they were having issues with the online classes not recognizing them as a site for the nurse aide hours. He/She said it is harder to ensure they complete the required hours through the on-line program.

Based on observation, interview and record review, facility staff failed to maintain a safe, clean, comfortable and homelike environment, when staff failed to maintain resident equipment and rooms in good repair for five residents (Resident #20, #23, #41, #50 and #57). The facility census was 62. 1. Review of the facility's policy titled, Safe and Homelike Environment, dated October 2017, showed staff were directed to do the following: -In accordance with resident's rights, the facility will provide a safe, clean, comfortable and homelike environment, allowing the resident to use his or her personal belongings to the extent possible; -The facility will maintain a clean environment; -The facility will provide and maintain bed and bath linens that are clean and in good condition; -Report any furniture in disrepair to Maintenance promptly; -Report any unresolved environmental concerns to the Administrator. Review of the facility's Night Shift Wheelchair Cleaning Schedule, undated, showed: -Rooms 100 through 209 on Mondays; -Rooms 300 through 404 on Tuesdays; -Rooms 500 through 511 on Wednesdays; -Rooms 600 through 612 on Thursdays; -Pick up any not done on Fridays. Further review, showed the cleaning schedule had boxes for staff to document the wheelchairs had been cleaned. No boxes had been marked. 2. Observation 09/06/23 at 9:48 A.M., showed Resident #20 sat in his/her wheelchair in his/her room. The wheelchair had built up dry food on the frame by the back wheels. Observation 09/07/23 at 9:10 A.M., the resident's wheelchair had built up food debris on the frame by the back wheels. Observation on 09/08/23 at 8:40 A.M., the resident sat in his/her wheelchair in a community area. The wheelchair had dried food debris stuck to the frame by the back wheels. 3. Observation on 09/06/23 on 9:10 A.M., showed Resident #23's wall by the bed had several areas of missing and chipped paint and black scratch marks on the floor. Observation on 09/07/23 at 10:14 A.M., showed the wall by the bed had several areas of missing and chipped paint and black scratch marks on the floor. Observation on 09/08/23 at 11:32 A.M., showed the wall by the bed had several areas of missing and chipped paint and black and scratch marks on the floor. 4. Observation on 09/06/23 at 9:04 A.M., showed Resident #41 sat in his/her wheelchair, at the nurse's station. The front left corner of the resident's pressure reducing cushion and wheelchair frame had a dried, crusty, yellow substance built up on it. Observation on 09/08/23 at 9:54 A.M., showed the resident's pressure cushion and wheelchair frame had the same dried, crusty, yellow substance on it. 5. Observation on 09/05/23 at 11:58 A.M., showed Resident #50's wheelchair armrest had pieces of the cover missing. Observation on 09/07/23 at 1:27 P.M., showed the resident's wheelchair had debris on the wheels and a worn armrest. Observation on 09/08/23 at 11:25 A.M. showed the resident's mattress worn with small tears. During an interview on 09/08/23 at 11:33 A.M., Certified Nurse Aide (CNA) B said he/she knew the resident's mattress was worn and he/she reported it to the Assistant to the Director of Nursing (ADON) last week. 6. Observation on 09/07/23 at 9:11 A.M., showed Resident #57's mattress worn with small tears and the floor tiles with scratch marks down the center. Observation on 09/08/23 at 11:27 A.M., showed Licensed Practical Nurse (LPN) J pulled back the fitted sheet from the resident's mattress. The mattress was worn with a few small tears and the floor tiles had scratch marks down the center. During an interview on 09/08/23 at 11:27 A.M., LPN J said he/she did not know if hospice provided the mattress, but the condition of the mattress should have been reported to maintenance. During an interview on 09/08/23 at 9:50 A.M., Licensed Practical Nurse (LPN) J said staff should document maintenance issues in the maintenance log. The LPN said he/she had not noticed any rooms with environmental concerns. The aides cleaned the wheelchairs in the evening or as needed, and staff should inspect the condition of the wheelchairs with any transfers. The LPN said it was disgusting to have food sitting on a wheelchair for four days. During an interview on 09/08/23 at 10:34 A.M., CNA B and Nurse Aide (NA) C said staff should report environmental concerns to the charge nurse, Director of Nursing (DON) or the Administrator. They said they had not noticed any rooms in disrepair, but had noticed residents with torn wheelchair armrests, including Resident #50. They said the wheelchairs were supposed to be cleaned every night, but they had noticed dirty wheelchairs and had reported it to the supervisor. During an interview on 09/08/23 at 11:45 A.M., the Maintenance Supervisor said staff should document environmental or equipment issues on the board located at the nurses station. He/She said he/she was responsible for ordering wheelchair parts, and new mattresses. The maintenance supervisor said no one had reported any issues with Resident #50's wheelchair or mattress or Resident #57's mattress. He/She said he/she knows about Resident #23's wall because he/she repaired it on a regular basis. He/She said the facility received bids to replace the flooring in the common area, but not the resident rooms. Rooms were inspected around the middle of each month. During an interview on 09/08/23 at 11:55 A.M., the Administrator and the DON said staff were directed to report environmental concerns and equipment in disrepair to the maintenance department. The DON said the wheelchairs are cleaned monthly and as needed, by the night shift CNAs. The DON said the night shift charge nurse should ensure the wheelchairs were cleaned, and he/she had just educated staff on 07/17/2023 in regard to cleaning wheelchairs. 42815

Based on observation, interview and record review, facility staff failed to ensure three residents (Residents #23, #35 and #50), who were unable to complete their own activities of daily living (ADLs) (showering/bathing, dressing, and personal hygiene), received the necessary care and services to maintain good personal hygiene. The facility census was 62. 1. Review of the facility's policy titled, Activities of Daily Living (ADLs), Supporting, dated March 2018, showed staff were directed to do the following: -Residents will be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out ADLs; -Residents who are unable to carry out ADLs independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene; -Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with hygiene (bathing, dressing, grooming, and oral care). 2. Review of Resident #23's Significant Change in Status (SCSA) Minimum Data Set (MDS), a federally mandated assessment tool, dated 06/28/23, showed staff assessed the resident as follows: -Severe cognitive impairment; -Required total assistance from one staff member for personal hygiene. Review of the resident's care plan, dated 02/21/23, showed staff documented the resident required extensive assistance with personal care and oral hygiene. Observation on 09/05/23 at 12:04 P.M., showed the resident's thumb nails long and uneven in length. Observation on 09/06/23 at 9:09 A.M., showed the resident's thumb nails long and uneven in length. The resident's facial hair was unkempt and his/her hair was disheveled. Observation on 09/06/23 at 9:52 A.M., showed Registered Nurse (RN) D provided care to the resident's hand. The resident's nails were long and the RN did not provide nail care. Observation on 09/07/23 at 11:54 A.M., showed the resident's thumb nails long and uneven in length, he/she had unkempt facial hair and his/her hair was disheveled. Observation on 09/07/23 at 3:10 P.M., showed the resident's thumb nails long and uneven in length. 3. Review of Resident #35's Quarterly MDS, dated [DATE], showed staff assessed the resident as follows: -Moderate cognitive impairment; -Required limited assistance from one staff member for personal hygiene. Review of the resident's medical record showed a diagnosis of the resident's need for assistance with personal care. Review of the resident's care plan, dated 03/21/23, showed staff documented the resident required extensive assistance with some ADLs related to a diagnosis of frontotemporal neurocognitive disorder (brain disorder), dementia, history of stroke and hallucinations. Required assistance for shaving his/her facial hair when unable to complete the task. Observation on 09/06/23 at 1:41 P.M., showed the resident had long fingernails, long nose hair and long hairs on his/her neck. Observation on 09/07/23 at 8:58 A.M., showed the resident had long fingernails, long nose hair and long hairs on his/her neck. Observation on 09/08/23 at 11:36 A.M., showed the resident had long fingernails, long nose hair, and long hairs on his/her neck. 4. Review of Resident #50's Admission MDS, dated [DATE], showed staff assessed the resident as follows: -Cognitively intact; -Required limited assistance from one staff member for personal hygiene. Review of the resident's care plan, dated 08/21/23, showed no direction for staff in regard to the resident's ADL care needs. Observation on 09/05/23 at 11:58 A.M., showed the resident had long nose hairs, and disheveled hair. Observation on 09/06/23 at 12:25 P.M., showed the resident had disheveled and greasy hair, long nose hairs and debris on the front of his/her shirt. Observation on 09/06/23 at 3:46 P.M., showed the resident had disheveled and greasy hair, long and uneven nails, long nose hairs and debris on the front of his/her shirt. Observation on 09/07/23 at 1:25 P.M., showed the resident had disheveled and greasy hair, long nose hairs and debris on the front of his/her shirt. During an interview on 09/08/23 at 9:50 A.M., Licensed Practical Nurse (LPN) J said there were only two Certified Nurse Aides (CNAs) providing care for the residents. The LPN said there was not enough staff to provide care for the residents. The resident's hair should be brushed when staff get them out of bed, and the aides should provide shaves including nose hair trimming, and nail care as need. The podiatrist provided nail care for residents with more difficult cases. The LPN said resident #23 had long nails, but he/she was diabetic, so a nurse should trim the nails. The resident's hands were contracted, so there was a concern with the long nails digging into his/her hands. LPN J said when staff placed the washcloth in the resident's hand, they should be checking if the resident needed his/her nails trimmed. During an interview on 09/08/23 at 10:34 A.M., CNA B and Nurse Aide (NA) C said they do not feel there was enough staff to provide care for the residents, and because of this some of the residents did not receive the care they needed. Nail care, hair brushing and nasal hair did not always get done. They said they did notice Resident #50's unbrushed hair. They said staff should brush the resident's hair when assisting them out of bed. They said some of the residents had long nose hair and the aides should be trimming it. During an interview on 09/08/23 at 11:55 A.M., the Administrator and the Director of Nursing (DON) said the bath aide or CNA provided nose hair trimming, nail care, and shaves when needed. They said volunteers came in once a month to trim the residents' nails and activity staff trimmed nails every other week. They said the nurses provided nail care for residents who were diabetic. They said staff should brush the residents' hair when they get them out of bed. If staff notice hygiene concerns, they should provide the necessary care.

Based on observation, interview, and record review, facility staff failed to review and revise the plan of care for three residents (Resident #22, #23, and #41). The facility census was 62. 1. Review of the facility's policy titled, Comprehensive Care Plans, dated September 2022, showed staff were directed to do the following: -It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment; -The care planning process will include process will include an assessment of the resident's strengths and needs, and will incorporate the resident's personal and cultural preferences in developing goals of care. Services provided or arranged by the facility, as outlined by the comprehensive care plan, shall be culturally-competent and trauma-informed; -The comprehensive care plan will be developed within seven days after the completion of the comprehensive Minimum Data Set (MDS), a federally mandated assessment tool completed by facility staff. All Care Assessment Areas (CAAs) triggered by the MDS will be considered in developing the plan of care. Other factors identified by the interdisciplinary team, or in accordance with the resident's preferences, will also be addressed in the plan of care; -The comprehensive care plan will describe, at a minimum, the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being and resident specific interventions that reflect the resident's needs and preferences and align with the resident's cultural identity, as indicated; -The comprehensive care plan will be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly MDS assessment; The comprehensive care plan will include measurable objectives and timeframes to meet the resident's needs as identified in the resident's comprehensive assessment. The objectives will be utilized to monitor the resident's progress. 2. Review of Resident #22's Quarterly MDS, dated [DATE], showed staff assessed the resident as: -Severe cognitive impairment; -Required extensive assistance from two staff members for bed mobility, transfers and toilet use; -Required extensive assistance from one staff member for dressing, bathing and personal hygiene; -Only able to stabilize with staff assistance during transfers; -Used a wheelchair; -Diagnoses of Stroke, Parkinson's disease (brain disorder that causes uncontrolled movements with decreased balance and coordination), and seizure disorder. Review of the resident's care plan, revised 07/10/2023, showed staff did not document the resident's preference, to get out of bed to eat lunch and dinner with his/her spouse in the dining room. Review of the facility's Meal Times, undated, showed the resident's lunch begins at 11:30 A.M. During an interview on 09/06/23 at 9:32 A.M., the resident said he/she preferred to get up and eat lunch with his/her spouse in the dining room. The resident said his/her spouse did not live in the same part of the facility and came over to eat lunch and dinner with him/her. Observation on 09/06/23 at 12:25 P.M., showed the resident remained in his/her room and waited for staff to assist him/her to the dining room so to eat with his/her spouse. Observation on 09/06/23 at 12:31 P.M., showed the resident's spouse sat alone at a table in the dining room. The resident's spouse had finished his/her meal. During an interview on 09/06/23 at 12:31 P.M., the resident's spouse said he/she came to the facility to eat lunch and dinner with the resident, but he/she was now finished. The spouse said the resident did not make it to lunch today because staff did not help the resident get out of bed. During an interview on 09/06/23 at 12:29 P.M., Nurse Aide (NA) C and Certified Nurse Aide (CNA) B said, We are so far behind and just now getting the resident up, because there is only two of us to get all of these people up. During an interview on 09/08/23 at 11:19 A.M., the MDS Coordinator said the resident's care plan should include that he/she eats with his/her spouse, because it is the resident's preference and individualized to him/her. During an interview on 09/08/23 at 12:11 P.M., the Director of Nursing (DON) said the resident gets very upset, if he/she does not get to have lunch or dinner with his/her spouse. It should probably be on his/her care plan. 3. Review of Resident #23's Significant Change in Status (SCSA) MDS, dated [DATE], showed staff assessed the resident as follows: -Severe cognitive impairment; -Diagnosis of Dementia. Review of the resident's medical record showed the resident had diagnoses of unspecified dementia, without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety. Review of the resident's care plan dated, 02/21/23, showed no direction for staff in regard to the resident's diagnosis of dementia. The care plan had not been reviewed or revised since 02/21/23. 4. Review of Resident #41's Admission MDS, dated [DATE], showed staff assessed the resident as follows: -Severe cognitive impairment; -Physical and verbal behaviors directed towards others four to six days out of the seven day look back period (period of time used to complete the assessment); -Received Antipsychotic medication seven out of the seven days in the look back period; -Received Hypnotic medication two out of seven days in the look back period; -Received Antidepressant medication seven out of seven days in the look back period; -diagnosed with Alzheimer's disease, anxiety disorder and depression. Review of the resident's Physician Note, dated 08/23/23, showed a new diagnosis of senile psychosis with a new order for Haldol (an antipsychotic medication). Review of the resident's Physician Order Sheets (POS), showed orders dated 08/23/23 for Haldol 5 milligrams (MG) once a day and Haldol 2 mg once a day. Review of the resident's care plan, revised 08/07/23, showed no direction for staff in regard to Haldol use, or medication side effects and behaviors to monitor for. During an interview on 09/08/23 at 9:50 A.M., Licensed Practical Nurse (LPN) J said the care plan directed staff on the type of care the resident needed and their preferences. LPN J said the MDS Coordinator was responsible for reviewing and revising the care plans but the nurses could update the care plans with changes. The care plans were updated quarterly and with any change in the residents condition. Care plans should include a diagnosis of dementia, and that Resident #22 likes to eat meals with his/her spouse. During an interview on 09/08/23 at 10:34 A.M., Certified Nurse Aide (CNA) B and Nurse Aide (NA) C said the care plans provided guidance for staff on how to care for the residents. During an interview on 09/08/23 at 10:49 A.M., the MDS Coordinator said he/she was responsible for updating and revising the care plans, but the nurses could update them. The information in the care plans was obtained by reviewing the residents' medical records, and interviews with staff and residents or their family. The care plans were updated after each MDS assessment, and with changes in resident condition. Care plans should address pertinent diagnoses such as dementia, and new mental health diagnoses as well as interventions for monitoring for effectiveness with the start of medications. The MDS coordinator said he/she started the position in June and he/she noticed some of the care plans had not been reviewed and revised. During an interview on 09/08/23 at 11:55 A.M., the Administrator and Director of Nursing (DON) said the care plan should direct staff in the type of care the resident required, and should be updated with a change in status and quarterly. They said the care plan should be updated by the department head in which the change had occurred. They said they expected the care plan to address pertinent diagnoses such as dementia. The DON said a new psychotic disorder diagnosis, and a new antipsychotic medication should be on the care plan. There should be interventions on the care plan and they should be measurable and resident specific. 42815

