Every finding on record at Stonebridge Westphalia

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 at risk of exposure which could lead to illness.The facility census was 54 with a capacity of 64.1. 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, cooling 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.2. Observation on 07/23/25 during the Life Safety Code tour showed the facility ice machine contained a filter dated 03/27/24.3. Review of the facility's Legionella Water management program, reviewed April 2025, showed:-The program did not contain facility specific policies related to water management for the prevention of Legionella;-The program did not identify members of the water management team;-Facility staff identified shower heads, sinks and ice machines as potential risk areas for the growth of Legionella;-Control measures included replacement of ice machine filter on a regular schedule. Review showed the documentation did not specify a frequency related to a regular schedule;-The program did not contain control measures related to sinks or shower heads;-The program did not contain actions to be taken when the specified control limits were not met.Review of the ice machine filter manufacturer's specifications showed filter changes were recommended every year. During an interview on 07/24/25 at 11:30 A.M., the Environmental Services Director said he/she and the administrator were responsible for the water management program. The director said he/she was familiar with the water management program, but he/she had not looked at it lately. The director said his/her staff flushed low use water areas in the facility but did not document the flushes. The director said he/she was not familiar with any risk areas other than low use areas. The director said he/she was responsible for changing the ice machine filter every six months, but he/she got busy with other things and missed the filter change.During an interview on 07/24/25 at 1:00 P.M., the administrator said he/she is responsible for the facility's Legionella program. The administrator said he/she started reviewing and updating the program in April 2025, but he/she had not completed the review. The administrator said the water management team included the Environmental Services Director, the Director of Nursing and himself/herself, but the team did not have regular meetings. The administrator said he/she was aware of facility risk areas, but he/she did not realize the risk areas lacked control measures, corrective actions and monitoring mechanisms. The administrator said the Environmental Services Director is responsible for changing the ice machine filter according to manufacturer's recommendations.

Based on observation, interview and record review, facility staff failed to ensure residents who are unable to carry out activities of daily living received the necessary services to maintain good grooming and personal hygiene for three (Resident #9, #10, and #15) out of five sampled residents who required assistance with bathing as scheduled. The facility census was 54. 1.Review of the facility's Bath, Shower/Tub policy, dated February 2018, showed the policy directed staff to document:-The date and time the shower/tub bath was performed;-The name and title of the individual who assisted the resident with the shower/tub bath;-All assessment data obtained during the shower tub/bath;-If the resident refused the shower/tub bath, the reason and the intervention taken;-The signature and title of the person recording the data. 2. Review of Resident #9's Annual Minimum Data Set (MDS), a federally mandated assessment tool, dated 07/16/25, showed staff assessed the resident as:-Cognitively impaired;-No behaviors or rejection of care;-Required substantial to maximum assistance for showers/tub baths;-Required partial to moderate assistance for shower/tub bath transfers;-Diagnosis of dementia. Review of the resident's care plan dated 07/23/25, showed staff assessed the resident required assistance with all activities of daily living. Review of the facility's shower schedule, undated, showed the resident scheduled to receive a shower every Monday and Thursday.Review of the resident's shower record from 04/23/25 through 07/23/25, showed the record did not contain documentation the resident received a shower/tub bath on 04/24, 04/28, 05/22, 05/26, 05/29, 06/05, 06/12, 06/16, 06/19, 06/23, 06/26, 06/30, 07/03, 07/07, 07/10, 07/17 and 07/21/25. Review of the medical record showed one unsigned, undated shower sheet with refused handwritten on it for the period of 04/23/25 through 07/23/25. Observation on 07/22/25 at 10:33 A.M., showed the resident with a foul odor. Observation on 07/23/25 at 02:06 P.M., showed the resident in bed with a foul odor. 3. Review of Resident #10's Quarterly MDS, dated [DATE], showed staff assessed the resident as:-Severely cognitively impaired;-Had verbal and physical behaviors one to three days in the look-back period;-No rejection of care;-Impaired range of motion in all extremities;-Dependent on staff for shower/tub baths and transfers;-Diagnosis if dementia.Review of the resident's care plan, dated 06/09/25, showed staff are directed to assist the resident with all activities of daily living to ensure they are completed adequately. Review of the facility's shower schedule, undated, showed the resident scheduled to receive a shower every Monday and Thursday.Review of the resident's shower record from 04/23/25 through 07/23/25, showed the record did not contain documentation the resident received a shower/tub bath on 04/24, 05/01, 05/08, 05/15, 05/19, 05/22, 05/29, 06/02, 06/05, 06/12, 06/16, 06/19, 06/23, 06/26, 06/30, 07/03, 07/17, and 07/21/25.Observation on 07/22/25 at 2:09 P.M., showed the resident reclined in a specialized wheelchair with greasy hair and long facial hair.Observation on 07/23/25 at 8:23 A.M., showed the resident in the dining room with greasy hair and long facial hair. During an interview on 10:57 A.M., Certified Nurse Aide (CNA) C said the resident can be resistive during shaves and staff may need to stop care but thinks it should be documented somewhere if the resident does that. 4. Review of Resident #15's Quarterly MDS, dated [DATE], showed staff assessed the resident as:-Cognitively impaired;-No behaviors or rejection of care;-Required supervision to touch assist for shower/tub bath and transfers;-Diagnosis of depression.Review of the resident's care plan, dated 06/23/25, showed staff are directed to assist the resident. Review of the facility's shower schedule, undated, showed the resident scheduled to receive a shower every Monday and Thursday.Review of the resident's shower record from 04/23/25 through 07/23/25, showed the record did not contain documentation the resident received a shower/tub bath on 04/24, 04/28, 05/01, 05/15, 05/26, 06/05, 06/12, 06/19, 06/23, 06/26, 07/10, and 07/21/25.Observation on 07/22/25 at 10:27 A.M., showed the resident in bed with family at bedside. The resident had a foul odor.During an interview on 07/22/25 at 10:27 A.M., the family said the resident is incontinent and will often have a smell. He/She does not feel the resident is getting showered as often as twice a week and sometimes not even once a week. He/She said the resident might refuse but feels the staff give up if the resident says no instead of trying again later or with different staff. 5. During an interview on 10:57 A.M., Certified Nurse Aide (CNA) C said showers are scheduled by room number. CNAs are supposed to complete shower sheets when giving a shower and turn them into the charge nurse and then document in the electronic health record. If the resident refuses, then he/she tells the charge nurse who he/she thinks makes a note in the record. The CNA said he/she does not think the showers are getting done twice a week but feels they are getting better. During an interview on 07/24/25 at 10:35 A.M., Licensed Practical Nurse (LPN) A said the aides have a shower schedule the are to go by to know when a resident is supposed to get a shower. The aides then complete a shower sheet that gets turned into the nurse to sign off on as completed. He/She is not sure how often residents are to get shaved but would think the resident would request it. Shower refusals are documented on the shower sheet and signed off by the nurse. He/She is not aware of any residents refusing showers or shaves. He/She said the nurses are responsible to monitor if the aides are completing their assigned showers. During an interview on 07/24/25 at 11:25 A.M., the administrator said he/she is aware there are issues with showers being completed. He/She said the Director of Nursing is working on a new process to ensure the showers are getting completed but has not got it up and running yet. Right now, there is a shower schedule the aides are to go by set up by room number. The aides are expected to document completion of the showers on a shower sheet and in the electronic record to include refusals of bathing. The residents should get at least one to two showers a week or more often if they wish.

Based on observation, interview and record review, facility staff failed to develop a comprehensive person-centered care plan to meet the medical, nursing, mental and psychosocial needs for three residents (Resident #21, #29, and #48) out of three sampled residents who self-administered medication and kept medication at the bedside. The facility census was 54.1. Review of the facility's policy titled Care Plans, Comprehensive Person-Centered, dated October 2017, showed:-A person-centered, comprehensive care plan that includes measurable objectives and timeframes to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident;-The care plan will describe services that are furnished to attain of maintain the resident's highest practicable physical, mental and psychosocial well-being;-Reflect the resident's expressed wishes regarding care and treatment goals. 2. Review of Resident #21's Quarterly Minimum Data Sheet (MDS), a federally mandated assessment tool, dated 06/05/25, showed staff assessed the resident as cognitively intact with a diagnosis of respiratory failure. Review of the resident's care plan, dated 06/08/25, showed the care plan did not contain direction or guidance for self-administration of medication or to keep at bedside.Observation on 07/22/25 at 9:42 A.M., showed a bottle of nasal spray and an inhaler labeled albuterol (prescription medication used to open airways) on the overbed table. The resident's roommate sat in a chair in reach of the medication. During an interview on 07/22/25 at 9:46 A.M., the resident said he/she takes his/her medication as needed and always has it in his/her room. 3. Review of Resident #29's Quarterly MDS, dated [DATE], showed staff assessed the resident as cognitively intact and a diagnosis of lung disease. Review of the resident's care plan, dated 06/20/25, showed the care plan did not contain direction or guidance for self-administration of medication or to keep at bedside.Observation on 07/22/25 at 9:42 A.M., showed a bottle of nasal spray and an inhaler labeled Combivent (prescription medication used to open the airways) on the overbed table. The roommate sat in proximity of the overbed table. During an interview on 07/22/25 at 9:42 A.M., the resident said he/she takes his/her nasal spray and inhaler as needed and keeps it in reach. 4. Review of Resident #48's Quarterly MDS, dated [DATE], showed staff assessed the resident as cognitively intact with a diagnosis of non-Alzheimer dementia. Review of the resident's care plan, dated 07/23/25, showed the care plan did not contain direction or guidance for self-administration of medication or to keep at bedside. Observation on 07/22/25 at 9:49 A.M., showed three medication cups with an unknown number of capsules and tablets stacked on top of one another on the resident's nightstand. The roommate is in proximity of the medication cups and the resident is in the bathroom, out of sight of the medication. During an interview on 07/22/25 at 10:00 A.M., the resident said he/she has the nurses leave his/her medication as he/she can take the medications by himself/herself. 5. During an interview on 07/24/25 at 10:57 A.M., Certified Nurse Aide (CNA) C said he/she knows how to access the care plans on the electronic health record (EHR) but does not take the time to read them. During an interview on 07/24/25 at 11:10 A.M., the MDS nurse said he/she is responsible for ensuring care plans are up to date and accurate. Care plans are reviewed at a minimum quarterly and sometimes are updated daily with resident changes. The MDS nurse said self-administration of medications should be included in the resident care plans but he/she is not aware of any resident that self-administers medication or that keeps medication in his/her room. During an interview on 07/24/25 at 11:25 A.M., the administrator said he/she did not know if there were any residents that self-administered medications unless it was Resident #21 and #29, in which, he/she did not know if they had been assessed for self-administration. He/She said residents are not able to self-administer medication or keep medication at bedside unless they have been assessed, have a physician's order and a care plan has been initiated. The administrator said the MDS nurse is responsible to ensure care plans are accurate and updated as needed.

Based on observation, interview and record review, facility staff failed to ensure the resident environment remained free of accident hazards when staff left medication at the bedside of three residents (Resident #21, #29, and #48) of eight sampled residents. The facility census was 54. 1.Review of the facility's Storage of Medication's policy, dated April 2007, showed drugs shall be stored in an orderly manner in cabinets, drawers, carts or automatic dispensing systems.Review of the Self-Administration of Medications policy, dated December 2016, showed self-administered medications must be stored in a safe and secure place, which is not accessible by other residents. If safe storage is not possible in the resident room, the medications of resident permitted to self-administer will be stored on a central medication cart or in the medication room. Staff will identify and give to the Charge nurse any medications found at the bedside that are not authorized for self-administration, for return to the pharmacy or family. 2. Review of Resident #21's Quarterly Minimum Data Sheet (MDS), a federally mandated assessment tool, dated 06/05/25, showed staff assessed the resident as cognitively intact with a diagnosis of respiratory failure. Observation on 07/22/25 at 9:42 A.M., showed a bottle of nasal spray and an inhaler labeled albuterol (prescription medication used to open airways) on the overbed table while the resident was in the restroom. The resident's roommate sat in a chair in reach of the medication.Observation on 07/24/25 at 8:32 A.M., showed a bottle of nasal spray and an inhaler labeled albuterol on the overbed table. The resident's roommate sat in a chair in reach of the medication. During an interview on 07/22/25 at 9:46 A.M., the resident said he/she takes his/her medication as needed and always has it in his/her room. 3. Review of Resident #29's Quarterly MDS, dated [DATE], showed staff assessed the resident as cognitively intact with a diagnosis of lung disease. Observation on 07/22/25 at 9:42 A.M., showed a bottle of nasal spray and an inhaler labeled Combivent (prescription medication used to open the airways) on the overbed table. The resident's roommate sat in proximity of the overbed table. Observation on 07/24/25 at 8:32 A.M., showed a bottle of nasal spray and an inhaler labeled Combivent on the overbed table. The resident's roommate sat in proximity of the overbed table. During an interview on 07/22/25 at 9:42 A.M., the resident said he/she takes his/her nasal spray and inhaler as needed and keeps it in reach. 4. Review of Resident #48's Quarterly MDS, dated [DATE], showed staff assessed the resident as cognitively intact with a diagnosis of non-Alzheimer dementia. Observation on 07/22/25 at 9:49 A.M., showed three medication cups with an unknown number of capsules and tablets stacked on top of one another on the resident's nightstand. The roommate in proximity of the medication cups and the resident in the bathroom, out of sight of the medication. During an interview on 07/22/25 at 10:00 A.M., the resident said he/she has the nurses leave his/her medication as he/she can take the medications by himself/herself. 5. During an interview on 07/24/25 at 10:35 A.M., Licensed Practical Nurse (LPN) A said he/she did not know of any residents who are able to self-administer medication. During an interview on 07/24/25 at 10:54 A.M., Certified Medication Technician (CMT) D said he/she is not aware of any residents who keep medication at the bedside or who self-administers medication. If he/she seen medication at the bedside and didn't know if the resident was approved to have it, he/she would give the medication to the charge nurse. He/She said if medication is left in the room another resident could go in there and take it. During an interview on 07/24/25 at 11:40 A.M., LPN B said he/she is not aware of any resident who self-administers medications at bedside. Leaving medication at the bedside could put residents at risk of overmedicating or other residents getting access to it. He/She would expect the CMT's to observe the resident take the medication and then return the remaining medication to the cart. During an interview on 07/24/25 at 11:10 A.M., the MDS nurse said he/she is not aware of any resident that self-administers medication or that keeps medication in his/her room. During an interview on 07/24/25 at 11:25 A.M., the administrator said he/she did not know if there were any residents that self-administered medications unless it was Resident #21 and #29. The Administrator said the residents should not keep medication at bedside unless the resident is assessed by staff and ordered by the physician.