Based on observation, interview, and record review, facility staff failed to remove soiled gloves and/or properly wash hands and provide an environment to prevent the spread of bacteria and other infection causing contaminants during the provision of wound care for one resident (Residents #1). Additionally staff failed to remove soiled gloves and/or properly wash hands during incontinence care for one resident (Resident #22). The facility census was 62. 1. Review of the facility's policy titled, Wound Care, dated October 2018, showed staff were directed to do the following: -Use disposable cloth (paper towel is adequate) to establish clean field on resident's over bed table. Place all items to be used during procedure on the clean field; -Dress wound. Pick up sponge with paper and apply directly to area. [NAME] tape with initials, time, and date and apply to dressing. Be certain all clean items are on a clean field; -Discard disposable items into the designated container. Discard all soiled laundry, linen, towels, and washcloths into the soiled laundry container. Remove disposable gloves and discard into designated container. Wash and dry hands thoroughly; -Review showed no direction for staff in regard to providing multiple wound treatments, glove changes and hand hygiene. Review of the facility's policy titled, Hand Hygiene, dated May 2021, showed staff were directed to do the following: -Staff will perform hand hygiene when indicated, using proper technique consistent with accepted standards of practice; -Wash hands with soap and water whenever they are visibly soiled; -The use of gloves does not replace hand hygiene, if task requires gloves, perform hand hygiene prior to donning gloves and immediately after removing gloves. 2. Observation on 09/05/23 at 2:34 P.M., showed Registered Nurse (RN) D provided wound care for Resident #1. The RN placed the bandage tape and dressing packages directly on the resident's bed linens, without a protective barrier, packed a wound on the resident's buttocks, then packed a different wound on the buttocks and applied dressings to both wounds without changing gloves or performing hand hygiene between wound care. The RN changed gloves, performed hand hygiene, cut and applied tape to the dressings, removed gloves, disposed of the wound care packaging, returned the same roll of bandage tape to the storage area, and placed scissors in his/her pocket, without sanitization. During an interview on 09/08/23 at 9:50 A.M., Licensed Practical Nurse (LPN) J said staff should place wound care supplies on a protective barrier, if not the supplies could be contaminated. Supplies should not be placed directly on bed linens. The LPN said staff should perform hand hygiene and change gloves between providing treatments to wounds at different sites because of the risk of cross contamination. During an interview on 09/08/23 at 11:55 A.M., the Administrator and the Director of Nursing (DON) said wound care supplies should be put on a clean surface, such as a protective barrier, or on a sanitized bed side table. They said the supplies should not be sat on bed linens because of contamination concerns. They said staff should perform hand hygiene and glove changes between each wound to prevent cross contamination. 3. Observation on 09/06/23 at 10:14 A.M., Nurse Aide (NA) C and Certified Nurse Aide (CNA) B entered the resident's room, washed their hands and applied gloves. The NA picked up the resident's catheter bag and placed it on the bed frame, and wiped his/her face with the same gloves on. The NA rolled the resident to his/her right side, while the CNA removed the resident's soiled brief. The NA then rolled the resident on their back, wiped the resident's perineal folds multiple times from back to front with the same wipe, and wiped the resident's perineal area in a circular motion with the same wipe. The NA and CNA rolled the resident back on to his/her right side, and the NA with the same gloves on, pulled a new wipe and wiped feces off of the resident. With the same gloves on, the NA helped the CNA apply cream to the resident's perineal folds, and touched the resident's clean brief and clothes. During an interview on 09/08/23 at 10:40 A.M., NA C said staff should change gloves and wash their hands, anytime they are dirty. The NA said he/she had been taught to wipe from front to back, and to fold the wipe with each swipe. The NA said he/she did not change gloves, or wipe front to back because he/she was in a hurry. During an interview on 09/08/23 at 10:40 A.M., CNA B said he/she is training NA C. The CNA said staff should provide perineal care before they move to the resident's backside. The CNA said after wiping feces, staff should should wash hands and change gloves. The CNA said staff should use a new wipe per swipe. The CNA said if a NA does something incorrectly he/she was supposed explain the process, so the NA did it correctly the next time. The CNA said he/she was in a hurry and did not notice the NA used the same wipe several times and did not change his/her gloves. The CNA said he/she should have noticed it. During an interview on 09/08/23 at 12:11 P.M., the DON said during incontinence care, he/she expected staff to wash hands, apply gloves and clean the resident front to back. The DON said when using disposable wipes to provide care, one swipe per wipe was best. The DON said he/she expected staff to change gloves and wash hands after incontinence care and before they handled the resident's clean brief and clothing. The DON said if the staff did not change gloves and wash their hands before touching clean briefs, the staff could transfer bacteria and cause infections. The DON said if staff provided bowel incontinence care and then moved to the front perineal area without washing their hands and changing their gloves, it could cause a Urinary Tract Infection (UTI). 42815

Based on observation, interview, and record review, facility staff failed to transfer two residents (Resident #22 and #20) in a safe manner, and failed to properly propel two residents (Resident #15 and #48) in wheelchairs in a manner to prevent accidents. The facility census was 62. 1. Review of the facility's policy titled, Safety and Supervision of Residents, dated July 2017, showed staff were directed to do the following: -Employees shall be trained on potential accident hazards and demonstrate competency on how to identify and report accident hazards, and try to prevent avoidable accidents; -The care team shall target interventions to reduce individual risks related to hazards in the environment, including inadequate supervision and assistive devices; -Due to complexity and scope, certain resident risk factors and environmental hazards are addressed in dedicated policies and procedures to include, safe lifting and movement of residents. Review of facility's Hoyer Instruction Manual, undated, showed staff are directed to ensure the legs of the hoyer lift base were opened and locked and the lift was in position, before the patient was lifted. 2. Review of Resident #22's Quarterly Minimum Data Set (MDS), a federally mandated assessment tool, dated 07/04/23, showed staff assessed the resident as: -Severe cognitive impairment; -Required extensive assistance from two staff members for bed mobility, transfers and toilet use; -Required extensive assistance from one staff member for dressing, bathing and personal hygiene; -Only able to stabilize with staff assistance during transfers; -Used a wheelchair; -Diagnoses of stroke, Parkinson's disease (brain disorder that causes uncontrolled movements and decreased balance and coordination) and seizure disorder. Review of the resident's care plan, revised 07/10/2023, showed staff documented the resident required the assistance of one to two staff members for transfers and was unsteady at times with a history of falls. Observation on 09/06/23 at 10:14 A.M., showed Nurse Aide (NA) C and Certified Nurse Aide (CNA) B entered the resident's room with a mechanical lift. The NA opened the base of the lift and pushed it up to the resident's wheelchair, secured the lift sling to the lift, lifted the resident from his/her wheelchair, closed the base of the lift with the resident suspended in the air, and pushed the lift toward the resident's bed, while the CNA stabilized the resident. The right leg of the lift became stuck on the bed frame at the foot of the bed, and the lift abruptly stopped. The NA kicked the right leg of the lift free from the bed frame, and continued to transfer the resident. During an interview on 09/08/23 at 8:51 A.M., NA C said staff were supposed to open the mechanical lift legs after lifting the resident. During an interview on 09/08/23 at 8:53 A.M., CNA B said staff had been trained to close the mechanical lift legs as the resident was moved closer to their bed. 3. Review of Resident #2's Quarterly MDS, dated [DATE], showed staff assessed the resident as: -Severe cognitive impairment; -Totally dependent on two staff members for transfers; -Required extensive assistance from two staff members for bed mobility, locomotion on and off the unit, dressing, toilet use and personal hygiene; -Required extensive assistance from one staff member for locomotion on the unit; -Only able to stabilize with staff assistance during transfers; -Uses a wheelchair; -Had two or more non-injury falls since last assessment; -Diagnoses of dementia, anxiety disorder and depression. Review of the resident's care plan, revised 07/27/2023, showed staff documented the resident had a history of falls while in the facility. Resident required a mechanical lift with two staff members for transfers. Observation on 09/07/23 at 4:00 P.M., showed CNA E and Restorative Aide (RA) F slid a mechanical lift under the frame of the resident's bed with the base closed. The CNA lifted the resident, pulled the lift out from under the bed, and with nothing under the resident, the CNA pushed the lift approximately six feet with the base of the lift closed. The CNA did not open the legs of the lift until he/she lowered the resident in to a wheelchair. During an interview on 09/07/23 at 4:03 P.M., CNA E said he/she had been taught to pull the resident out from his/her bed and then open the legs of the lift to transfer the resident to the wheelchair. The CNA said he/she did not open the lift legs before lifting the resident, because the legs get caught on the resident's bed frame. The CNA said he/she was supposed to have the legs of the lift open before lifting residents, so the residents do not tip over. During an interview on 09/08/23 at 12:11 P.M., The Director of Nursing (DON) said staff should open the legs of the lift when they begin to lift the resident. The legs of the lift should be open when the resident was lifted in the air, and should not be closed until the resident was being lowered. The DON said if the mechanical lift legs were closed, it was dangerous for the resident because the lift could tip over. 4. Review of Resident #15's Significant Change in Status (SCSA) MDS, dated [DATE], showed staff assessed the resident as follows: -Severe cognitive impairment; -Required extensive assistance from two staff members for locomotion on unit; -Required supervision from one staff member for locomotion off unit; -Used a wheelchair. Observation on 09/08/23 at 9:58 A.M., showed NA C propelled the resident in a wheelchair down the hallway. The resident's foot hung between the foot pedals and dragged the floor. 5. Review of Resident #48's Quarterly MDS, dated [DATE], showed staff assessed the resident as follows: -Cognitively intact; -Required supervision from one staff member for locomotion on unit; -Required extensive assistance from one staff member for locomotion off unit; -Used a wheelchair. Observation on 09/08/23 at 9:52 A.M., showed CNA K propelled the resident in a wheelchair down the hallway, without foot pedals. The resident held his/her feet up. During an interview on 09/08/23 at 9:50 A.M., Licensed Practical Nurse (LPN) J said staff should use foot pedals anytime they propelled a resident in a wheelchair. The LPN said he/she had seen staff propelling residents without foot pedals, and it could cause injury to the residents. During an interview on 09/08/23 at 10:34 A.M., CNA B and NA C said staff should always use foot pedals when propelling a resident in a wheelchair, and should ensure the resident's feet were on the foot pedals. They said the resident could be injured if their feet touched the ground. During an interview on 09/08/23 at 11:55 A.M., the Administrator and the DON said staff were educated to always use foot pedals when propelling a resident, and should ensure the resident's feet were on the foot pedals. They said the resident could be injured if foot pedals are not used, or if the resident's feet were not placed on the pedals correctly. 42815

Based on interview and record review, facility staff failed to develop and implement a comprehensive person-centered care plan for two residents (Resident #4, and #50). The facility census was 62. 1. Review of the facility's policy titled, Comprehensive Care Plans, dated September 2022, showed staff were directed to do the following: -It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframe's to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment; -The care planning process will include an assessment of the resident's strengths and needs, and will incorporate the resident's personal and cultural preferences in developing goals of care. Services provided or arranged by the facility, as outlined by the comprehensive care plan, shall be culturally-competent and trauma-informed; -The comprehensive care plan will be developed within seven days after the completion of the comprehensive Minimum Data Set (MDS), a federally mandated assessment tool. All Care Assessment Areas (CAAs) triggered by the MDS will be considered in developing the plan of care. Other factors identified by the interdisciplinary team (IDT), or in accordance with the resident's preferences, will also be addressed in the plan of care; -The comprehensive care plan will describe, at a minimum, the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being and resident specific interventions that reflect the resident's needs and preferences and align with the resident's cultural identity, as indicated; -The comprehensive care plan will include measurable objectives and timeframe's to meet the resident's needs as identified in the resident's comprehensive assessment. The objectives will be utilized to monitor the resident's progress. 2. Review of Resident #4's Admission Minimum MDS, dated [DATE], showed staff assessed the resident as: -Cognitively intact; -Diagnosis of dementia; -Care Area Assessments (CAA) did not trigger for cognitive loss/dementia. Review of the resident's medical record showed diagnoses of unspecified dementia, cognitive communication deficit, and unspecified symptoms and signs involving cognitive function and awareness. Review of the resident's care plan, dated 07/28/23, showed no direction for staff in regard to the resident's cognition or dementia. 3. Review of Resident #50's Admission MDS, dated [DATE], showed staff assessed the resident as: -Cognitively intact; -Required limited assistance from one staff member for personal hygiene; -Required extensive assistance from one staff member for bed mobility, transfers, dressing and toileting; -Required setup assistance for eating; -Very important to listen to music he/she likes, and to keep up with the news; -Somewhat important to be around animals, such as pets, to do things with groups of people, to do a favorite activity, and to go outside to get fresh air when the weather is good; -Not very important to have books, magazines, and newspapers to read or to participate in religious services or practices. Review of the resident's medical record, showed staff documented the resident enjoyed watching television, including comedy shows and football, spending time with his/her family, listening to rock and roll music and attending afternoon activities with assistance from staff. Review of the resident's Physician's Order Sheets (POS), dated 06/01/23, showed a code status order of Full Code (if found without a heart beat, and not breathing, all resuscitation procedures will be provided to keep them alive) order. Review of the resident's care plan, dated 07/28/23, showed no direction for staff in regard to Activities of Daily Living (ADLs), code status, or activity preferences for the resident. During an interview on 09/08/23 at 9:50 A.M., Licensed Practical Nurse (LPN) J said the care plan directed staff on the type of care the resident needed and their preferences. The LPN said the MDS Coordinator was responsible for reviewing and revising the care plans but the nurses could update the care plans with changes. The care plans were updated after a change in resident condition, falls, and on a quarterly basis, and should include code status, ADL needs, activity preferences and a pertinent diagnoses, such as dementia. During an interview on 09/08/23 at 10:34 A.M., Certified Nurse Aide (CNA) B and Nurse Aide (NA) C said the care plans provide guidance for staff on how to care for the residents. During an interview on 09/08/23 at 10:49 A.M., the MDS Coordinator said he/she was responsible for updating and revising the care plans, but the nurses could update them. He/She obtained the information in the care plans by reviewing the residents' medical records, and interviewed with staff and residents or their family. He/She updated the care plans after each MDS assessment, and with changes in resident condition. The care plans should address pertinent diagnoses such as dementia, code statues, ADL needs and activity preferences. The MDS coordinator said he/she started the position in June and he/she noticed some of the care plans had not been reviewed and revised. During an interview on 09/08/23 at 11:55 A.M., the Administrator and Director of Nursing (DON) said the care plan should direct staff in the type of care the resident required, and should be updated with a change in status and quarterly. They said the care plan should be updated by the department head in which the change had occurred. They said they expected the care plan to address ADLs, codes status, activity preference, and pertinent diagnoses such as dementia. They said information in the care plan should be based on the Care Area Assessment (CAA) report. 45489