Based on interview and record review, facility staff failed to provide written information to the resident and/or the resident's representative of the bed hold policy at the time of transfer to the hospital for two residents (Resident #7 and #9) out of three residents sampled. The facility census was 54.1. Review of the facility's policy titled Bed Hold Notice Prior to Transfer, dated October 2017, showed:-In the event of a resident transfer to the hospital or the resident goes on therapeutic leave, the facility will provide written information to the resident and/or the resident representative regarding the bed hold;-The notice will be provided prior to leave, if possible;-In the event the notice is not provided prior to leave due to unforeseen circumstances, the notice will be provided within the requirements for such notices. Review of the facility's policy titled Transfer and Discharges, dated September 2017, showed: -Before the facility transfers a resident to a hospital or allows a resident to go on therapeutic leave, the social service designee or other designated staff member should provide written information to the resident and a family member or legal representative of the bed-hold and admission policies;-In cases of emergency transfers, the notice of the bed-hold policy under the State plan and the facility's bed-hold policy should be provided the to resident or resident's representative within 24 hours of the transfer. This may be sent with other papers accompanying the resident to the hospital. 2. Review of Resident #7's medical record showed staff documented the resident discharged from the facility to the hospital on [DATE] and readmitted to the facility on [DATE]. The medical record did not contain documentation staff issued a bed hold notice upon discharge with the resident or the resident's responsible party.3. Review of Resident #9's medical record showed staff documented the resident discharged from the facility to the hospital on [DATE] and readmitted to the facility on [DATE]. The medical record did not contain documentation staff issued a bed hold notice upon discharge with the resident or the resident's responsible party.4. During an interview on 07/24/25 at 8:58 A.M., the Social Service Designee (SSD) said the nurses are responsible to complete and send bed hold notices with the resident on discharge. He/She said if the resident is sent out emergently the nurses are responsible to call the resident contact and discuss the bed hold via phone. During an interview on 07/24/25 at 10:35 A.M., Licensed Practical Nurse (LPN) A said he/she has only worked at the facility about a month and has not sent a bed hold notice and did not know who was responsible to complete it.During an interview on 07/24/25 at 10:42 A.M., LPN B said bed holds are sent with the resident on discharge to the hospital and if sent out emergently, the nurse should contact the resident's responsible party and inform them of the bed hold. He/She said he/she could not find a documented bed hold for resident #7 or #9 and did not know why it was not discussed or sent with the resident. The LPN said there are a lot of new nurses that may not know the procedure.During an interview on 07/24/25 at 11:25 A.M., the administrator said the nurses are responsible to send bed holds with the resident when going to the hospital. If it's an emergency transfer, the SSD can send it the next day. The electronic medical record (EMR) should trigger a bed hold during the discharge process and he/she did not know why the facility was missing bed holds for resident #7 or #9.

Based on observation, interview, and record review, facility staff failed to meet professional standards when staff did not complete weekly skin assessments per facility policy, for three residents (Resident #1, #2, and #3) out of three sampled residents. The facility census was 49. 1. Review of the facility's Pressure Injury Prevention and Management Policy, dated October 2018, showed licensed nurses will conduct a full body skin assessment on all residents upon admission/readmission, weekly, and after any newly identified pressure injury. Findings will be documented in the medical record. 2. Review of Resident #1's Admission Minimum Data Set (MDS), a federally mandated assessment tool, dated 6/11/24, showed staff assessed the resident as: -Cognitively intact; -Impairment to both upper and lower extremities on both sides; -Substantial/maximal assistance with bed mobility, transfers, and toileting; -Diagnosis of Pressure Ulcer of left buttock unstageable (a type of bed sore that occurs when prolonged pressure on the skin causes tissue loss and prevents blood flow and oxygen from reaching the area), right ankle unstageable pressure ulcer, Deep Tissue Injury (a type of pressure ulcer that occurs when prolonged pressure or shear forces damage the tissues beneath the skin) of left heel, and pressure ulcer of unspecified buttock stage II (partial thickness loss of dermis presenting as a shallow open ulcer with red or pink wound bed, without slough or bruising); -At risk for pressure ulcers with unhealed pressure ulcers. Review of the residents care plan, revised 8/14/24, showed the resident admitted with stage II pressure ulcer to buttocks required daily treatments, an facility acquired pressure ulcer to left heel and buttocks, deep tissue injury to left heel, two pressure ulcer to scrotum, deep tissue injury right ankle, and pressure ulcer to left hip. Interventions included weekly skin and wound assessments until resolved. Review of the resident's medical record, dated 6/6/24 to 9/6/24, showed staff did not complete skin assessment upon admission or weekly. 3. Review of Resident #2's Quarterly MDS, dated [DATE], showed staff assessed the resident as: -Cognitively intact; -Impairment to lower extremities on both sides; -Diagnosis of acute kidney failure, type II Diabetes; -At risk for pressure ulcers. Review of the resident's care plan, revised 8/22/24, showed open areas on top of left swollen hand. Interventions included to treat as ordered and complete weekly skin and wound assessments Review of the resident's medical record from 6/10/24 to 9/6/24 showed staff completed one skin assessment dated [DATE]. Review showed staff did not complete weekly skin assessments or a skin assessment upon readmission. 4. Review of Resident #3's Admission MDS, dated [DATE], showed staff assessed the resident as: -Cognitively intact; -Impairment to upper and lower extremities on both sides; -Substantial/maximal assistance for bed mobility; -Diagnosis of pressure ulcer stage II (partial thickness tissue loss), pressure ulcer to left buttock stage III (full thickness tissue loss), pressure ulcer to left ankle stage II, and pressure ulcer of unspecified heel; -At risk for pressure ulcers with unhealed pressure ulcers. Review of the resident's care plan, revised 8/27/24, showed the resident admitted with a pressure to the left heel, stage II coccyx pressue ulcer, and acquired a stage III pressure ulcer to right heel and deep tissue injury to the right foot. Interventions included weekly skin and wound assessments until resolved. Review of the resident's medical record, dated 7/9/24 to 9/6/24 showed staff completed an admission skin assessment on 7/9/24. Review showed staff did not complete weekly skin assessments thereafter. 5. During an interview on 9/6/24 at 1:38 P.M., Licensed Practical Nurse (LPN) D said skin assessments will depend upon the resident but thinks they are completed weekly at this facility. LPN D said he/she works part-time. He/She said if a resident is due to have a skin assessment it will pop up on the Treatment Administration Record (TAR) and it is the only time he/she has completed one. He/She is not aware there are missing skin assessments and does not know who is responsible for making sure they are completed. During an interview on 9/6/24 at 1:47 P.M., the Director of Nursing (DON) said skin assessments are completed upon admission, readmission, and if there are new skin developments. He/She does not know how often the skin assessments are completed and why they are not completed. He/She is new to the position and said it would be the DON's responsibility to make sure they were completed. During an interview on 9/6/24 at 1:57 P.M., LPN E said he/she looks under assessments to see if any are due. He/She does not know who is responsible for making sure they are completed. During an interview on 9/13/24 at 10:45 A.M., the administrator said skin assessments should be completed upon admission, readmission, and weekly. He/She said the DON, Assistant DON, and wound care nurse would be responsible for making sure these are completed. He/She does not know why these have not been completed weekly. MO00241576

Based on observation, interview, and record review, staff failed to ensure medications were stored in a safe and effective manner, when staff failed to ensure medications were properly labeled and contained in their original package until time of administration on two medication carts. Staff failed to ensure multi-dose medications were dated when opened. Staff failed to discard expired medications in one medication room. Staff failed to store time scheduled controlled medications (drug or other substance that may cause addiction) in a separately locked, permanently affixed compartment. The facility census was 50. 1. Review of the facility's Storage of Medication policy, revised 04/2007, showed drugs and biologicals shall be stored in the packaging, containers or other dispensing systems in which they are received. Drug containers that have missing, incomplete, improper, or incorrect labels shall be returned to the pharmacy for proper labeling before storing. Staff shall not use discontinued, outdated, or deteriorated drugs or biologicals. All such drugs shall be returned to the dispensing pharmacy or destroyed. Drugs shall be stored in an orderly manner in cabinets, drawers, carts, or automatic dispensing systems. Each resident's medications shall be assigned to an individual cubicle, drawer, or other holding area to prevent the possibility of mixing medication of several residents; 2. Observation on 05/06/24 at 9:09 A.M., showed the 200 hall medication cart contained an envelope with two pills inside. During an interview on 05/06/24 at 9:09 A.M., CMT I said the medication in the envelope is for a resident who is going out for the day. He/She said he/she plans to give the medication to the resident to take with him/her. He/She said he/she was unsure of what policy was. During an interview on 05/09/24 at 3:04 P.M., the administrator said it is his/her expectation staff should not pre-pop medications. He/She said the risk for pre-popping medications is there is a risk medications are not given timely, medications can get missed, other staff may not know what the medications are. He/She said medications should be kept in their original containers until it is time for them to be given. 3. Observation on 05/06/24 at 9:20 A.M., showed the 100 hall medication cart contained three loose pills. During an interview on 05/06/24 at 9:25 A.M., the administrator said medication carts should be checked at change of shift and staff should be looking for loose pills. He/She said he/she is not sure why this cart has loose pills. 4. Observation on 05/06/24 at 9:20 A.M., showed the 100 hall medication cart contained: -An opened bottle of Milk of magnesia, undated; -An opened bottle of polyethylene glycol 3350 powder (to treat occasional constipation), undated; -An opened bottle of megestrol acetate oral suspension 40 milligram (mg)/milliliter (ml) (used to treat loss of appetite), undated; -An opened bottle of guaifenesin oral solution 100mg (for cough relief), undated; -An opened bottle of Carbamazepine suspension 100mg/5ml (used to treat and manage epilepsy), undated. 5. Observation on 05/08/24 at 10:15 A.M., showed the 100 hall medication cart contained: -An opened bottle of Aspirin 81mg, undated; -An opened bottle of docusate sodium 100mg (used for constipation), undated; -An opened bottle of zinc 50 mg, undated. During an interview on 05/08/24 at 10:29 A.M., CMT F said when opening a new bottle, need to make sure to date the bottle with the open date. He/She said it is important to date bottles when they are opened so he/she is not giving expired medications. During interview on 05/09/24 at 2:26 P.M., the Director of Nursing (DON) said he/she expects staff to date the bottle once opened. He/She said if opened bottles are not dated, then no one knows how long it has been opened or if the medication is any good and they have to be wasted. During an interview on 05/06/24 at 9:25 A.M., the administrator said he/she is working the medication cart in the 100 hall today. It is his/her expectation staff date all medications in the cart when they open them. He/She said he/she does not know why they medications in the 100 medication cart are not dated. He/She said it should be checked at every change of shift. 6. Observation on 05/06/24 at 9:24 A.M., showed the medication room contained: -An expired bottle of aspirin 325 mg; -An expired bottle of magnesium 250 mg; -An expired bottle of cranberry 450 mg; -An expired bottle of vitamin A 3000 microgram (mcg). During an interview on 05/08/24 at 10:29 A.M., CMT F said the CMTs should check for expired medications everyday. He/She said expiration dates should be checked when pulling the bottle from the medication room shelf. He/She said the supply person puts the over the counter medication in the medication room and he/she usually rotates the bottles. During interview on 05/09/24 at 2:26 P.M., the DON said it is the CMTs and nurses' responsibility to check medication room and medication carts for expired medications. He/She said the pharmacy checks the medication cart and medication room once a month to check for expired medication. 7. Observation on 05/06/24 at 9:24 A.M., showed the medication room refrigerator contained two Lorazepam (used to treat anxiety) 2 mg/ml vials in a removable unlocked box. During an interview on 05/06/24 at 9:25 A.M., the administrator said nurses are responsible for maintaining medication rooms. He/She said Lorazepam is a control medication and should be behind two locks. He/She said he/she does not know why it is in there. He/She said it should be in the medication safe.