Based on observation, interview and record review, facility staff failed to maintain sanitary conditions for two resident's catheter tubing (Residents #5 and #51) of 19 sampled residents. Additional observation showed staffed failed to provide proper hand hygiene during care for two residents (Residents #11 and #51). The census was 86. 1. Review of the facility's Catheter Care, Urinary Policy, dated (MONTH) 2014, showed staff are instructed to check the resident frequently to be sure he or she is not lying on the catheter and to keep the catheter and tubing without kinks, and to be be sure the catheter tubing and drainage bag are kept off the floor. Staff should clean perineal area in circular [MEDICAL CONDITION] outward and change the position of the washcloth with each cleansing stroke. Review of Resident #51's significant change Minimum Data Set (MDS), a federally mandated assessment tool, dated 2/23/18, showed facility staff assessed the resident as follows: -Required extensive, two person assistance with bed mobility and transfers; -Required extensive, one person assistance locomotion on and off of the unit; -Required extensive, one person assistance with dressing, eating and hygiene; -Required total, two person assistance with toilet use and bathing; -Indwelling catheter. Observation on 04/03/18 at 3:04 P.M., showed the resident in his/her wheelchair in his/her room. His/her catheter tubing lay on the floor. Observation on 04/04/18 at 11:58 A.M., showed staff assisted the resident to the dining room. Further observation showed the resident's catheter tubing lay on the floor. Review of the resident's nurse's notes, dated 04/04/18, showed the resident's physician ordered staff to start the resident on [MEDICATION NAME] 500 mg one tab, twice daily, for 14 days for a Urinary Tract Infection. 2. Review of Resident #5's quarterly MDS, dated [DATE], showed staff assessed the resident as follows: -Totally dependent, and required one person assistance with toileting; -Required extensive, one person assistance with mobility and dressing; -Required limited, one person assistance with hygiene; -Foley catheter present. Observation on 04/04/18 at 12:15 P.M., showed the resident in the hallway in his/her wheelchair with his/her feet resting on the catheter tubing. Observation on 04/04/18 at 2:13 P.M., showed the resident in the hallway in his/her wheelchair with his/her feet resting on the catheter tubing. Additional observation showed multiple staff walked by, but did not assist the resident to move the tubing off the floor. 3. During an interview on 04/05/18 at 1:43 P.M., Certified Nursing Assistant (CNA) E said there is an attachment that allows staff to hook the tubing on the bag. He/She said when staff find the tubing is on the floor, they are to assist the resident to the bathroom to hook the tubing back on the bag. During an interview on 04/05/18 at 2:04 P.M. CNA C said catheter bags are to be placed in a privacy bag and the tubing should not touch the floor. He/She said staff should notify the charge nurse to change the tubing if it touched the floor. During and interview on 04/05/18 at 1:56 P.M., Licensed Practical Nurse (LPN) D said staff should make sure the tubing and bag doesn't touch the ground. The LPN said he/she expects staff to clean the tubing or have the nurse replace it, if it touches the ground. During an interview on 04/05/18 at 2:12 P.M., the DON and administrator said they expect staff to secure catheter bag in a dignity bag with the tubing off the floor. They said if the tubing is found on the floor, staff should disinfect it with a wipe or alcohol. The DON and administrator said if a resident is found standing on his/her catheter tubing, staff should disinfect and secure it. 4. Review of the facility's Personal Protective Equipment-Using Gloves Policy, dated (MONTH) 2010, instructs staff to use non-sterile gloves primarily to prevent the contamination of the employees' hands when providing treatment or services to the patient and when cleaning contaminated surfaces. Wash hands after removing gloves. Review of the facility's Handwashing/Hand Hygiene Policy, dated (MONTH) (YEAR), states staff are instructed to use a alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap and water for the following situation: before and after direct contact with residents and after removing gloves. Observation on 04/04/18 at 2:51 P.M., showed CNA B did not wash his/her hands after he/she removed his/her gloves after he/she provided incontinent care or before he/she placed a clean brief for Resident #11. Observation on 04/04/18 at 2:51 P.M., showed CNA A did not change the area of the washcloth with each cleansing stroking when he/she provided incontinent care for Resident # 11. Observation on 04/05/18 at 9:05 A.M., showed CNA C did not wash his/her hands after he/she removed his/her gloves during incontinent care for Resident #51. During an interview on 04/05/18 at 2:04 P.M. CNA C said staff are to clean in a circular motion and use a new area of the cloth with each wipe. He/She said staff should change their gloves after they clean the front, wash their hands in between gloves changes, and change gloves after dirty tasks and before a clean task. During an interview on 04/05/18 at 2:12 P.M., the DON and administrator said staff should use a new or clean spot on a wash cloth with each wipe during incontinence care , changes their gloves before the place a new brief and wash their hands after they take their gloves off and before they don new gloves.

Based on observation, interview and record review, the facility failed to serve food in accordance with the nutritionally calculated menus to residents who received consistent carbohydrate/low concentrated sweets (CCHO/LCS) and pureed diets. The facility census was 80. 1. Review of meal tray cards for Residents #16, #17, #18, #19, #20, #21, #22, #23, #24, #25 and #26 showed staff directed to provide the residents with a CCHO/LCS diet. Review of the facility menus, dated 02/23/17 (Day 26), showed staff directed to provide the residents on CCHO/LCS diets with three ounces of augratin potatoes. Observation on 02/23/17 during the noon meal service beginning at 11:30 A.M., showed Cook B served Residents #16 through #26, a #8 (four ounce) scoop of augratin potatoes (one ounce more than directed by the menus). During an interview on 02/23/17 at 12:20 P.M., Cook B said he/she reviewed the menus for portions sizes prior to service, but did not see that the residents on CCHO/LCS diets got a different portion of potatoes. During an interview on 02/23/17 at 12:23 P.M., the Dietary Manager (DM) said he/she expects staff to serve food in accordance with the menus and all cooks have been trained on that requirement. 2. Review of meal tray cards for Residents #2, #3, #7, 10, #11, #12, #27, #28, #29, #30, #31 and #32 showed staff directed to provide the residents with pureed diets. Review of the facility menus, dated 02/23/17 (Day 26), showed staff directed to provide the residents on pureed diets with a #20 (1.6 ounce) scoop of pureed buttered bread. Observation on 02/23/17 during the noon meal service beginning at 11:30 A.M., showed staff did not prepare or serve pureed buttered bread at directed by the menus. During an interview on 02/23/17 at 11:40 A.M., Cook B said he/she had worked at the facility for many years and they had never served pureed bread. The cook said the bread is pureed in with the vegetables. Review of the recipe for pureed broccoli and cauliflower showed staff directed to add one half slice of bread per serving when preparing the puree. During an interview on 02/23/17 at 12:23 P.M., the DM said the facility does not serve pureed bread because the bread is blended into the vegetables. The DM said he/she did not know even though the recipe said to add bread when preparing the pureed vegetables that they should provide the additional pureed bread if it was included on the menus.

Based on observation, interview, and record review, facility staff failed to offer fluids after providing care and/or treatments for eight dependent residents (Resident #1, #2, #3, #4,#7, # 11, #12, and #13) of 16 sampled resident and for one off-sampled resident (Resident #32). Additionally the facility failed to keep one resident (Resident #4) of 16 sampled, clean and dry. The facility census was 80. 1. Review of resident #1's quarterly minimum data set (MDS), a federally mandated assessment tool, dated 2/16/16, showed staff assessed the resident as follows: -Mild cognitive impairment; -Extensive assist of two staff members for transfers; -Extensive assist of one staff member for eating; Observation on 2/22/17 at 10:43 A.M., showed two unidentified staff members transferred the resident to bed, and Registered Nurse (RN) N provided wound care. The staff did not offer the resident any fluids before or after they provided care. 2. Review of Resident #2's quarterly minimum data set (MDS), a federally mandated assessment tool, dated 1/19/17, showed staff assessed the resident as follows: - Severely impaired cognition; - Dependent on two staff for transfers and bed mobility; - Extensive assistance of one staff for eating. Observation on 2/22/17 at 9:35 A.M., showed certified nursing assistant (CNA) A and CNA I provided perineal care to the resident. The staff did not offer the resident any fluids before or after they provided care. 3. Review of Resident #3's annual MDS, dated [DATE], showed staff assessed the resident as follows: -Cognition severely impaired; -[DIAGNOSES REDACTED]. -Required extensive assistance of two staff for bed mobility, transfers, dressing, personal hygiene, and toilet use; -Required extensive assistance of one staff to eat; -Uses a wheelchair; -Totally dependent on one staff for locomotion on unit (how resident moves between locations in his/her room and adjacent corridor on the same floor); -Impaired functional range in motion on both sides of his/her upper and lower extremities. Review of the resident's plan of care, dated 2/2/17, showed the following information: -Encourage good nutrition and hydration; -Liquids are pudding consistency. Observation on 2/21/17 at 12:17 P.M., showed the resident in the dining room. Observation showed staff assisted the resident to drink his/her thickened liquids. Observation on 2/23/17 at 11:08 A.M., showed CNA A and CNA C entered the resident's room to provide perineal care and transferred the resident from bed to his/her wheelchair. Additional observation showed no liquids in the resident's room and showed staff did not offer the resident any liquids before or after care. 4. Review of Resident #7's MDS, dated [DATE], showed staff assessed the resident as follows: -Severely impaired cognition; -Requires extensive assistance of one staff for bed mobility and transfers; -Dependent on one staff for locomotion (movement in wheelchair) in his/her room and surrounding areas; -Requires set up assistance of one staff for eating. Observation on 2/22/17 on 2:50 P.M., showed Certified Medication Technician (CMT) D and CNA E entered Resident #7's room to provide perineal care for the resident. After perineal care CMT D and CNA E assisted the resident into his/her wheelchair. Staff did not offer fluids to the resident during or after the completion of care. 5. Review of resident #11's quarterly MDS, dated [DATE], showed staff assessed the resident as follows: -Severe cognitive impairment -Extensive assist of two staff members for bed mobility, and transfers -Total dependence of one staff member for eating Observation on 2/22/17 at 3:30 P.M., showed CNA S and CNA T provided perineal care to the resident. Further observation showed the CNAs did not offer the resident any fluids before or after care was provided. 5. Review of Resident #12's MDS, dated [DATE], showed staff assessed the resident as follows: -Requires extensive assistance of two staff for transfers and bed mobility; -Requires extensive assistance of one staff to eat. Review of the resident's care plan dated 2/10/17, showed staff are directed the resident requires extensive assist with all ADL's. Observation on 2/24/17 at 10:23 A.M., showed CNA H and CNA I provided perineal care for the resident. Staff did not offer the resident any fluids during or after the completion of care. During an interview on 2/24/17 at 7:13 A.M., CNA C said CNAs do not offer the resident liquids throughout the day because the resident is a choking hazard. The CNA said he/she thinks the nurses provides the resident with liquids between meals. During an interview on 2/24/17 at 12:03 P.M., CNA L said CNAs are expected to offer fluids to residents between meals and if a resident receives thickened liquids, staff can go to the kitchen and request thickened liquids for the resident. During an interview on 2/24/17 at 12:52 P.M., licensed practical nurse (LPN) M said the nurses usually offer the resident liquids between meals. The LPN said the resident used to have thickened liquids scheduled at 10:00 A.M., and 2:00 P.M., but is not scheduled anymore due to staff being busy. The LPN said the thickened liquids would sit in the residents room and he/she would not get it, so now staff push more liquids at meal time. During an interview on 2/24/17 at 12:58 P.M., the director of nursing (DON) said he/she would expect staff to offer fluids anytime staff has contact with the residents. He/She said if the resident is on thickened liquids, CNAs and nurses can both offer and provide to the resident. The DON said he/she thinks CNAs see the nurses feed the resident during meal times and assume they cannot offer fluids between meals due to the residents issues with swallowing. 6. Review of Resident #13's MDS, dated [DATE], showed staff assessed the resident as follows: -Requires total assistance of one staff to eat; -Requires total assistance of two staff for transfers and bed mobility. Review of the resident's care plan dated 1/4/17, showed staff are directed the resident requires total assist with all ADL (Activities of Daily Living). The care plan also identified the resident needs assistance with meals. Observation on 2/24/17 at 9:41 A.M., showed CNA F and CNA G provided perineal care for the resident. Staff did not offer the resident any fluids during or after the completion of care. 7. Review of resident #32's quarterly MDS, dated [DATE], showed staff assessed the resident as follows: -Resident is rarely/never understood; -Total dependence on two staff members for bed mobility, and transfers; -Required extensive assistance of one person to eat. Observation on 2/22/17 at 9:13 A.M., showed CNA C and CNA L provided perineal care for the resident. Further observation showed CNA C and CNA L did not offer the resident any fluids before or after they provided care. 8. During an interview on 2/24/17 at 9:23 A.M., CNA J said staff are expected to provide fluids to dependent care residents every time care is provided. During an interview on 2/24/17 at 10:00 A.M., LPN K said staff should offer dependent care residents fluid every two hours, or when assisting them to use the restroom. During an interview on 2/24/17 at 12:03 P.M., CNA L said CNA's are expected to offer fluids to residents between meals and if a resident receives thickened liquids, staff can go to the kitchen and request thickened liquids for the resident. During an interview on 2/24/17 at 12:58 P.M., the director of nursing (DON) said he/she would expect staff to offer fluids anytime staff has contact with the residents. He/She said if the resident is on thickened liquids, CNA's and nurses can both offer and provide to the resident. 9. Review of Resident #4's significant change MDS), dated [DATE], showed staff assessed the resident as follows: - Moderately impaired cognition; -Requires extensive assistance of two staff for transfers, bed mobility, and toileting; -Requires extensive assistance of one staff for personal hygiene; - Frequently incontinent of bowel and bladder; - Presence of pressure ulcers. Review of the resident's care plan, last updated 12/15/17, showed staff are directed to assist with toileting and perineal/incontinence care every two hours and as needed. Review of residents Braden (an assessment used to assess risk of pressure ulcers) assessment dated [DATE] showed staff assessed the resident at an eight, very high risk for skin breakdown. Observation on 2/22/17 at 9:28 A.M., showed the resident sat in his/her Broda Chair (reclining chair on caster wheels) at the nurses' desk. Observation on 2/22/17 at 10:00 A.M., showed the resident sat in his/her Broda chair, at the nurses' desk. Observation on 2/22/17 at 11:00 A.M., showed the resident sat in his/her Broda chair, at the nurses' desk. Observation on 2/22/17 at 11:20 A.M., showed the resident sat in his/her Broda chair at the nurses' desk. Observation on 2/22/17 at 11:27 A.M., showed the resident sat in his/her Broda chair in the living room area with his/her family member. Observation on 2/22/17 at 12:00 P.M., showed the resident sat in his/her Broda chair at a dining room table. Observation on 2/22/17 at 12:55 P.M., showed staff propelled the resident in his/her Broda chair from the dining room to a common area near the nurses' desk. Observation on 2/22/17 at 1:20 P.M., showed the resident sat in his/her Broda chair in a common area near the nurses' desk. During an interview on 2/22/17 at 1:25 P.M., CNA H said, I don't know the last time I changed him/her (Resident #4). Observation on 2/22/17 at 1:55 P.M., showed CNA A and CNA H transferred the resident from his/her Broda chair to the bed. Observation showed the lift sling visibly wet, and the resident's pants wet in the center and back. Additional observation showed the resident's brief visibly saturated. The CNAs provided pericare. Observation showed the resident's front perineal area red, and the back perineal area red but blanchable with deep wrinkles in his/her skin from the wet brief. Wet pieces of the brief adhered to the resident's skin. The staff did not offer the resident a drink before or after they provided care to the resident. During an interview on 2/24/17 at 9:37 A.M., CNA H said he/she was assigned to provide care for the resident. He/She said he/she did not know how long it was before the resident was changed on 2/24/17. The CNA said he/she thought another staff might have provided incontinence care. He/She said the resident was really wet, and did not know how long he/she went without incontinence care. He/She said staff should have communicated better to make sure the resident didn't have to wait over two hours for incontinence care. The CNA said when staff enter a residents room they should offer residents a drink, and said I don't do it every time but I try.