Based on observation, interview, and record review, facility staff failed to perform appropriate hand hygiene, and glove changes during incontinence care for two (Resident #19 and #21) out of two sampled residents. Facility staff failed to perform appropriate hand hygiene, and glove changes during catheter care for one (Resident #4) out of one sampled resident. Facility staff failed to appropriately sanitize a multi-use glucometer (a device for monitoring blood sugars) between use for two residents (Resident #19 and #28) out of four sampled residents to prevent the spread of infection causing contaminants. The facility census was 50. 1. Review of the facility's hand hygiene policy, undated, showed all staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. Staff will perform hand hygiene when indicated, using proper technique consistent with accepted standards if practice: -Hand hygiene is indicated and will be performed under the conditions listed in, but not limited to, the attached hand hygiene table; -The use of gloves does not replace hand hygiene. If your task requires gloves, perform hand hygiene prior to donning gloves, and immediately after removing gloves; Hand Hygiene Table; -Soap and water; -Hands are visibly dirty; -Hands are visibly soiled with blood or other bodily fluids; -Either soap and water or alcohol based hand rub (ABHR); -Between resident contacts; -After handling contaminated objects; -Before applying or after removing personal protective equipment (PPE), including gloves; -Before or after handling clean or soiled dressings, linens, etc.; -Before performing resident care procedures; -After handling items potentially contaminated with blood, body fluids, secretions, or excretions; -When during resident care, moving from a contaminated body site to a clean body site; -After assistance with personal body functions (e.g., elimination, hair grooming, smoking). Review of the facility's Perineal Care Procedure policy, undated, showed staff are directed to: -Wash perineal area, wiping front to back. (Note: If the resident has an indwelling catheter, gently wash the junction of the tubing from the urethra down the catheter about 3 inches. Gently rinse and dry the area.); -Continue to wash the perineum moving from outward to and including thighs, alternative from side to side, and using downward strokes. Do not reuse the same washcloth -Wash the rectal area thoroughly, -Remove gloves and discard into designated container. Wash and dry your hands thoroughly. 2. Review of Resident #19's Quarterly Mininmal Data Set (MDS), a federally mandated assessment instrument competed by facility staff, dated 05/01/24, showed staff assessed the resident as follows: -Moderate cognitive impairment; -Dependent on staff for toileting and lower body dressing; -Always incontinent of bladder and frequently incontinent of bowel; -Diagnosis of stroke. Observation on 05/07/24 at 11:00 A.M., showed Certified Nursing Aide (CNA) G entered the resident's room to provide perineal care applied gloves and cleaned the resident's front side. With the same soiled gloves, CNA G rolled the resident to their left side and cleaned bowel movement off the resident bottom. CNA G removed his/her soiled gloves, did not perform hand hygiene and applied clean gloves. CNA G assisted the resident to roll onto their right side and wiped feces from the residents left buttock. CNA G continued to wear the same soiled gloves, threw the soiled brief in the trash and placed the residents clean brief and pants on. During an interview on 05/07/24 at 5:22 P.M., CNA G said gloves are supposed to be changed between clean and dirty tasks. CNA G said he/she thought he/she changed hiis/her gloves before putting on the resident's clean brief, and knows he/she should have. 3. Review of Resident #21's Quarterly MDS, dated [DATE], showed the following: -Cognitively intact; -Dependent for toileting hygiene and shower/bathing; -Substantial/maximal assistance for personal hygiene; -Always incontinent or bowel and bladder. Observation on 05/07/24 at 2:10 P.M., CNA J entered the resident's room to perform perineal care. CNA J did not perform hand hygiene before he/she applied gloves. CNA J used the mechanical lift to tarnsfer the resident to his.her bed. CNA J performed perinal care to the resident. With the same soiled gloves, CNA J applied a clean brief underneath the resident, rolled the resident to his/her back, put the residents pants, touch the mechanical lift and remote to lift. CNA J removed his/her soiled gloves, did not perform hand hygiene, applied clean gloves and removed the mechanical lift sling straps. During an interview on 05/15/24 at 9:20 A.M., CNA J said hand hygiene should always be performed before putting gloves on. He/She said gloves should be changed when gloves become soiled. He/She said he/she should perform hand hygiene between removing gloves and before applying new gloves. He/She said hand hygiene should be performed after removing gloves and before leaving the residents room. During an interview on 05/09/24 at 2:26 P.M., the Director of nursing (DON) said it is his/her expectation staff wash their hands or sanitize when they enter the resident's room, anytime contact is made with the resident, when they become visibly dirty, and any time you take gloves off. He/She said to prevent the spread of infectants, he/she said staff should have one staff perform the care and the other staff member hand them the clean care items. He/She said if the gloves come into contact with bodily fluids, they should change them and perform hand hygiene before replacing them. 4. Review of the facility's policy titled, Catheter Care, Urinary, revised 9/2014, showed staff are directed to: -Maintain clean technique when handling or manipulating the catheter, tubing, or drainage bag; -Wash and dry your hands thoroughly; -Put on gloves; -Wash the resident's genitalia and perineum thoroughly with soap and water. Rinse the area well and towel dry; -Remove gloves and discard into the designated container. Wash and dry your hands thoroughly; -Use one area of the washcloth for each downward, cleansing stroke. Change the position of the washcloth with each downward stroke. Next, change the position of the washcloth and cleanse around the urethral meatus. Do not allow the washcloth to drag on the resident's skin or bed linen. With a clean washcloth, rinse with warm water using the above technique; -Use a clean washcloth with warm water and soap to cleanse and rinse the catheter from insertion site to approximately four inches outward; -Discard disposable items into designated containers. Remove gloves and discard into designated container. Wash and dry your hands thoroughly. 5. Review of Resident #4's significant change MDS, dated [DATE], showed the following: -Moderate Cognitive impairment; -Has an indwelling catheter; -Always incontinent of bowel and bladder; -Diagnosis of obstructive uropathy (a disorder of the urinary tract that occurs due to obstructed urinary flow). Observation on 05/07/24 at 2:58 P.M., showed CNA J entered the resident's room to perform perineal and catheter care. CNA J did not perform hand hygiene before he/she applied his/her gloves. CNA J used a clean wipe and cleaned the residents abdomen. With the same soiled wipe, CNA J wiped the residents groin eight times with the same portion of the wipe. CNA J used a clean wipe, cleaned the resident's left groin four times with the same portion of the wipe before he/she discarded it into the trash. CNA J wiped down the center of the resident's front side four times with the same portion of the wipe before he/she discarded it into the trash. CNA J wiped down the center of the resident's front side and then with the same portion of the wipe he/she wiped up and down the catheter tubing. CNA J wiped down the resident's front side and with the same wipe, he/she wiped the resident's abdomen and thigh before he/she dicarded it in the trash. CNA J did not perform hand hygeine after he/she removed his/her gloves or before he/she gave the resident a drink. CNA J applied gloves without performing hand hygiene and wiped the residents back side five different times with the same portion of the wipe before he/she discarded it into the trash. CNA J again wiped the residents back side five different times with the same portion of the wipe before he/she discarded it into the trash. CNA J wiped the residents back side nine different times with the same portion of the wipe before he/she discarded it into the trash. During an interview on 05/15/24 at 9:20 A.M., CNA J said hand hygiene should always be performed before putting gloves on. He/She said when performing peri care he/she should wipe once in one spot and get new wipe for another spot. He/She said to wipe front to back and clean to dirty. He/She said when cleaning catheter tubing always wipe from base outward from the body. He/She said it is a risk for infection if using same wipe in same spot and wiping in the wrong direction. He/She said he/she was in a hurry that day to get the resident to hospital and knew he/she had messed up and forgot to perform correct hand hygiene. During an interview on 05/09/24 at 2:26 P.M., the DON said it is his/her expectation that his/her staff perform perineal care, and then hand hygiene and glove changes prior to initiating catheter care. He/She said failure to perform hand hygiene and glove changes can introduce bacteria into the catheter and can cause infection. He/She said he/she expects staff to wipe away from the urethra and to only use one wipe per swipe. During an interview on 05/09/24 at 3:04 P.M., the administrator said she expects staff to perform perineal care before they do any catheter care. She expects them to change gloves and perform hand hygiene before they start the catheter care. She expects staff to wipe away from the body and down the tube. She said staff should only use one clean wipe per swipe and throw it away. She said staff should never wipe the catheter tubing with a dirty wipe because it could introduce bacteria. 6. Review of the facility's policies showed staff did not provide a policy for cleansing and disinfecting multi-use glucometers. Review of the multi-use blood glucose monitor system manufractures manual, undated, showed the disinfection procedure is needed to prevent the transmission of blood-borne pathogens. A variety of the most commonly used Environmental Protection Agency (EPA) registered wipes have been tested and approved for cleaning and disinfecting of the multi-use blood glucose monitoring system. The disinfectant wipes listed below have been shown to be safe for use this meter: -Clorox Germicidal Wipes; -Dispatch Hospital cleaner Disinfectant Towels with Bleach; -Super Sani-Cloth Germicidal Disposable Wipes; -CaviWipes1. -After disinfection, the user's gloves should be removed and thrown away. Wash hands before proceeding to the next patient. 7. Observation on 05/08/24 at 5:45 A.M., showed Licensed Practical Nurse (LPN) C obtained Resident #19's blood sugar with the multi-use glucometer, removed gloves, exited the room, and did not perform hand hygiene. The LPN placed the glucometer on the medication cart without a barrier, got supplies together, and wiped the multi-use glucometer with alcohol wipes. The LPN did not use the disinfectant wipes shown to be approved for the meter. During an interview on 05/08/24, at 5:58 A.M., LPN C said he/she can use alcohol to clean the glucometer. During an interview on 05/09/24 at 1:45 P.M., the Infection Preventionist (IP) said there are at least two glucometers on the cart and staff are to rotate them, while one is disinfecting, they use the other one. The IP said alcohol is not appropriate to clean or disinfect glucometers, their wipes used specificity for the cleaning and disinfecting of glucometer. During an interview on 05/09/24 at 2:35 P.M., the DON said glucometers need to be cleaned between residents, if clean with alcohol and then needs to be disinfected afterwards with the appropriate wipes for 3-5mins. The DON said he/she expects wipes to be in addition to alcohol. The DON said hands should be washed before and after blood sugars. During an interview on 05/09/24 at 3:04 P.M., the administrator said she expects staff to use two glucometers when performing blood sugar checks. She said after taking the residents blood sugar she expects staff clean the glucmeter then place on a barrier wrapped in a sani wipe for three minutes. 47193 50422

Based on interview and record review, facility staff failed to provide an ongoing program of activities designed to meet three (Resident # 5, #13 and #41) out of 13 sampled residents interest on the weekends. The facility census was 50. 1. Review of the facility's policy titled, Life Enrichment Program, dated 10/21, showed this facility will provide an ongoing program to support residents in their choice of activities based on their comprehensive assessment, care plan, and preferences of each resident. Review showed staff were directed to: -Activities will be designed with the intent to enhance the residents sense of well-being, promote or enhance physical activities, promote or enhance cognition, and promote or enhance emotional health; -Events may be conducted in different ways, life enrichment programs to include a combination of large and small groups, one to one, and self-directed as the resident desires to attend; -Events will reflect residents' interest and age, be enjoyable, help the residents to feel useful, provide sense of belonging, reflect cultural and religious interests of the resident, and reflect residents choices. Review of the facility's activity calendar, dated May 2024, showed: -Saturday, 05/04/24; 09:30 A.M., Rosary; -Sunday, 05/05/24; 09:30 A.M., Rosary and 09:45 A.M. Catholic Church Service; -Saturday, 05/11/24; 09:30 A.M., Rosary; -Sunday, 05/12/24; 09:30 A.M., Rosary and 09:45 A.M. Catholic Church Service; -Saturday, 05/18/24; 09:30 A.M., Rosary; -Sunday, 05/19/24; 09:30 A.M., Rosary Communion; -Saturday, 05/25/24; 09:30 A.M., Rosary; -Sunday, 05/26/24; 09:30 A.M., Rosary and 09:45 A.M. Catholic Church Service. 2. Review of Resident #5's Significant Change Minimum Data Set (MDS), a federally mandated assessment tool, dated 01/25/24, showed staff assessed the resident as follows: -Cognitively intact; -Activity preferences to be rery important to do things with groups of people. During an interview on 05/06/24 at 2:30 P.M., the resident said the weekends are dead and there are no activities. He/She said they try to do things to keep themselves busy. The resident said he/she would like to have some activities on the weekends because the weekends drag on. 3. Review of Resident #13's Annual MDS, dated [DATE], showed staff assessed the resident as follows: -Independent for decisions; -Very important to have books, newspapers and magazines to read and keep up with the news, do favorite activities, participate in religious services or practices; -Somewhat important to do things with groups of people. Review of the resident's care plan, dated 04/16/24, showed staff documented the resident will attend one to two group activities per week through next review. Review showed staff documented the resident enjoys bingo, some music, and sometimes other group activities. During an interview on 05/06/24 at 10:50 A.M., the resident said he/she loves activities. He/She said weekends are long without activities unless family comes and visits. He/She said he/she would love if there were activities on the weekends. 4. Review of Resident #41's Annual MDS, dated [DATE], showed staff assessed the resident as follows: -Independent for decisions; -Very important to have books, newspapers and magazines to read and keep up with the news, do favorite activities, to do things with groups of people; -Somewhat important to participate in religious services or practices and listen to music. Review of the resident's care plan, dated 04/16/24, showed staff documented the resident will attend 2-3 activities per week through next review. Said resident enjoys games, some music, some parties, and sometimes other group activities. During an interview on 05/06/24 at 10:30 A.M., the resident said he/she goes to activities during the week. He/She said the facility does not have activities on the weekends. He/She said he/she is not Catholic and does not attend Rosary or Catholic church services. He/She said that he/she is normally in his/her room on the weekend since no activities are happening. 5. During an interview on 05/09/24 at 11:46 A.M., Nurse Aide (NA) E said he/she has seen church on Sunday mornings. He/She said that is all he/she has seen on the weekends. During an interview on 05/09/24 at 11:58 A.M., Certified Medication Tech (CMT) C said he/she has only seen rosary and family visits on the weekends. He/She said that a housekeeper helps on Saturday to turn on rosary and a priest comes in on Sunday to do rosary and Catholic Services. During an interview on 05/09/24 at 12:03 P.M., Registered Nurse (RN) D said he/she does not remember many activities on the weekends. He/She said there is church on Sunday mornings and then family visits on the weekends. He/She said there are not any organized activities on the weekends. During an interview on 05/09/24 at 12:12 P.M., the Activity Director said on the weekend residents have a lot of family visits, so they try to keep activities small. He/She said a Deacon comes in on Sunday morning to do rosary and church service. He/She said packets with coloring sheets and word searches are handed out on Friday afternoons that residents can do on the weekend. He/She said a if resident is not catholic, they can do the packet, puzzles, or read books. He/She said on weekends its usually volunteer lead activities or the housekeeper that will help with rosary in the mornings on the weekend. During an interview on 05/09/24 at 2:26 P.M., the Director of Nursing (DON) said on the weekends the facility has rosary. He/She said he/she is not aware of any staff led activities on the weekends. He/She said if residents are not catholic he/she is not sure what the resident does. During an interview on 05/09/24 at 3:03 P.M., the administrator said there is a lot of family visits on the weekends. He/She said that housekeeping helps set up rosary on the weekends. He/She said that the activity director passes out word searches and coloring pages on Friday afternoons.

Based on interview and record review, facility staff failed to ensure the arbitration agreement was explained in a form and manner which correctly describes the arbitration process, or the option to decline the arbitration agreement. The census was 50. 1. Review of the facility's policies showed staff did not provide a policy for Arbitration Agreements. 2. Review of the facility's Admission Packet showed a one page Arbitration Agreement did not contain a place to decline arbitration. During an interview on 05/08/24 at 2:12 P.M., the Social Services Director (SSD) said he/she goes over the admission packet with new residents and their family at admission. The SSD said he/she lets them know if they sign, it avoids going to court and cuts on court cost for everyone. The SSD said he/she explains even though they sign and agree to the arbitration, doesn't mean they can't go to court still. He/She said he/she doesn't typically read the arbitration agreement to the resident or residents' family, but tries to explain if they have questions. The SSD said he/she was not aware that the arbitration agreement information mean they could not take matters to court if you sign the agreement. If the resident or family declines the they just dont sign the paper. During an interview on 05/09/24 at 3:20 P.M., the administrator said the residents and their family have the option whether to sign or not sign the arbitration agreement. The administrator said it is the SSD's responsibility during the admission process to explain the form and answer any questions. She was not aware the information was not explained in a form and manner that best describes the process.

Based on observation, interview, and record review, facility staff failed to ensure call lights were within reach for three residents (Resident #6, #37, and #42) out of 13 sampled residents. The facility census was 50. 1. Review of the facility's policy titled, Call Light Accessibility and Response, dated 9/21, showed all staff will be educated on the proper use of the resident call system, including how the system works and ensuring resident access to the call light. All residents will be evaluated on how to call for help by using the resident call system. Staff will ensure the call light is within reach of resident and secured, as needed. The call system will be accessible to residents while in their bed or other sleeping accommodations within the resident's room. The call system should be accessible to a resident lying on the floor. 2. Review of Resident #6 Quarterly Minimum Data Set (MDS), a federally mandated assessment tool, dated 02/05/24, showed staff assessed the resident as follows: -Cognitively moderately impaired; -Responds adequately to simple, direct communication only; -No impairment to upper extremities, but impairment on both lower extremities; -Dependent for ADL's and transfers. Review of the resident's care plan, dated 04/16/2024, showed the plan did not direct staff on how to care for the resident or direct staff on where to place call light. Observation on 05/06/24 at 11:07 A.M., showed the resident in his/her wheelchair in his/her room, with the call light attached to his/her lower bedrail not within reach. Observation on 05/07/24 at 9:28 A.M., showed the resident in his/her wheelchair in his/her room, with the call light attached to his/her lower bedrail not within reach. Observation on 05/08/24 at 10:55 A.M., showed the resident in his/her wheelchair in his/her room, with the call light attached to his/her lower bedrail not within reach. 3. Review of Resident #42's Quarterly MDS, dated [DATE], showed staff assessed the resident as follows: -Cognitively Impaired; -Responds adequately to simple, direct communications only; -Upper extremity impairment on one side; -Dependent for activities of daily living (ADL)s and transfers. Review of the resident's care plan, dated 04/16/2024, showed the plan did not direct staff on how to care for the resident or direct staff on where to place call light. Observation on 05/06/24 at 1:36 P.M., showed the resident in his/her broda [NAME](a type of wheelchair that gives patients the ability to tilt and recline) in the middle of his/her room faced opposite of doorway in front of his/her television with his/her call light not within reach. Observation on 05/07/24 at 8:59 A.M., showed the resident in his/her broda chair in the middle of his/her room faced opposite of doorway in front of his/her television with his/her call light not within reach. Observation on 05/07/24 at 10:53 A.M., showed the resident in his/her broda chair in the middle of his/her room faced opposite of doorway in front of his/her television with his/her call light not within reach. Observation on 05/07/24 at 3:46 P.M., showed the resident in his/her broda chair in middle of his/her room faced opposite of doorway in front of his/her television, with the call light not within reach. Resident heard yelled Help. 4. Review of Resident #37's Annual MDS, dated [DATE], showed staff assessed the resident as follows: -Clear comprehension and makes self-understood and understands others; -Severely impaired with making decisions; -No impairment to upper extremities, but impairment to both lower extremities; -Substantial/maximal assistance with ADL's and transfers. Review of the resident's care plan, dated 04/16/2024, showed staff should keep call light within each reach. Observation on 05/06/24 at 10:59 A.M., showed the resident in his/her wheelchair in the middle of his/her room, with the call light on the floor beside the bed. Observation on 05/07/24 at 9:29 A.M., showed the resident in his/her wheelchair in middle of his/her room, with the call light on the floor beside the bed. Observation on 05/07/24 at 2:06 P.M., showed the resident in his/her wheelchair in middle of his/her room, with the call light on the floor beside the bed. Observation on 05/09/24 at 11:31 A.M., showed the resident in his/her wheelchair in middle of his/her room, with the call light on the floor beside the bed. 5. During an interview on 05/09/24 at 11:34 A.M., Certified Nurse Aide (CNA) H said call lights should always be within reach of residents. He/She said he/she clips the call light on the resident. He/She said if the call light is not within reach the resident may need something and the resident can end up in danger if call light not within reach. During an interview on 05/09/24 at 11:50 A.M., Registered Nurse (RN) G said residents should always be given their call light, He/She said he/she shows the resident where the call light is or clips it to them. He/She said if call light is not within reach that the resident could get up and fall. During interview on 5/09/24 at 2:26 P.M., the Director of Nursing said the residents should defiantly have the call light on them and not out of reach. He/She said if call light is not within reach the resident will try and get up and will likely fall. He/She said safety is number one. He/She said all staff should make sure call light is within reach when resident is in room. During interview on 05/09/24 at 3:03 P.M., the administrator said that call lights should always be where the resident can reach them. He/She said that if call lights are not within reach, then the resident would not be able to notify staff if they need something.