Based on observation, interview and record review, the facility failed to provide an ongoing program of activities to meet the interests and physical, mental and psychosocial well-being for four dependent care residents (Residents #3, #4, #10,#12). The census was 80. 1. Review of Resident #3's annual minimum data set (MDS), a federally mandated assessment tool, dated 1/27/17, showed staff assessed the resident as follows: -Cognition severely impaired; -[DIAGNOSES REDACTED]. -Uses a wheelchair; -Enjoys listening to music and receiving baths. Review of the resident's plan of care, dated 2/2/17, showed staff identified the resident as having limited interest in activities. Additional observation showed the plan of care did not include any specific activities for staff to provide for the resident. Review of the resident's activities note, dated 11/1/16, showed staff documented the resident up per wheelchair with staff assist. Vision and hearing are good. Does not speak, but does say mama. Enjoys time in his/her room with the TV on. Faces window to see outdoors. Attends parties and social events and staff interaction. Family lives out of state and he/she is cheerful and cooperative. Review of the resident's activities note, dated 1/25/17, showed staff documented the resident up per wheelchair with staff assist. Vision and hearing are good. Does not speak, but does say mama. All needs anticipated per staff. Enjoys time in his/her room with the TV on. Faces window to see outdoors. Attends parties and social events and staff interaction. Family is not involved and he/she is cheerful and cooperative. Review of the resident's social services note, dated 1/24/17, showed staff documented the resident is confined to his/her bed or wheelchair. He/She doesn't attend many activities, but will stay in his/her room and listens to music. When sitting by the nurses station he/she gets excited and will scream, laugh, and repeat good girl. He/She doesn't communicate well and will just say good girl and momma. Review of the facility's December 2016 activities calendar showed the following scheduled activities: -12/1/16: Music activity at 6:30 P.M.; -12/6/16: Hermann Grade School Performance at 1:00 P.M.; -12/7/16: Music activity at 2:30 P.M.; -12/9/16: St. George Christmas Performance. Review of the resident's December 2016 activities calendar showed the resident did not participate in the activities scheduled on 12/1/16, 12/6/16, 12/7/16, and 12/9/16. Additional review of the resident's activities calendar showed the resident did not participate in any weekend activities for December 2016. Review of the facility's January 2017 activities calendar showed the following scheduled activities: -1/5/17: Music activity at 6:30 P.M.; -1/23/17: Sing Along activity at 2:00 P.M.; -1/25/17: Karaoke activity at 2:00 P.M.; -1/26/17: Name That Tune at 2:30 P.M. Review of the resident's January 2017 activities calendar showed the resident did not participate in the activities scheduled on 1/5/17, 1/23/17, 1/25/17, and 1/26/17. Additional review of the resident's activities calendar showed the resident participated in only one weekend activity during January 2017. Review of the facility's February 2017 activities calendar showed the following scheduled activities: -2/2/17: Music activity at 6:30 P.M.; -2/22/17: Karaoke activity at 2:00 P.M. Review of the resident's February 2017 activities calendar showed the resident did not participate in the activities scheduled on 2/2/17 and 2/22/17. Additional review of the resident's activities calendar showed the resident participated in only one weekend activity during February 2017. Observation on 2/21/17 at 2:13 P.M., showed the resident in his/her room and in bed with the TV on. Additional observation showed the resident looked out into the hallway, not at the TV. Staff did not position the resident to look out the window or engage the resident in any other activity. Observation on 2/22/217 at 9:17 A.M., showed the resident in his/her room and in bed with the TV on. Staff did not position the resident to look out the window or engage the resident in any other activity. Observation on 2/22/17 at 10:43 A.M., 11:15 A.M., 11:47 A.M., and 1:18 P.M. showed the resident in his/her wheelchair in his/her room, positioned in front of the TV. Observation showed the resident looked out into the hallway, not at the TV. Additional observation showed staff did not position the resident where he/she could look out his/her window and did not engage the resident in any other activity. Observation on 2/22/17 at 1:52 P.M., showed the resident in his/her room and in bed with the TV on. Additional observation showed the resident looked out into the hallway, not at the TV. Staff did not position the resident where he/she could look out his/her window or engage the resident in any other activity. Observation on 2/22/17 at 1:57 P.M., showed multiple residents listened to live karaoke in the activity room. Observation showed staff did not bring the resident to the activity. Observation on 2/22/17 at 2:48 P.M. and 3:03 P.M., showed the resident in his/her room and in bed with the TV on. Additional observation showed the resident looked out into the hallway, not at the TV. Staff did not position the resident where he/she could look out his/her window or engage the resident in any other activity. Observation on 2/23/17 at 10:50 A.M., showed the resident in his/her room and in bed with the TV on. Additional observation showed the resident looked out into the hallway, not at the TV. Staff did not position the resident where he/she could look out his/her window or engage the resident in any other activity. Observation on 2/23/17 at 11:49 A.M. and 12:05 P.M., showed the resident sat in hallway C by a hallway recliner chair. Additional observation showed no other residents or staff near the resident. Staff did not position the resident's chair to allow him/her to look out the door at the end of hallway C and did not engage the resident in any other activity. Observation on 2/23/17 at 12:55 P.M., showed the resident sat in his/her wheelchair in his/her room. Additional observation showed the resident's wheelchair positioned in front of the TV. Staff did not position the resident's chair to allow him/her to look out his/her window and did not engage the resident in any other activity. Observation on 2/23/17 at 3:32 P.M. and 4:48 P.M., showed the resident sat in hallway C between two hallway recliner chairs. Additional observation showed no other residents or staff near the resident. Staff did not position the resident's chair to allow him/her to look out the door at the end of hallway C and did not engage the resident in any other activity. Observation on 2/24/17 at 9:02 A.M., showed the resident in his/her room and in bed with the TV on. Additional observation the resident looked out into the hallway, not at the TV. Staff did not position the resident's chair to allow him/her to look out his/her window and did not engage the resident in any other activity. During an interview on 2/24/17 at 6:35 A.M., certified nursing assistant (CNA) C said the resident enjoys listening to music and sitting by the nurses station. CNA C said the resident can get loud, yells out, laughs, and gets excited when he/she sits by the nurses station. The CNA said he/she does not see staff doing any one on one activities with the resident. During an interview on 2/24/17 at 11:58 P.M., the AD (Activity Director) said the resident gets easily excited during activities. The AD said the resident likes big events, looking outdoors, or out the window at the end of his/her hall. The AD said staff know to take the resident to end of hall C to watch out the window. During an interview on 2/24/17 at 12:00 P.M., the social services director (SS) said the resident's family is not involved, the resident loves to stay in his/he room and listen to music, and the resident likes to look out the window. The SS said the resident can become over stimulated if the environment is too loud, but staff will sit the resident by the nurse's station or other social area until the resident becomes over stimulated. SS said staff provide one on one activities with the resident such as when they provide care and when staff talk with the resident. SS said the resident likes it when staff talk with him/her. During an interview on 2/24/17 at 12:08 P.M., CNA L said the resident likes to have his/her TV on, likes to go listen to live music, and enjoys sitting outside in the sun. The CNA said the resident can get agitated with a lot of activity, but staff would still take the resident to listen to music and take him/her back to his/her room if becomes too agitated. The CNA said he/she does not know of any one on one activities with the resident, but the resident usually attends group activities. During an interview on 2/24/17 at 12:52 P.M., licensed practical nurse (LPN) M said the resident watches TV in his/her room and staff will sometimes sit the resident at the end of the hall so he/she can look out the window. LPN M said the resident will sometimes go to the music activities and also likes to sit in the sun. The LPN said no one CNA is responsible to complete activities with the resident and it just depends on the CNA who is working. The LPN said charge nurses do not monitor resident activities. During an interview on 2/24/17 at 2:00 P.M., the director of nursing (DON) said he/she would expect more information about activities on the residents plan of care. The DON said he/she would expect staff to position the resident so he/she can look out the window, expects staff to take the resident to some group activities, and to complete one on one activities. 2. Review of Resident #4's significant change MDS, dated [DATE], showed staff assessed the resident as follows: Activity Preferences: -Reading books, newspapers, or magazines; -Listening to music; -Keeping up with the news; -Doing things with groups of people; -Participating in religious activities or practices. Review of the resident's care plan, last updated 12/15/16, showed the resident enjoys watching TV in his/her room. The care plan directed staff the resident also enjoyed music, news, doing things with groups of people, participating in religious activities or practices, and what church the resident attends. Review of a Social Service note dated 2/21/17, showed staff documented the resident likes to be in the activity room when things are going on. Review of the resident's activity and one on one program, dated December 2017, did not contain documentation of activities, or one on one programs for 27 calendar days out of 31 calendar days in December 2016. Documentation showed the resident did not attend eight events titled social and coffee time. Documentation showed the resident did not attend 11 events titled mass and/or religious activities. Documentation showed the resident did not attend music events on 12/1/16, 12/6/16. 12/7/16, 12/9/16, and 12/26/16. Documentation showed the resident did not attend the activity titled reminisce on 12/8/16 and 12/22/16. Review of the resident's activity and one on one program, dated January 2017, did not contain documentation of activities, or one on one programs for 26 calendar days out of 31 calendar days in January 2017. Documentation showed the resident did not attend 12 events titled social and coffee time. Documentation showed the resident did not attend 14 events titled mass and/or religious activities. Documentation showed the resident did not attend music events on 1/5/17, 1/23/17. and 1/25/17. Documentation showed the resident did not attend the activity titled reminisce on 1/19/17, or current events on 1/13/17. Review of the resident's activity and one on one program, dated February 2017, did not contain documentation of activities, or one on one programs for 20 calendar days out of 28 calendar days in February. Documentation showed the resident did not attend 15 events titled social and coffee time. Documentation showed the resident did not attend 10 events titled mass and/or religious activities. Documentation showed the resident did not attend music events on 2/2/17, and 2/27/17. Documentation showed the resident did not attend the activity titled reminisce on 2/16/17, or current events on 2/24/17. Observation on 2/21/17 at 2:05 P.M., showed the resident on his/her right side in his/her bed. Observation showed his/her privacy curtains were pulled shut. Observation showed his/her television to be on, on the other side of the curtain. His/Her call light hung from the privacy curtain out of his/her reach. Observation on 2/21/17 at 2:20 P.M., showed the resident on his/her right side in his/her bed Observation showed his/her privacy curtains were pulled shut. Observation showed his/her television to be on, on the other side of the curtain. His/Her call light hung from the privacy curtain out of his/her reach. Observation on 2/22/17 at 9:28 A.M., showed the resident sat in his/her Broda Chair (reclining chair on caster wheels). Observation showed the resident's chair positioned toward the nurses' desk, and not toward a television. Staff did not provide any reading material or music. Staff did not engage the resident in any other activity. Observation on 2/22/17 at 10:00 A.M., showed the resident sat in his/her Broda chair. Observation showed the resident's chair positioned toward the nurses' desk, and not toward a television. Staff did not provide any reading material or music. Staff did not engage the resident in any other activity. Observation on 2/22/17 at 11:00 A.M. and at 11:20 A.M., showed the resident sat in his/her Broda chair. Observation showed the resident's chair positioned toward the nurses' desk, and not toward a television. Staff did not provide any reading material or music. Staff did not engage the resident in any other activity. Observation on 2/22/17 at 12:55 P.M., showed the resident sat in his/her Broda chair. Observation showed the resident's chair positioned toward the nurses' desk, and not toward a television. Staff did not provide any reading material or music. Staff did not engage the resident in any other activity Observation on 2/22/17 at 1:20 P.M., showed the resident sat in his/her Broda chair. Observation showed the resident's chair positioned toward the nurses' desk, and not toward a television. Staff did not provide any reading material or music. Staff did not engage the resident in any other activity Observation on 2/23/17 at 10:30 A.M., 10:45 A.M., 11:00 A.M., and 11:20 A.M., showed the resident sat in his/her Broda chair. Observation showed the resident's chair positioned toward the nurses' desk, and not toward a television. Staff did not provide any reading material or music. Staff did not engage the resident in any other activity. Observation on 2/23/17 at 1:00 P.M., showed the resident sat in his/her Broda chair. Staff positioned the resident's chair toward the nurses' desk, and not toward a television. Staff did not provide any reading material or music. Staff did not engage the resident in any other activity. During an interview on 2/24/17 at 9:10 A.M., CNA F said activities staff tells them who to bring to activities. They usually take the dependent residents to music activities. The CNA said activity staff schedule music activities just about every week. Sometimes they sit the residents in the sun. The CNA said there are very few activities on the weekend, usually movie and popcorn, and church. Some of the alert residents play cards on the weekend. 3. Review of Resident #10's MDS, dated [DATE], showed staff assessed the resident as follows: -It is somewhat important to the resident to go outside when weather is good, and to do his/her favorite activities. Review of the facility's one on one activity log, dated 1/31/17 through 2/21/17, shows staff did not document the resident received any one on one activities other than family visits. Review of the resident's December activity calendar showed staff did not document any activities for the resident on Sundays and Mondays, and on all but one Wednesday, Thursday and Saturday. Staff did not document any activities for the resident on 26 of the 35 days on the activity calendar. Observation on 2/22/17 at 9:35 A.M., showed the resident in a wheelchair by the nurses' station. Observation showed staff did not interact with the resident, and did not offer any activities to the resident. Observation on 2/23/17 at 10:30 A.M., showed the resident in a wheelchair by the nurses' station. Further observation at 11:15 A.M., showed the resident in the same location and position. Staff did not interact with the resident and did not offer any activities to the resident. Observation on 2/23/17 at 4:55 P.M., showed the resident in a wheelchair by nurses station. Staff did not interact with the resident and did not offer any activities to the resident. Observation on 2/24/17 at 6:44 A.M. showed the resident in a wheelchair by nurses station. Staff did not interact with the resident and did not offer any activities to the resident Observation on 2/24/17 at 8:25 A.M. showed the resident in a wheelchair by nurses station. Staff did not interact with the resident and did not offer any activities to the resident 4. Review of Resident #12's MDS, dated [DATE], showed staff did not complete Section F, the activity and interest portion of the MDS. Staff assessed the resident with severely impaired vision. Review of the resident's care plan dated 2/10/17 showed the resident enjoys listening to books on tape. Review of the facility's one on one activity log, dated 1/26/17 through 2/22/17, showed staff did not document the resident received any one on one activities other than family visits. Review of the facility's December activity calendar for the resident showed staff did not document activities scheduled for Fridays, Saturdays or Sundays. Of the 36 days on the activity calendar, 20 of the days are blank for activities. Review of the facility's January activity calendar for the resident showed staff did not document activities scheduled on Thursdays, Saturdays, Sundays and most of the Mondays. Of the 35 days on the activity calendar, 22 of the days are blank for activities. Observation on 2/21/17 at 2:03 P.M., showed the resident lay in his/her bed, awake. Observation showed staff did not provide books on tape or any other activity. Observation on 2/22/17 at 2:20 P.M., showed the resident awake in bed. Observation showed staff did not provide books on tape or any other activity. Observation on 2/23/17 at 4:58 P.M. showed the resident sat reclined in a geri chair by the nurses' station. Observation showed staff did not provide books on tape or any other activity. Observation on 2/24/17 at 6:36 A.M. and 7:23 A.M., showed the resident sat reclined in a geri chair. Observation showed staff did not provide books on tape or any other activity. Observation on 2/24/17 at 9:19 A.M. showed the resident sat reclined in a geri chair by the nurse station. Observation showed staff did not provide books on tape or any other activity. 5. During an interview on 2/24/17 at 9:10 A.M., CNA F said activities staff tells them who to bring to activities. They usually take the dependent residents to music activities. The CNA said activity staff schedule music activities just about every week. Sometimes they sit the residents in the sun. The CNA said there are very few activities on the weekend, usually movie and popcorn, and church. Some of the alert residents play cards on the weekend. During an interview on 2/24/17 at 9:23 A.M., CNA J said he/she does not know what activities the facility provides for dependent residents on the weekend. During an interview on 2/24/17 at 10:00 A.M., LPN K said the CNA's and LPN's provide weekend activities, and there is an activity cart for dependent residents. The AD said there is a movie at 2 P.M. on Saturdays and church on Sundays. There is an activity cart as well. The AD said the CNA's assist dependent residents with the activity cart, but they do not document this. The AD said there is no direction given to the weekend staff for activities. During an interview on 2/24/17 at 12:55 P.M., the Administrator said staff are expected to bring dependent residents to activities they enjoy, they may be passive (just watch) during the activity. Activities staff are expected to do one on one visits and chart the one on one activities they do with the dependent residents. He/She said the care plan for each dependent resident should direct staff on the resident's preferred activities.

Based on observation, interview and record review the facility failed to properly assess pressure ulcers for one resident (Resident #1) of 16 sampled residents. Additionally the facility staff failed to properly administer insulin from an insulin pen for one additionally sampled resident (Resident #21). The facility census was 78. 1. Review of the Centers for Medicare & Medicaid Long-Term Care Facility Resident Assessment Instrument 3.0 Version 1.14, Section M, updated October 2016, showed: -For each pressure ulcer, determine the deepest anatomical stage. Do not reverse or back stage. Consider current and historical levels of tissue involvement. -Observe and palpate the base of any identified pressure ulcers present to determine the anatomic depth of soft tissue damage involved. -Ulcer staging should be based on the ulcer's deepest anatomic soft tissue damage that is visible or palpable. If a pressure ulcer's tissues are obscured such that the depth of soft tissue damage cannot be observed, it is considered to be unstagable (see Step 2 below). Review the history of each pressure ulcer in the medical record. If the pressure ulcer has ever been classified at a higher numerical stage than what is observed now, it should continue to be classified at the higher numerical stage. Nursing homes that carefully document and track pressure ulcers will be able to more accurately code this item. 2. Review of the National Pressure Ulcer Advisory Panel, dated September 2016, showed the following definitions: -Stage 2 pressure injury is a partial-thickness loss of skin with exposed dermis (the thick layer of living tissue below the top layer of skin that forms the true skin). The wound bed is viable, visible and deeper tissue are not visible. Granulation tissue (new connective tissue), slough (dead tissue in the process of separating from the body which is usually light colored, soft, moist, or stringy), and eschar (dead tissue that sheds or falls off from health skin) are not present; -Stage 3 pressure injury is a full thickness loss of skin, where adipose (fat) is visible in the ulcer and granulation tissue and rolled wound edges are often present. Slough and eschar may be visible, but do not obscure the extent of tissue loss. The depth of tissue damage varies by the location on the body. Undermining and tunneling may occur. Fascia (a thin sheath of fibrous tissue), muscle, tendon, ligament, cartilage or bone are not exposed; -Stage 4 pressure injury is a full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer. Slough and or eschar may be visible, but do not obscure the extent of tissue loss. Rolled edges, undermining and or tunneling often occur. Depth varies by location; 3. Review of resident #1's quarterly minimal data set (MDS), a federally mandated assessment tool, dated 12/16/16, showed staff assessed the resident as follows: -Stage four pressure ulcer present on admission -Stage four pressure ulcer present at time of assessment Review of the resident's wound assessment dated [DATE], shows staff staged the resident's coccyx (tailbone) pressure ulcer as a stage four. Review of the resident's wound assessments, dated 1/17/17 through 2/15/17, showed staff staged the resident's coccyx pressure ulcer as a stage two. Observation on 2/22/17, at 10:43 A.M., showed RN N perform wound care to coccyx ulcer. Ulcer measured 3.4 centimeters (cm) by 1.4 centimeters (cm). Observation showed the wound bed contained granulation (new healing and connective tissue) tissue and a small amount of slough (yellow, green or gray adherent dead tissue). During an interview on 2/22/17, at 10:43 A.M., RN N (Registered Nurse) said he/she uses the Point Click Care tool to stage wounds, and said the wound went from a stage four to a stage two. During an interview on 2/24/17, at 12:34 P.M., RN N said the resident's wound was a stage 4 on admission, and it is now a stage two. Furthermore RN N said it was appropriate to down stage the wound, and the physician did not question it. During an interview on 2/24/17, at 12:45 P.M., the Director of Nursing (DON) said to down stage a wound you must have a physician consultation. 4. Review of the facility policy for Insulin Administration, dated October 2010, showed the following: -Staff will have access to specific instructions (from the manufacturer if appropriate) on all forms of insulin delivery system(s) prior to their use. Review of the Manufacturer's Recommendations for use of the insulin pen, also used with the facility policy for use of the insulin pen, dated 2/2015, showed staff are directed: -Priming your [MEDICATION NAME]. Turn the dose selector to select 2 units -Hold the insulin pen with the needle pointing up. Tap the cartridge gently with your finger a few times to make any air bubbles collect at the top of the cartridge. -Keep the needle pointing upwards, press the push-button all the way in. The dose selector returns to zero. A drop of insulin should appear at the needle tip. If you do not see a drop in insulin repeat the 2 units to prime no more than 6 times. If you till do not see a drop of insulin change the needle and repeat the procedure no more than 6 times. - Turn the dose selector to select the number of units you need to inject. - Choose your injection site and cleanse with alcohol swab. - Insert the needle. - Press and hold the dose button until the dose counter shows 0. - Keep the needle in your skin after the dose counter has returned to 0 and slowly count to six - When the dose counter returns to 0 you will not get your full does until six seconds later. If the needle is removed before you count to six, you may see a stream of insulin coming from the needle tip. - Pull the needle out of your skin. Review of the resident's Physician's orders, dated 2/22/17, showed an order for [REDACTED]. Observation on 2/22/17 at 11:35 A.M., showed certified medication technician (CMT) D prepared an insulin flex pen for administration to the resident. The CMT said the current insulin pen had 17 units, so he/she would need a new pen to give the remaining 33 units of the 50 units ordered. He/She placed the needle on the first pen and dialed the pen to 17 units. The CMT did not prime the needle as directed. He/She placed the needle on the second pen. The CMT did not prime the needle as directed. Additional observation showed the CMT did not alternate sites, he/she administered both prepared needles to the resident's abdomen. The CMT did not wait six seconds after the dose counter returned to 0 before he/she removed the needle after both [MEDICATION NAME] administrations. Observation showed the CMT wiped clear fluid from the resident's abdomen after both [MEDICATION NAME] administrations. He/She did not give the insulin according to manufacturers guidelines to ensure the proper dose. During an interview on 2/22/17 at 11:38, CMT D said staff only have to prime the pen when it is new and he/she forgot to prime the new pen. He/She also said you pull the needle right out of the skin when the dose dial goes to 0. During an interview on 2/24/17 at 12:00 P.M., LPN K said staff are expected to prime each needle when you use a [MEDICATION NAME] or you lose 2 units with each needle. He/She said you have to hold the needle in the skin for five full seconds after the dose dial returns to 0 because the insulin is still coming out, and if you pull the needle out too soon the insulin will shoot out or run out on the skin because the [MEDICATION NAME] uses such a small needle. During an interview on 2/24/17 at 12:55 P.M., the director of nursing (DON) said staff are expected to prime the needle each time you use an insulin pen, and you should hold the needle in the skin 10 seconds after the dose dial returns to 0, to ensure the proper dose is delivered.