Based on observation, interview and record review, facility staff failed to post, in a form and manner accessible to the residents and resident representative, the required telephone number to the Department of Health and Senior Services (DHSS) hotline (to report allegations of abuse and neglect), or a list of names, addresses, and phone numbers of the State Survey Agency (SSA). The census was 50. 1. Review of the facility's Facility Postings Policy, dated October 2017, showed the facility will post required postings in an area accessible to all staff and residents. The facility posting include a list of names, addresses (mailing and email), and telephone numbers of all pertinent State Agencies and advocacy groups to include but not limited to: -State Survey Agency; -Adult Protective Services. 2. Observation of the facility on 05/06/24 through 05/09/24, showed the facility did not post the name, address and toll free telephone number for the DHSS Abuse and Neglect Hotline or the SSA information in a form and manner accessible to residents or visitors. During an interview on 05/09/24 at 11:45 A.M., Resident #56 said he/she did not know where the hotline number is posted. He/She has not been told where it's posted and he/she has not seen it anywhere. During an interview on 05/09/24 at 11:50 A.M., Resident #40 said the hotline number is not posted anywhere but it should be. During an interview on 05/09/24 at 1:40 P.M., Certified Medication Technician (CMT) I said he/she did not know if the abuse and neglect hotline number is posted visibly anywhere. He/She said there is a policy book behind the nurse's station and they believe the number is in the book. During an interview on 05/09/24 at 1:50 P.M., the Social Service Designee (SSD) said he/she thought it was posted in the dining room. The SSD said he/she was not able to find it posted anywhere. The SSD said the abuse and neglect hotline information should be posted for residents, family and staff to see, but he/she is not sure why it is not. During an interview on 05/09/24 at 3:15 P.M., the Director of Nursing (DON) said she did not know the required information was not posted. The DON said it should be posted visible for everyone to see, family, residents and staff. During an interview on 05/09/24 at 3:16 P.M., the administrator said the SSD is responsible making sure the information is posted. The administrator said is not why the required hotline information was not posted, but she would expect it to be visible for everyone to see.

Based on observation, interview, and record review, facility staff failed to transfer three residents (Residents #1, #2 and #3) in a safe manner, when staff did follow the facility's policy and procedures for the mechanical lift, which resulted with one resident (Resident #1) with fracture of facial bones and laceration of the head. The facility census was 50. 1. Review of the mechanical lift owner's manual, dated June 2015, showed staff are to move lift so that it is positioned directly over the individual and utilize leg opening function if required. Attach the straps of the sling to the hooks of the carry bar. Be sure to double check to ensure the straps are properly attached to the carry bar, and the individual is properly positioned in the sling prior to lifting. Observation on 10/12/23 at 10:48 A.M., showed a sign on the mechanical lift directed two staff required for the mechanical lift transfer. 2. Review of Resident #1's Quarterly Minimum Data Set (MDS), a federally mandated assessment tool, dated 07/30/23, showed staff assessed the resident as follows: -Cognitively intact; -Dependent on a staff for transfers from bed to chair, transferring from chair bed and transferring to toilet; -Weighs 215 pounds; -Always incontinent of bowel and bladder; -Used a manual wheelchair; -Diagnoses of Heart Failure (a chronic condition in which the heart doesn't pump blood as well as it should), Cerebral Palsy (impaired muscle coordination typically caused by damage to brain before or during birth), Hemiplegia (paralysis of one side of the body), Epilepsy (neurological disorder marked by sudden and recurrent episodes of sensory disturbance, loss of consciousness, associated with abnormal electrical activity in the brain). Review of the resident's plan of care, revised 10/11/23, showed staff assessed the resident used a mechanical lift with all transfers and required two staff to assist for all transfers. Review of resident's progress note, dated 10/10/23, showed Registered Nurse (RN) E documented CNA F reported to him/her the resident was on the floor. The CNA and RN were going down the 100 hall and heard the Director of Nursing (DON) yell, I need help, call 911. RN E entered the room to see the resident lay face down on the floor with the DON at his/her side, with a pool of blood at the resident's head. The DON said he/she could not tell where the blood was coming from. RN E ran across the hall for a wash rag and called 911 on his/her own cell phone. RN E handed the rag to the DON and left the room to get the treatment cart. The DON told the resident he/she needed to roll the resident over and the resident said okay. Nursing staff performed neurological assessments with conversation to the resident who voiced pain with the rolling over and of being on the floor. Two aides, DON and RN E rolled the resident to his/her back. Staff assessed the resident had a laceration on his/her forehead and left brow evident. Blood covered the left side of the resident's face. Emergency Medical Staff (EMS) was informed resident was on coumadin (blood thinner). Review of the resident's hospital record showed on 10/10/23, the hospital staff documented the resident with an unspecified fracture of facial bones and laceration without foreign body of other part of head. Review of the Hospital Discharge paperwork, dated 10/10/23, showed the hospital treated the resident for facial bone fracture and facial laceration. Further review showed cuts on the resident's face were closed with stitches. Review of the resident's Physician Order Sheet (POS), dated 10/11/23, showed staff were directed to apply icepack to forehead three times daily to lesson swelling and bruising, use hairnet to hold in place for 20 minutes at a time, related to injury to face. Further review showed staff were directed to gently cleanse the forehead and left eye with Vashe (wound cleanser) and apply layer of petroleum jelly daily, for skin care related to injury of face. Observation on 10/12/23 at 10:30 A.M., showed the resident's left eye and forehead dark purple, a laceration with sutures on left eyebrow and a semi-circular laceration sutured on the forehead. The resident's right eye was light purple and swollen. During an interview on 10/12/23 at 10:35 A.M., the resident said CNA F completed the transfer by himself/herself, but they usually do it with two staff members. The resident said the staff member was lifting him/her in the mechanical lift and he/she fell out. The resident said staff are supposed to have two staff to assist with his/her transfers, but he/she guessed the other aide wasn't there. During an interview on 10/12/23 at 11:22 A.M., CNA F said he/she was getting the resident ready for shower and got the resident on mechanical lift pad in bed. The CNA said RN E was going to come help him/her and then the RN got busy. The CNA said, I got impatient, so he/she used the mechanical lift and lifted the resident out of bed by himself/herself. The CNA said, I knew I was not supposed to do that and was supposed to use two staff with mechanical lift transfer. The CNA said he/she had received mechanical lift training and in-services about mechanical lift transfers before the incident happened. The CNA said he/she pulled the mechanical lift back and thought the lift sling broke, but the administrator said the lift sling didn't break. He/She said he/she must have not gotten it clipped all the way. The CNA said the resident fell on his/her face first and hit his/head, and there was blood everywhere. The CNA said he/she went and got the Director of Nursing (DON). The CNA said he/she did not normally do mechanical transfers with one staff. He/She had a long list of showers and he/she was just trying to get them done. The CNA said he/she had been doing mechanical lift transfers on residents with one staff, and he/she knew it is wrong. The CNA said the DON told him/her not to do the transfers by himself/herself. During an interview on 10/12/23 at 12:37 P.M., the administrator said CNA F did the mechanical lift transfer by himself/herself. The administrator said he/she believed the CNA got in a hurry and was tired of waiting for the DON. The administrator said the CNA knew better, he/she believed the CNA got impatient. The administrator said the hospital reported the resident had bilateral fractures and they sutured his/her forehead and eyebrow. The administrator said the lift sling had not broken and nothing was wrong with the mechanical lift device. During an interview on 10/13/23 at 3:25 P.M., the DON said staff were getting resident's up and he/she had to go get a battery for another mechanical lift. The DON said he/she saw CNA F at the nurse's station and he/she went to the resident's room. The DON said when he/she went into the resident's room, the resident lay face down, with blood everywhere. The DON said he/she saw three parts of the sling attached and one part hanging down. The DON said the sling was not broken. The DON said he/she told the CNA he/she was never supposed to do mechanical lift with one staff. The DON said the CNA had been trained on using two staff for mechanical lift transfers before the incident. The DON said the CNA did not say why he/she lifted the resident by himself/herself. The DON said the CNA made a poor choice and the resident got harmed. 3. Review of Resident #2's Quarterly MDS, dated [DATE], showed staff assessed the resident as follows: -Moderate cognitive impairment; -Dependent on a staff members for transfers from bed to chair, chair to bed and to toilet; -Always incontinent of bowel and bladder; -Uses a manual wheelchair; -Diagnoses of Coronary Artery Disease, Heart Failure, Hypertension, Peripheral Vascular Disease (a systemic disorder that involves the narrowing of peripheral blood vessels ) and Dementia (progressive or persistent loss of intellectual functioning, especially with impairment of memory and abstract thinking, resulting from organic disease of the brain). Observation on 10/12/23 at 12:58 P.M., showed Nurse Aide (NA) A and Licensed Practical Nurse (LPN) B entered the resident's room with a mechanical lift. Observation showed an instruction card which instructed staff to widen base for transfers of residents. The NA widened the base and placed the mechanical lift over the resident in a broda chair (chair that gives the resident the ability to tilt and recline in place). The NA used the mechanical lift and raised the resident into the air and backed away from the broda chair. The NA propelled the mechanical lift forward, towards the lowered bed and the mechanical lift hit the bed frame and then stopped. The resident was still suspended in air above tile floor, and the NA closed the base of the mechanical lift and propelled it forward to place the legs of the mechanical lift under the bed. The NA then lowered resident to the bed with the base closed. During an interview on 10/24/23 at 1:41 P.M., the NA said it takes two staff to complete a mechanical lift. The NA said staff should constantly have mechanical lift legs open, during a transfer of a resident. The NA said he/she had to close the mechanical lift legs to be able to get them under the resident's bed. The NA said the resident's bed will go up and down. The NA said the resident's bed was in the low position. The NA said putting the mechanical lift legs in during a transfer, would risk tilting the mechanical lift over. The NA said he/she had recently had a mechanical lift safety in-service. 4. Review of Resident #3's Significant Change MDS, dated [DATE], showed staff assessed the resident as follows: -Severe cognitive impairment; -Dependent on a staff members for transfers from bed to chair, chair to bed and to toilet; -Always incontinent of bowel and bladder; -Used a manual wheelchair; -Diagnoses of Heart Failure, Hypertension, Peripheral Vascular Disease, Cerebrovascular Accident and Dementia. Observation on 10/12/23 at 1:14 P.M., showed CNA C and CNA D entered the resident's room with the mechanical lift. Observation showed an instruction card which instructed staff to widen the base for transfers of residents. The resident sat in his/her broda chair. CNA C controlled the lift and propelled the mechanical lift legs under the resident's broda chair from the side. CNA C and CNA D attached the sling straps to the carry bar of mechanical lift. CNA C lifted the resident from the broda chair, CNA D removed the broda chair and the resident remained suspended in the air with mechanical lift legs still in the closed position. CNA C turned the mechanical lift at an 180 degrees to face the resident's bed with the legs of the mechanical lift legs closed. Observation showed the resident's bed in the high position. CNA C then propelled the resident forward in the mechanical lift until the legs of the mechanical lift legs were fully under the bed. CNA D did not support or have hands on the resident, to stabilize the resident, during the 180 degree turn. CNA C then completed the transfer, as he/she lowered the resident to the bed. During an interview on 10/12/23 at 1:22 P.M., CNA C said staff are supposed to open the legs of the mechanical lift when turning resident in the lift. The CNA said he/she knew he/she did not open the legs to the lift during the transfer. The CNA said he/she wasn't thinking, he/she thought about it, right after the transfer. The CNA said a mechanical lift can tip over, if staff don't open the legs, with the weight of the lift and the resident. The CNA said the instruction card was right in front of him/her. During an interview on 10/12/24 at 1:25 P.M., CNA D said he/she did not think about opening the mechanical lift legs. The CNA said right after the transfer, he realized they forgot to open the legs. The CNA said the weight could tilt the mechanical lift over. 5. During an interview on 10/12/24 at 2:02 P.M., the administrator said staff should open the mechanical lift legs for the entire transfer of a resident. During an interview on 10/13/24 at 3:25 P.M., the DON said during a mechanical lift transfer of a resident, staff should open the base of the mechanical lift. MO00225696