Based on observation, interview, and record review, facility staff failed to provide care and services to identify, treat, and prevent pressure ulcers for one resident (Resident #4) of 16 sampled residents. The facility census was 78. 1. Review of the National Pressure Ulcer Advisory Panel (NPUAP), dated September 2016, showed the following definitions: -Deep Tissue Pressure Injury (DTPI) is an area of intact or non-intact skin with localized area of persistent non-intact skin and/or with localized area of persistent non-blanchable deep red, maroon, purple discoloration or [MEDICATION NAME] separation revealing a dark wound bed or blood filled blister. This injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface. The wound may evolve rapidly to reveal the actual extent of tissue, injury, or may resolve without tissue loss. 2. Review of facility's policy for Prevention of Pressure Ulcers, dated February 2014, showed: -Pressure ulcers are usually formed when a resident remains in the same position for an extended period of time causing increased pressure or a decrease of circulation (blood flow) to that area and subsequent destruction of tissue. -The most common site of a pressure ulcer is where the bone is near the surface of the body including the back of the head around the ears, elbows, shoulder blades, backbone, hips, knees, heels, ankles, and toes. -Pressure ulcers are often made worse by continual pressure, heat, moisture, irritating substances on the resident's skin (i.e., perspiration, feces, urine, wound discharge, soap residue, etc.), decline in nutrition and hydration status, acute illness and/or decline in the resident's physical and/or mental condition. General Preventative Measures: -For a person in bed: change position at least every two hours or more frequently if needed; determine if resident needs a special mattress. -For a person in a chair: change position at least every hour; use foam, gel or air cushion to relieve pressure. -Refer resident to a rehabilitation program, or a restorative nursing program. -Encourage the resident to participate in active and passive range of motion exercises to promote circulation. -Contractures need to be addressed and managed to prevent skin integrity disruption -Every attempt should be made to float heels (keep heels off of the bed) by placing a pillow from the knee to ankle or with other devices as recommended by clinical staff or by the physician. -Risk factors include: moisture; friction and sheer; bed-fast/chair-fast; Immobility; bowel/bladder incontinence; poor nutrition; lowered mental awareness; 3. Review of Resident #4's significant change minimum data set (MDS), a federally mandated assessment tool, dated 12/1/16, showed staff assessed the resident as follows: - Moderately impaired cognition; - [MEDICAL CONDITION] (stroke) with [MEDICAL CONDITION] (paralysis on one side of the body); - Transferred with extensive assistance of 2 staff; - Bed mobility extensive assistance of 2 staff; - Toileting extensive assistance of 2 staff; - Hygiene extensive assistance of 1 staff; - Frequently incontinent of bowel and bladder; - Presence of pressure ulcers; - weight loss, not on a physician prescribed plan; Review of the resident's physician orders, dated 2/16/17, showed staff are directed to apply heel protectors at all times. Additional review showed the orders did not contain any orders for treatment to the resident's right heel. Review of the resident's care plan, last updated 12/15/17, showed staff are directed: - Complete weekly skin assessments and measure area weekly. Report any changes to the physician; - Provide peri care after incontinence. Apply protective ointment cream with peri care; - Turn and reposition every two hours and prn (as needed); - Anti pressure device to bed and wheelchair. Please make sure they are in place; - Keep heel protectors on at all times; - Report any changes to skin integrity the nurse and physician. Review of the resident's Braden assessment (an assessment used to assess risk of pressure ulcers), dated 2/21/17, showed staff assessed the resident at an eight, very high risk. Review of the resident's weekly skin assessment, dated 2/21/17, showed staff documented the resident with no skin issues and no open areas. Observation on 2/21/17 at 2:05 P.M., showed the resident on his/her right side in his/her bed. He/She did not have a pillow under his/her legs or heel protectors on. Observation on 2/21/17 at 2:20 P.M., showed the resident on his/her right side in his/her bed. His/Her call light hung from the privacy curtain out of his/her reach. He/She did not have a pillow under his/her legs or heel protectors on. Observation on 2/21/17 at 2:45 P.M., showed the resident on his/her right side in his/her bed. He/She did not have a pillow under his/her legs or heel protectors on. Observation on 2/22/17 at 9:12 A.M., showed the resident sat in his/her Broda chair (reclining chair on caster wheels), propelled by staff down the hall. He/She did not have any splints, pillows, or heel protectors on. His/Her heels rested directly on the foot rest of the Broda chair. Observation on 2/22/17 at 9:28 A.M. and 10:00 A.M., showed the resident sat in his/her Broda chair. He/She did not have any splints, pillows, or heel protectors on. His/Her heels rested directly on the foot rest of the Broda chair. Observation on 2/22/17 at 11:00 A.M. and 11:20 A.M., showed the resident sat in his/her Broda chair. He/She did not have any splints, pillows, or heel protectors on. His/Her heels rested directly on the foot rest of the Broda chair. Observation on 2/22/17 at 11:27 A.M., showed the resident sat in his/her Broda chair in the living room area with his/her family member. He/She did not have any splints, pillows, or heel protectors on. His/Her heels rested directly on the foot rest of the Broda chair. Observation on 2/22/17 at 12:00 P.M., showed the resident sat in his/her Broda chair at a dining room table. He/She did not have any splints, pillows, or heel protectors on. His/Her heels rested directly on the foot rest of the Broda chair Observation on 2/22/17 at 12:55 P.M., showed staff propelled the resident in his/her Broda chair from the dining room to a common area near the nurses' desk. He/She did not have any splints, pillows, or heel protectors on. His/Her heels rested directly on the foot rest of the Broda chair. Observation on 2/22/17 at 1:20 P.M., showed the resident sat in his/her Broda. He/She did not have any splints, pillows, or heel protectors on. His/Her heels rested directly on the foot rest of the Broda chair. During an interview on 2/22/17 at 1:25 P.M., CNA H said, I don't know the last time I changed him/her. Observation on 2/22/17 at 1:55 P.M., showed CNA A and CNA H transferred the resident from his/her Broda chair to the bed. Observation showed the lift sling visibly wet, and the resident's pants wet in the center and back. Additional observation showed the resident's brief visibly saturated. The CNAs provided pericare. Observation showed the resident's front perineal area red, and the back perineal area red but blanchable with deep wrinkles in his/her skin from the wet brief. Wet pieces of the brief adhered to the resident's skin. Additional observation showed the resident without heel protectors. Staff removed the resident's socks. Observation showed the resident's right inner heel with a dime sized area, deep red in the center with peeling skin around it. CNA A said the area felt hard and applied finger tip pressure and the area did not blanch (a red area should lose redness when touched). Additional observation showed the staff did not offer the resident a drink before or after they provided care to the resident. Observation on 2/24/17 at 9:25 A.M., showed RN N, CNA A, and CNA G provided care to the resident. Observation showed the resident's right inner heel with a dime sized area, dark reddish/purple in the center that did not blanch, with peeling skin around it. During an interview on 2/24/17 at 9:25 A.M., RN N said the area on the resident's right heel was like a hard cap and he/she assessed it as healed because it was like a callous. During an interview on 2/24/17 at 9:37 A.M., CNA H said he/she was assigned to provide care for the resident. He/She said he/she did not know was not sure how long it was before the resident was changed on 2/24/17. The CNA said he/she thought another staff might have provided incontinence care. He/She said the resident was really wet, and did not know how long he/she went without incontinence care. He/She said staff should have communicated better to make sure the resident didn't have to wait over two hours for incontinence care. The CNA said when staff enter a residents room they should offer residents a drink, and said I don't do it every time but I try. The CNA said the resident has not had his/her heel protectors for a month or so, and said staff are expected to float heels with a pillow if heel protectors are not available. During an interview on 2/24/17 at 12:00 P.M., LPN K said staff did not discontinue the resident's heel protectors. If the heel protectors are missing, staff should float the heels with a pillow. If there is a physician's orders [REDACTED]. Staff are expected to keep the residents clean and dry. Staff are expected to turn and reposition at least every two hours to prevent skin breakdown. During an interview on 2/24/17 at 12:55 P.M., the Director of Nursing (DON) said staff are expected to place heel protectors on the resident or float heels with pillows because he/she kicks off the heel protectors sometimes. Heel protectors are always available. The DON said a deep tissue injury is maroon or purple and can be hard, mushy, or thick skin. The DON said the area may heal and have nothing under it, or could become worse. He/She said staff are expected to check, change, and reposition residents at least every two hours.

Based on observation, record review, and interview facility staff failed to ensure the resident environment remained free of accident hazards when staff propelled 3 sampled residents (Resident's #33,#12,#34) of a sample of 34 residents in wheelchairs without foot rests, failed to complete entrapment assessments for three residents with side rails (Resident #2, #12, and #28), and failed to secure sharps, cleaning chemicals, medicated shampoos, and ointments in a manner to prevent resident access. The facility census was 80. 1. Observation on 2/22/17 at 12:08 P.M. showed Certified Nursing Assistant (CNA) C propelled Resident #33 in a wheelchair without footrests down the hall into the dining room. Observation showed the resident's feet slid on the floor. 2. Observation on 2/22/17 at 3:12 P.M. showed CNA Q propelled Resident #12 in a Broda (specialized reclining chair) Chair. Observation showed the resident's feet slid on the floor. 3. Observation on 2/24/17 at 9:21 A.M. showed CNA J propelled Resident #34 in wheelchair without foot rests down B hall to the activity room. Observation showed the resident's right foot bounced up and down on the floor as the CNA propelled him/her. During an interview on 2/24/17 at 9:23 A.M., CNA J said Resident #34 should have foot rests on his/her wheelchair when staff propel him/her, but the resident said he/she didn't need them. CNA J said if staff propel residents in wheelchairs, the residents should have foot rests on their wheelchairs. 4. During an interview 2/24/17 at 10:00 A.M., LPN K said staff should use footrests on residents' wheelchairs anytime staff propel them in their wheelchairs. During an interview on 2/24/17 at 12:55 A.M., The Director Of Nursing (DON) said staff should put foot rests on wheelchairs before they propel residents. 5. Review of Resident #1's medical records showed staff did not complete a required entrapment assessment for the use of side rails. Observation on 2/21/17 at 2:07 P.M., showed the resident lay in bed on his/her left side. Further observation showed both upper side rails in the up position on the bed. Observation on 2/22/17 at 10:43 A.M., showed staff transferred the resident to bed. Further observtion showed the resident's bed with both upper side rails in the up position on the bed. Observation on 2/22/17 at 12:03 P.M., showed the resident lay in bed on his/her right side. Further observation showed both upper side rails in the up position on the bed. Observation on 2/23/17 at 11:21 P.M., showed resident #1 laying in bed on his/her rigth side. Further observation showed both upper side rails up on bed. Observation on 2/24/17 at 9:12 A.M., showed resident in her room, in bed, with both upper side rails up. 6. Review of resident #2's medical records showed staff did not complete a required entrapment assessment for the use of side rails. Observation on 2/22/17 at 2:17 P.M., showed the resident in her/his bed asleep, with side rails on both upper sides of the bed up in the locked position. 7. Review of resident #12's medical records showed staff did not complete a required entrapment assessment for the use of side rails. Observation on 2/21/17 at 2:03 P.M., showed the resident lay in bed awake with both upper side rails up in a locked position. Observation on 2/22/17 at 2:20 P.M., showed the resident moved around in bed, with both upper side rails on his/her bed up in a locked position. 8. Review of resident #28's medical records showed staff did not complete a required entrapment assessment for the use of side rails. Observation on 2/21/17 at 2:06 P.M., showed the resident in bed asleep. One side of the resident's bed was pushed against the wall and a side rail up in the locked position on the other side of the bed. 9. During an interview on 2/24/17 at 12:55P.M., the Administrator said the side rails are up for different reasons, some residents are not safe in their room without them, and they may fall. The Administrator said he/she is not aware of any entrapment assessment requirements. 10. Observation on 2/21/17 at 12:21 P.M., showed the 600 Hall shower room unlocked and unattended. Further observation showed a tube of A& D ointment (an ointment used on skin), and a tube of protective ointment, laying on the back of the toilet unattended. Furthermore, the tubes of ointment had a printed warning that showed if swallowed get medical help or contact poison control center right away. Further observation showed a visibly soiled container of white powder, labeled cornstarch on shower room sink. Observation on 2/21/17 at 12:28 P.M., showed the 100/200 Hall shower room unlocked and unattended. Further observation showed a bottle containing a pink liquid labeled whirlpool disinfectant cleaner, twelve blue twin blade disposable razors, a bottle of dandruff control shampoo, and a bottle of prescription strength anti-dandruff shampoo with a prescription label which contained specific resident identification information. Further observation showed the whirlpool disinfectant and dandruff control shampoo with a printed warning that showed if ingested contact poision control center, or get medical help right away. Observation on 2/22/17 at 12:05 P.M., showed the 100/200 Hall shower room unlocked and unattended. Further observation showed a bottle of yellow whirlpool disinfectant, seven twin blade disposable razors, a tube of A&D ointment on the sink, and a bottle of prescription strength anti-dandruff shampoo with prescription label which contained specific resident identification information. Further observation showed the bottle of whirlpool disinfectant, A&D ointment, and anti-dandruff shampoo with a printed warning that showed if ingested contact poision control center, or get medical help right away. Observation on 2/22/17 at 12:07 P.M., showed the 600 Hall shower room unlocked and unatteded. Further observation showed a visibly soiled container, labeled cornstarch, which contained white powder substance, a tube of A&D ointment and a tube of protective ointment on the back of the toilet, with warning labels that read if swallowed, get medical help, or contact posion control center rigth away, four twin blade razors in unlocked unattended drawer, and a half empty box of razors sitting on the cabinet. Observation on 2/23/17 at 11:24 A.M., showed the 400/500 Hall shower room to be unlocked and unattended. Further observation showed two disoposable twin blade razors, and a bottle of classic whirlpool disinfectant. Observation showed the disinfectant with a warning label that read if swallowed, get medical help, or contact poison control center right away. Observation on 2/24/17 at 10:40 A.M., showed the 100/200 Hall shower room unlocked and unattended. Further observation showed twin blade disposable razors unlocked and unattended. During an interview on 2/22/17 at 9:13 A.M., CNA L said the shower rooms are never locked. Furthermore CNA L said that chemicals, and ointments should be locked on the shower carts. During an interview on 2/24/17 at 7:01 A.M., CNA H said the shower rooms are never locked, and said chemicals and ointments should be locked up in the bath carts. During an intervew on 2/24/17 at 9:26 A.M., LPN K said the shower rooms are not locked, and said chemicals and razors should be locked up. Furthermore, LPN K said he/she expects staff to keep razors and chemicals locked up. During an interview on 2/24/17 at 12:45 P.M., the Director of Nursing said she expects razors, disinfectants, ointments and other treatments to be locked up if unattended.

Based on observation, record review, and interview, facility staff failed to properly wash hands and change their gloves to prevent the spread of bacteria causing contaminants during the provision of care and treatments for six residents (Residents #2,#3,#7, #11,#12,#13) of 16 sampled residents. Additionally, facility staff failed to store residents oxygen cannulas and tubing and nebulizer masks for two residents (Resident #11 and #21) in an appropriate manner when not in use. The facility census was 80. 1. According to Infection Control Guidelines for Long Term Care Facilities (Section 3.0 Body Substance Precautions): *Dirty gloves are worse than dirty hands because micro-organisms adhere to the surface of a glove easier than to the skin of your hands. *Hand washing remains the single most effective means of preventing disease transmission; wash hands whenever they are soiled with body substance and when each resident's care is completed. 2. Review of the facility's Handwashing/Hand Hygiene policy, revised April 2012, showed staff are directed to wash their hands as follows: -Before and after direct resident contact; -Before and after dressing changes; -After handling soiled or used linens, dressings, bedpans, catheters and urinals; -After removing gloves or aprons. -Hand hygiene is always the final step after removing and disposing of personal protective equipment and the use of gloves does not replace hand washing/hand hygiene. 3. Review of the facility's Standard Precautions policy, Revised December 2007, showed staff are directed as follows: -Change gloves, as necessary, during the care of a resident to prevent cross-contamination from one body site to another (when moving from a dirty site to a clean one); -Remove gloves promptly after use, before touching non-contaminated items and environmental surfaces, and before going to another resident and wash hands immediately to avoid transfer of microorganisms to other residents or environments. 4. Observation on 2/22/17 at 9:35 A.M., showed Certified Nursing Assistant (CNA) H and CNA I entered Resident #2's room, washed their hands, and applied gloves. Observation showed CNA H provided perineal care, and continued to touch the residents skin and clean brief with his/her soiled gloves. The CNA removed his/her gloves, did not wash his/her hands and touched the resident's clean linens, pillows, call light, and bed controls. The CNA did not wash his/her hands and change his/her gloves during the provision of care in order to prevent the spread of bacteria. During an interview on 2/22/17 at 9:45 A.M., CNA H said staff are directed to wash their hands and change their gloves before working with a resident, between dirty and clean task, and every time they remove or change gloves. The CNA said he/she did not because he/she was nervous. 5. Observation on 2/22/17 at 2:20 P.M., showed Certified Medication Technician (CMT) D and CNA E entered Resident #7's room to provide perineal care. CNA E cleansed the resident's frontal perineal area, and touched the resident's privacy curtain, call light and clean brief with his/her soiled gloves. CNA E cleansed the resident's back perineal area, and touched the gait belt and resident's pants with the same soiled gloves. The CNA did not wash his/her hands and change his/her gloves during the provision of care in order to prevent the spread of bacteria. During an interview on 2/22/17 at 3:04 P.M., CNA E said staff should wash hands and put on gloves before care. The CNA said staff should change soiled briefs, dispose of the soiled brief, and wash hands before they leave the room. CNA E said he/she did not change gloves or wash his/her hands between soiled and clean items. 6. Observation on 2/22/17 at 3:30 P.M., showed CNA S and CNA T entered Resident #11's room and provided perineal care. Further observation showed CNA T wiped the resident's perineal area from back to front multiple times with the same soiled area of a cleansing wipe. During an Interview on 2/22/17 at 3:42 P.M., CNA T said staff are expected to wash their hands before and after they change their gloves. Furthermore CNA T said he/she is expected to wipe the perineal area down instead of up to prevent infection, and he/she should not continue to use a soiled cleansing wipe. 7. Observation on 2/23/17 at 11:08 A.M., showed Certified Nursing Assistant (CNA) A and CNA C entered Resident #3's bedroom to provide perineal care. Observation showed CNA A cleansed the residents front perineal area, turned the resident on his/her side, and wiped the residents backside. Observation showed CNA A, with the same soiled gloves, touched the residents bare leg, clean incontinence brief and clean clothing. The CNA did not change his/her gloves during the provision of care in order to prevent the spread of bacteria. During an interview on 2/23/17 at 12:00 P.M., CNA A said staff should change gloves when going from a dirty to clean task and said he/she should have changed his/her gloves after providing perineal care to the resident, but forgot because he/she was nervous. 8. Observation on 2/24/17 at 9:41 A.M., showed CNA F and CNA E entered Resident #13's room to provide perineal care. CNA F cleansed the resident's back perinal area and did not wash hands or change gloves before he/she applied [MEDICATION NAME] ointment (protective ointment) to the resident's perineal area. CNA F also handled the resident's clean brief with the same contaminated gloves. During an interview on 2/24/17 at 9:58 A.M., CNA F said staff should wash hands and change gloves between dirty and clean items. CNA F said he/she tried to use his/her other hand, but should have washed hands and changed gloves. 9. Observation on 2/24/17 at 10:23 A.M., showed CNA H and CNA I assisted Resident #12 to the restroom. CNA H cleansed the resident's back perineal area, and did not wash hands or change gloves before he/she cleansed the resident's front perineal area. CNA H handled the resident's clean brief and clean clothing with the same contaminated gloves. During an interview on 2/24/17 at 10:40 A.M. , CNA H said he/she should have washed his/her hands and changed gloves between back to front during perineal care, and between soiled and clean tasks. 10. During an interview on 2/24/17 at 12:58 P.M., the Director of Nursing (DON) said staff are expected to wash their hands when entering a residents room, between glove changes, and after leaving the residents room. The DON said he/she expects staff to change gloves when going from a dirty to clean task. 11. Observation on 2/23/17 at 10:42 A.M., showed resident #11's oxygen tubing undated and uncovered in his/her room. Further observation showed the oxygen tubing without storage for when not in use. 12. Observation on 2/23/17 at 1:07 P.M., showed resident #11 not in his/her room. Further observation showed the resident's oxygen tubing undated, and without storage for when not in use. 13. Observation on 2/24/17 at 6:45 A.M., showed a nebulizer mask and tubing lay uncovered on a table beside Resident #21's bed. 14. During an interview on 2/24/17 at 1:40 P.M., the (Director of Nursing) DON said nebulizer masks and oxygen tubing are to be stored in bags when not in use. The DON also said medication nebulizers should be cleansed, put on a paper towel to air dry, and then stored in a bag.

Based on observation, record review, and interview, the facility staff failed to provide appropriate assistance and foot support during wheelchair locomotion transport, to prevent future avoidable accidents, for four dependent residents (Residents #5, #10, #11, and #12), out of 15 sampled residents, and four dependent off sample residents (Residents #16, #17, #18, and #19). Facility staff failed to apply wheelchair foot rests to residents' wheelchairs, prior to assisting the residents relocate throughout the facility, failing to prevent future accidents. The facility census was 69. 1. Review of Resident #5's Quarterly Minimum Data Set (MDS), a federally mandated assessment instrument, dated 2/03/16, showed staff assessed the resident as follows: - Total assistance and one person physical assist for bathing activity; - Extensive assistance and two plus persons physical assist for transfers, toilet use, and hygiene; - Extensive assistance and one person physical assist for locomotion on and off of unit, dressing, and eating; - Uses a wheelchair. Review of the resident's plan of care, updated 11/04/15, showed staff planned the following interventions: - Resident requires extensive assist with Activities of Daily Living (ADL's); -Transfers with a hoyer lift and assistance of two; - Incontinent of bowel and bladder. To be toileted every two hours. Is not to be left alone on the toilet; - Total assistance of one for locomotion in a wheelchair; - Does not ambulate but stands up and down from wheelchair repeatedly. To be placed in front of a table in the sitting room so he/she can stand up and down as he/she wishes; - To be monitored closely; - To wear correct fitting shoes and socks; - Resident has the potential for falls with injury, due to a history of falls at home and in the facility, dementia, pain medication, antipsychotic medication, anxiety medication, decreased safety awareness, and resistance to care. Review of the resident's plan of care showed staff did not document interventions to direct staff regarding the application of foot rests when staff wheel the resident in his/her wheelchair. During an interview on 2/02/16 at 1:30 P.M., Registered Nurse (RN) A said the resident has a history of falls, and uses a wheelchair for locomotion. Observation on 2/02/16 at 5:10 P.M., showed Certified Nurse Aide (CNA) C propel the resident in his/her wheelchair from the sitting area at the nurse's station to the dining room. The resident did not have foot rests on the wheelchair, and the resident's feet slid along the floor while staff propelled the resident. Observation on 2/03/16 at 6:00 P.M., showed CNA C propel the resident in his/her wheelchair. Staff did not place the foot rests on the wheelchair and the resident's feet made a soft scuffing sound as his/her feet slid along the floor of the facility. Observation on 2/04/16 at 6:45 A.M., showed CNA F propel the resident from the sitting area by the nurse's station into the dining room. Staff did not place the foot rests on the wheelchair. The resident's feet slid on the floor as staff propelled him/her. During an interview on 2/04/16 at 6:55 A.M., CNA F said he/she did not know if the resident had foot rests for the wheelchair. The CNA said he/she did hear the resident's feet sliding on the floor and did not know if the resident put his/her feet down to stop the wheelchair propelled by staff. The CNA did not know of a policy regarding the use of foot rests on the wheelchair when a resident is propelled. 2. Review of Resident #18's Quarterly MDS, a federally mandated assessment instrument, dated 12/16/15, showed staff assessed the resident as follows: - Total assistance and one person physical assist for bathing activity; - Extensive assistance and one person physical assist for transfers, dressing, toilet use, and hygiene; - Limited assistance and one person assist for locomotion off of unit; - Uses a walker and wheelchair. Review of the resident's plan of care, last updated 01/01/16, showed staff planned the following interventions: - Resident requires extensive assist with ADL's, including oral care, dressing, bathing, toileting, ambulation, transfers and repositioning; - Uses wheelchair with set up assistance; - Resident has the potential for falls due to a history of falling, antidepressant medication, antipsychotic medication, unsteady gait, lack of safety awareness, confusion, lack of physical mobility, and impatient; - To have a personal alarm on at all times. Monitor frequently as the resident has the potential to remove his/her alarms; - Observe, record, and report all unsafe conditions and situations; Review of the resident's plan of care showed staff did not document interventions to direct staff regarding the application of foot rests when staff propel the resident in his/her wheelchair. Observation on 2/03/16 at 10:45 A.M., showed an unidentified staff member propel the resident to the dining room table in his/her wheelchair. The resident held his/her feet off the floor and touched the floor intermittently with his/her feet while staff propelled him/her. Observation on 2/04/16 at 7:15 A.M., showed CNA E propel the resident to the dining room in his/her wheelchair. The resident held his/her feet slightly above the floor and the wheelchair did not have foot rests. During an interview on 2/04/16 at 7:20 A.M., CNA E said he/she does not think there are foot rests for the resident's wheelchair. The CNA said the resident does not propel the wheelchair. The CNA is not sure about a policy for foot rests but does not think there is one. 3. Review of Resident 11's Quarterly MDS, a federally mandated assessment instrument, dated 12/02/15, showed staff assessed the resident as follows: - Extensive assistance and one person physical assist for transfers, dressing, toilet use, and hygiene; - One person physical assist for locomotion on and off of unit; - Uses a wheelchair. Review of the resident's plan of care, dated 12/07/15, showed staff planned the following interventions: - Resident requires supervision to extensive assist with ADL's, depending on the kind of day the resident is having; - Assess function level; - Uses wheelchair. Review of the resident's plan of care showed staff did not document interventions to direct staff regarding the application of foot rests when staff wheel the resident in his/her wheelchair. Observation on 2/03/16 at 4:38 P.M., showed an unidentified staff member wheel the resident in his/her wheelchair. The resident held his/her feet up while staff propelled him/her into the dining room. Staff did not put the foot rests on the resident's wheelchair. 4. Review of Resident #10's Admission MDS, a federally mandated assessment instrument, dated 1/27/16, showed staff assessed the resident as follows: - Extensive assistance and one person physical assist for transfers, dressing, toilet use, and hygiene; - Extensive assistance and one person physical assist for locomotion on and off of unit; - Uses a wheelchair. Review of the resident's plan of care, undated, showed staff planned the following interventions: - Requires supervision to extensive assist with ADL's, depending on the kind of day the resident is having; - Assess function level; - Uses wheelchair; - Resident has the potential for falls, injury, due to limited mobility; - Observe, record, and report all unsafe conditions and situations; - Encourage to ask for assistance. Review of the resident's plan of care showed staff did not document interventions to direct staff regarding the application of foot rests when staff wheel the resident in his/her wheelchair. During an interview on 2/02/16 at 1:12 P.M., RN A said the resident has a history of falls and uses a wheelchair for locomotion. Observation on 2/03/16 at 4:45 P.M., showed an unidentified staff member wheel the resident in his/her wheelchair. Observation showed staff did not place foot rests on the resident's wheelchair. The resident's feet made a soft scuffing sound as his/her feet slid along the floor of the facility. 5. Review of Resident #12's Quarterly MDS, a federally mandated assessment instrument, dated 12/02/15, showed staff assessed the resident as follows: - Extensive assistance and one person physical assist for transfers, dressing, toilet use, and hygiene; - Limited assistance and one person assist for locomotion on and off of unit; - Uses a walker and wheelchair. Review of the resident's plan of care, updated 12/07/15, showed staff planned the following interventions: -Requires supervision to extensive assist with ADL's, depending on the kind of day the resident is having; - Assess function level; - Therapy referrals as needed; - Extensive assistance with ambulation; - Uses wheelchair; - Resident has the potential for falls, injury, due to a history of falls; - Resident has the potential for falls due to unsteady gait, confusion, lack of safety awareness, use of antidepressant medications, and impaired vision; - Observe, record, and report all unsafe conditions and situations; - Encourage to ask for assistance. Review of the resident's plan of care showed staff did not document interventions to direct staff regarding the application of foot rests when staff wheeled the resident in his/her wheelchair. During an interview on 2/02/16 at 1:42 P.M., RN A said the resident uses a wheelchair for locomotion. Observation on 2/03/16 at 4:49 P.M., showed CNA B assist the resident in his/her wheelchair from the resident's room to the salad bar, in the main dining room of the facility. Further observation showed the resident's feet made a soft scuffing sound as his/her feet slid along the floor of the facility, for approximately 103 feet. During an interview on 2/03/16 at 4:52 P.M., CNA B said the resident does not have foot rests to use on his/her wheelchair. CNA B said the resident does not propel himself/herself, but uses his/her feet to rotate direction in his/her wheelchair. CNA B said he/she did not hear the resident's feet sliding across the floor, and staff did not instruct him/her to use foot rests to assist the resident with locomotion in his/her wheelchair. 6. Review of Resident #17's Quarterly MDS, a federally mandated assessment instrument, dated 1/19/16, showed staff assessed the resident as follows: - Extensive assistance and two plus persons physical assist for transfers, dressing, and toilet use; - Extensive assistance and one person physical assist for locomotion on and off of unit, and hygiene; - Uses a walker and wheelchair. Review of the resident's plan of care, undated, showed staff documented the resident utilizes a wheelchair for transportation. Further review showed staff did not document interventions to direct staff regarding the application of foot rests when staff wheeled the resident in his/her wheelchair. Observation on 2/03/16 at 5:45 P.M., showed the Director of Nursing (DON) wheel the resident in his/her wheelchair. Observation showed staff did not place foot rests on the resident's wheelchair. The resident's feet made a soft scuffing sound as his/her feet slid along the floor of the facility. During an interview on 2/03/16 at 5:50 P.M., the DON said the resident has foot rests for his/her wheelchair. The DON said the resident uses his/her feet to rotate direction in his/her wheelchair. She said she instructs staff to use foot rests to assist the resident with locomotion in his/her wheelchair. 7. Review of Resident #16's admission MDS, a federally mandated assessment instrument, dated 1/27/16, showed staff assessed the resident as follows: - Extensive assistance and one person physical assist for transfers, dressing, toilet use, and hygiene; - Extensive assistance and one person physical assist for locomotion on and off of unit; - Uses a wheelchair. Review of the resident's plan of care, undated, showed staff planned the following interventions: - Requires supervision to extensive assist with ADL's, depending on the kind of day the resident is having; - Assess function level; - Extensive assistance with ambulation; - Uses wheelchair; - Resident has the potential for falls, injury, due to lack of mobility; - Observe, record, and report all unsafe conditions and situations; - Encourage to ask for assistance. Review of the resident's plan of care showed staff did not document interventions to direct staff regarding the application of foot rests when staff wheeled the resident in his/her wheelchair. Observation on 2/04/16 at 6:56 A.M., showed Licensed Practical Nurse (LPN) D wheel the resident in his/her wheelchair. Observation showed staff did not place foot rests on the resident's wheelchair. The resident's feet made a soft scuffing sound as his/her feet slid along the floor of the facility. During an interview on 2/04/16 at 7:00 A.M., LPN D said the resident does not have foot rests for his her wheelchair. LPN D said the resident uses his/her feet to rotate direction in his/her wheelchair. LPN D said staff should use foot rests to assist the resident with locomotion in his/her wheelchair. 8. Review of Resident #20's Quarterly MDS, a federally mandated assessment instrument, dated 12/29/15, showed staff assessed the resident as follows: - Extensive assistance of one with most ADLs, including transfers, locomotion, dressing, and toileting; - Does not ambulate; - Uses a wheelchair; - One fall since admission. Review of the resident's plan of care, undated, showed the staff planned the following interventions: - Increased risks for falls due to a history of falls; - Increased potential for falls due to Parkinson's disease, short term memory loss, lack of safety awareness, and unsteady gait; - Locomotion with a wheelchair; - Call light within reach and encourage to ask for assistance; - Monitor closely; - Pressure alarm on at all times. The nurse will check the functioning of the alarms once a shift. - The CNA's will monitor alarm placement during personal cares. Has the ability to take off or silence the alarm; - Notify physician and family of any falls; - Provide extensive assistance with ADLs, including ambulating, locomotion, transferring and toileting. Observation on 2/4/16 at 6:55 A.M., showed CNA C propel the resident to the dining room without foot rests on his/her wheelchair and the resident's feet skimmed the floor. 9. Review of Resident #19's Quarterly MDS, a federally mandated assessment instrument, dated 11/11/15, showed staff assessed the resident as follows: - Extensive assistance and two plus persons physical assist for transfers, dressing, toilet use, and hygiene; - Extensive assistance and one person physical assist for locomotion on and off of unit; - Impairment on one side, lower extremity; - Uses a wheelchair. Review of the resident's plan of care, updated 12/07/15, showed staff planned the following interventions: - Requires supervision to extensive assist with ADL's, depending on the kind of day the resident is having; - Assess function level; - Therapy referrals as needed; - Extensive assistance with ambulation; - Uses wheelchair; - Resident has the potential for falls, injury, due to a history of falls; - Resident has the potential for falls due to unsteady gait, confusion, lack of safety awareness, use of antidepressant medications, and impaired vision; - Observe, record, and report all unsafe conditions and situations; - Encourage to ask for assistance. Review of the resident's plan of care showed staff did not document interventions to direct staff regarding the application of foot rests when staff wheel the resident in his/her wheelchair. Observation on 2/04/16 at 7:20 A.M., showed LPN G wheel the resident to the restorative dining room in his/her wheelchair. The resident's left lower leg was amputated and the wheelchair did not have a leg support or foot rest for the resident's right leg. During an interview on 2/04/16 at 7:25 A.M., LPN G said he/she did not know of a policy for using foot rests when propelling a resident in a wheelchair. He/She said he/she could not find the foot rests for the resident's wheelchair. He/She said he/she has seen residents in other facilities put their feet down when being pushed in a wheelchair. 10. During an interview on 2/14/16 at 8:10 A.M., the Physical Therapy Assistant (PTA) said the therapists want nursing staff to encourage the residents to use their legs as much as possible, however he/she expects a resident to have foot rests when wheeled by a staff member to avoid possible injury. 11. During an interview on 2/04/16 at 10:00 A.M., the administrator said the therapy department evaluates residents during the first 24 hours after admission to determine which devices are best for the resident, including the use of foot rests.

Based on observation, interview, and record review licensed staff failed to follow professional standards of quality to ensure medications were stored and monitored in a safe and effective manner by failing to dispose of expired and outdated medications stored in the medication room and on the medication carts. The facility also failed to date medications upon opening. The facility census was 71. Review of The United States Pharmacopoeia Dispensing Information (USPDI) showed an in-use vial of any [MEDICATION NAME] (liquid made from or resembling water) preserved sterile product, which includes insulin, be used within 28 days due to the risk of contamination. Review of the manufacturer's recommendations for storage of the serum showed vials in use more than 30 days should be discarded due to possible oxidation and degradation which may affect potency. 1. Observation on 2/03/16 at 9:00 A.M., of Medication Room ABC, showed the following expired and outdated items in the medication room and cart: -Two bottles of liquid [MEDICATION NAME] (a controlled medication in a multidose bottle) stored in an unlocked refrigerator in the medication room; - One bottle of [MEDICATION NAME], opened 9/7/15; - Two [MEDICATION NAME] Suppositories Expired 1/2016; - 12 [MEDICATION NAME] AC 25 milligram (mg) suppositories with no date; - Two open bottles of [MEDICATION NAME] eye drops with no open date; - One bottle of artificial tears Expired 6/27/15; - Open bottle of [MEDICATION NAME] 1% with no open date; - One bottle of opened [MEDICATION NAME] DM with no open date and expiration date of 1/2016; - One bottle of Daily Vitamins Expired 12/2015 - Opened bottle of Silace syrup with no open date; - Opened bottle of Latanoprost 0.005% eye drops with no open date; - One open bottle of Calcitonin Nasal Spray with no open date. The label reads the drug expires six weeks from opening; - One open tube of [MEDICATION NAME] Ophthalmic Ointment with no open date; - One open bottle of ear wax removal drops with no open date; - One prescription bottle of medication labeled [MEDICATION NAME] with the residents name torn off. 2. Observation on 2/03/16 at 10:00 A.M., of Medication Room DEF, showed the following expired and outdated medications in the medication room and cart: - One bottle of Levimir Insulin with the open date of 10/29/15; - Two open Levimir Insulin pens with no open date; - One bottle of Humalog Insulin with no open date; - Three refrigerated specimen collection tubes with expiration of 2/01/16; - One bottle of open saline with no open date; - One open bottle of Dry Eye Drops with no open date; - One open bottle of [MEDICATION NAME] eye drops with no open date; - One open bottle of [MEDICATION NAME] eye drops with no open date; - One open bottle of [MEDICATION NAME] eye drops with no open date; - One open bottle of Dorzolamide eye drops with no open date; - One open bottle of [MEDICATION NAME] with no open date; - One open tube of [MEDICATION NAME] 0.5% eye ointment with no open date; - One open tube of Puralube eye ointment with no open date; - One open bottle of [MEDICATION NAME] Z 0.004% with no open date; - Three open bottles of [MEDICATION NAME] with no open date; - One open bottle of Flusone with no open date; - One open bottle of saline nasal spray with no open date; - One open bottle of [MEDICATION NAME] with no open date. 3. During an interview on 2/3/16 at 11:00 A.M., Registered Nurse (RN) A said when a new bottle of medication is opened it is to be dated and initialed by the person opening it. Some medications expire within 30 days of opening and an expiration date should be put on those medications. Expired medications should be disposed of. The pharmacist comes monthly and inspects the medication rooms, checking the expiration dates. The pharmacist informs the nursing staff of expired medications and the nursing staff disposes of them. During an interview on 2/4/16 at 8:30 A.M., Licensed Practical Nurse (LPN) D said anytime a new bottle of medication is opened it should be dated and initialed.

Based on interview and record review, facility staff failed to administer cardiopulmonary resuscitation (CPR) to one full code resident (Resident #1) in a review of three residents requesting CPR after the resident experienced a change in condition and staff assessed the resident with "no respirations and no vital signs". The facility census was 84. 1. Review of the facility policy on CPR, Revised [DATE], under the section titled "Policy Interpretation and Implementation" showed section nine directed staff as follows: - "If an individual is found unresponsive and not breathing normally, a licensed staff member who is certified in CPR/BLS (basic life support) shall initiate CPR unless: a. It is known that a Do Not Resuscitate (DNR) order that specifically prohibits CPR and/or external defibrillation exists for that individual; or b. There are obvious signs of irreversible death (e.g., rigor mortis)." Review of the facility policy on CPR under the section titled "Emergency Procedure-Cardiopulmonary Resuscitation" showed section three directed staff to "Begin CPR if the adult victim is unresponsive and not breathing normally (ignoring occasional gasps) without assessing the victim's pulse." Review of Resident #1's "Outside the Hospital Do-Not-Resuscitate Order" showed the resident's representative signed on [DATE] to revoke the declaration to withhold CPR in the event of cardiac or respiratory arrest. Review of the resident's most recent Minimum Data Set (MDS), a federally mandated comprehensive assessment tool, dated [DATE], showed staff assessed the resident as follows: -had clear speech and was able to make self understood; -knew the year, and knew the month within five days; -did not walk and was totally dependent on staff for transfers; -had [DIAGNOSES REDACTED]. Review of the resident's most recent physician order sheet (POS), dated "[DATE]", showed "FULL CODE " at the top of the page. Review of the resident's nursing notes, dated [DATE], showed: -At 7:22 A.M. Licensed Practical Nurse (LPN) F documented administering an as needed (PRN) pain medication; -At 8:20 A.M. LPN F documented the result of the PRN pain administration as "no further complaints." -At 9:05 A.M. LPN F documented the resident died at 8:25 A.M. -At 9:20 A.M. LPN F documented the resident was up in his/her wheelchair for breakfast and accepted oral medications. LPN F also wrote "Certified Nurse Aide (CNA)s transferred resident to bed with hoyer and became unresponsive, resident was cyanotic (blue/purple appearance of skin due to low oxygen levels at surface of skin) with no respirations and no vital signs." -At 11:45 A.M. LPN F documented he/she notified the physician at 8:45 A.M. During an interview on [DATE] at 1:26 P.M., CNA B said he/she and CNA G assisted the resident to bed on [DATE] after breakfast. While up in the mechanical lift the resident "suddenly turned blue". CNA B said the resident turned blue, but still had shallow breaths with occasional gasps. CNA B said he/she got LPN F and LPN F came in and measured the resident's vitals which were "normal". CNA B said he/she checked the resident's pulse at this time and the resident had a weak pulse that went away in about one minute. CNA B said LPN F checked the resident's vital signs three times. CNA B said the resident "still had a blood pressure even though he/she had no pulse" and "appeared dead". CNA B said LPN A came in with CPR supplies, but LPN A said the resident "was gone." During an interview on [DATE] at 1:52 P.M., CNA G said on [DATE] after breakfast as he/she and CNA B wheeled the resident to his/her room, the resident appeared blue and unresponsive. CNA G said when they transferred him/her to bed, he/she appeared "really blue", so they got LPN F. CNA G said LPN F took the resident's vital signs, but the resident had no vital signs. CNA G said LPN F got LPN A who also checked the resident's vital signs and LPN A said the resident was "already gone". During a telephone interview on [DATE] at 2:42 P.M., LPN F said right after breakfast on [DATE], the aides called him/her to the resident's room. LPN F said he/she found the resident with a "weak blood pressure, but no pulse or respiration, and gray in color." LPN F said he/she did not start CPR on the resident because the resident had no pulse or respiration and he/she "was already gone." LPN F said he/she did not know when the resident stopped breathing or having a pulse and he/she did not ask the aides about this. LPN F said prior to [DATE], if he/she came upon a resident with a full code status (resident who requests CPR) with no pulse or respiration and skin discoloration; he/she would not have performed CPR. During an interview on [DATE] at 1:15 P.M., LPN A said staff called him/her and LPN F to the resident's room. LPN A said the resident was "completely gray" and had no pulse or respiration. LPN A said he/she did not perform CPR on the resident. LPN A said LPN F took a blood pressure device which measured "something incredibly low like ,[DATE]", but LPN A said he/she did not understand the low reading given the resident "was completely gray and obviously appeared dead." LPN A did not know whether the resident was cold or had rigor mortis at the time. LPN A said CNA B and CNA G were present in the room during this event. LPN A said the resident did not display distress prior to this event and said the resident ate breakfast and took his/her medications that morning. During an interview on [DATE] at 2:06 P.M., LPN A said if he/she came upon a resident with no pulse and no respiration, he/she would not perform CPR on that resident. LPN A said he/she would only perform CPR on a resident that he/she observed declining to the point of not having a pulse. During an interview on [DATE] at 2:20 P.M., LPN A said he/she was not aware if staff notified the resident's physician at the time of the incident. LPN A said he/she checked the resident's code status and by the time he/she got down there, the resident had no pulse or respiration and looked gray. LPN A did not know when the resident turned blue and said he/she did not ask the aides when the resident stopped breathing or turned blue. During an interview on [DATE] at 12:42 P.M., LPN A said he/she did not recall any training the facility provided about when to initiate CPR or when to contact the physician during the process. LPN A said he/she did not know if the facility had a policy regarding CPR. During an interview on [DATE] at 1:05 P.M., LPN C said he/she did not recall any training the facility provided about when to initiate CPR or when to contact the physician during the process. LPN C said he/she did not know if the facility had a policy regarding CPR. During a telephone interview on [DATE] at 2:14 P.M., LPN D said he/she did not recall any training the facility provided about when to initiate CPR or when to contact the physician during the process. LPN D said he/she did not know if the facility had a policy regarding CPR. During a telephone interview on [DATE] at 2:22 P.M., LPN E said he/she did not recall any training the facility provided about when to initiate CPR or when to contact the physician during the process. LPN E said he/she did not know if the facility had a policy regarding CPR. During a telephone interview on [DATE] at 2:42 P.M., LPN F said he/she did not recall any training the facility provided about when to initiate CPR or when to contact the physician during the process. LPN F said he/she did not know if the facility had a policy regarding CPR. During a telephone interview on [DATE] at 3:41 P.M., CNA G said he/she did not recall any training the facility provided about when to initiate CPR. CNA G said he/she did not know if the facility had a policy regarding CPR. CNA G said he/she did not initiate CPR on the resident, because he/she was afraid and called the nurse to assist. During an interview on [DATE] at 1:40 P.M., the director of nursing (DON) said staff are trained in CPR through a hospital course. She said she could not recall any training the facility provided about the facility CPR policy or on when to initiate CPR. The DON said staff could access the facility's CPR policy by looking in the policy and procedure manual located at the nurse's station. When asked how they ensure staff know when to initiate CPR, she said nurses learn this as part of their training to be nurses; she said she expected them to know this. Review of LPN A, LPN F, and CNA G's copies of CPR certification cards showed all had "successfully completed and competently performed the required knowledge and skill objectives for this program". These cards showed the training occurred in [DATE] and showed an expiration date of [DATE]. During a telephone interview on [DATE] at 12:30 P.M., the resident's attending physician said when CPR needs to be provided, he would expect staff to initiate the CPR, call EMS (emergency medical services), and then call him/her after that. The attending physician said staff notified him/her that the resident had died , but did not provide details. The resident's attending physician said if staff find a resident with a full code status without a pulse and without respiration, but rigor mortis has not set in or been determined, he/she would expect staff to begin CPR. The resident's attending physician said if there were no signs a resident with a full code status had been dead for awhile like rigor mortis or a cold body, then it would be out of the scope of practice for a nurse to decide not to perform CPR, if he/she came upon a resident without a pulse or respiration. NOTE: At the time of the abbreviated survey, the violation was determined to be at the immediate and serious 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 address and lower the violation at the time. During the onsite visit, the facility immediately in-serviced LPN A, posted in-service information on initiating CPR and contacting the physician/emergency services during the process, and began a program of in-servicing all licensed staff prior to their next shift on CPR initiation and notifying emergency service/physician. The facility is continuing to inservice all licensed nurses on the CPR policy including when to initiate CPR. 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 be taken to address Class I violation(s). MO 892