Based on interviews and record review, facility staff failed to notify the family/resident representative in a timely manner of a change in condition, to include slurred speech, incoherent behavior, and altered cognition for one resident (Resident #1). The facility census was 54. 1. Review of the facility's Change in a Resident's Condition or Status policy, revised May 2017, showed a facility representative will notify the resident, his/her family, or representative when there is a change in the resident's level of care status. 2. Review of Resident #1's significant change Minimum Data Set (MDS), a federally mandated assessment tool used to plan care, dated 1/26/22, showed staff assessed the resident as follows: -Severe cognitive impairment; -Diagnosis of Diabetes Mellitus (a group of diseases that result in too much sugar in the blood, high blood glucose), and manic depression (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs). Review of the resident's nurses notes, dated 2/17/23, showed staff documented, they assessed that morning the resident had slurred speech, was only oriented to self, and had smeared tooth paste all over his/her face. Staff notified the resident's physician who gave new orders to stop hydrocodone (narcotic pain medication) and Prednisone (steroid). Review showed staff did not document they notified the resident's responsible party/family regarding the assessed changed in condition to the resident or the medication order changes. During an interview on 2/23/23 at 12:15 P.M., the Director of Nurses (DON) said he/she would expect staff to call the family anytime they identified a change in condition with a resident to include slurred speech, change in cognition, and incoherent behaviors. During an interview on 2/23/23 at 12:30 P.M., the Administrator said the family and physician should be notified with any change in clinical status per the policy. He/She said that he/she would have expected the family to be notified when the resident was identified with a change in condition. During an interview on 2/24/23 at 1:49 P.M., LPN C said that he/she had not notified the family when he/she identified the resident had a change in condition but that he/she should have. LPN C said, I am not sure why I did not notify the resident's family, I must have just got pulled away, but I should have followed up and didn't. MO00214254

Based on observation, interview and record review, the facility staff failed to perform hand hygiene as often as necessary using approved techniques to prevent cross-contamination. The facility census was 54. 1. Review of the facility's Glove and Hand Washing Procedures policy, dated 2011 and posted in the kitchen, showed the policy directed staff to wash their hands upon entering the kitchen from any other location, after all breaks, between all tasks, before and after handling foods, and after touching any part of the uniform, face, or hair. Review also showed the policy directed staff to turn off the faucet with a paper towel after they wash their hands. Observation on 11/29/22 at 9:47 A.M., showed Dietary Aide (DA) N washed his/her hands at the handwashing sink and then turned the faucet off with his/her wet bare hands. Observation also showed Cook P washed his/her hands at the handwashing sink. Observation showed the cook turned the faucet off with a paper towel and then used the same paper towel to dry his/her hands before he/she continued to prepare food items for service at the noon meal. Observation on 11/29/22 at 9:52 A.M., showed DA N reentered kitchen and washed his/her hands at the handwashing sink. Observation showed the DA turned the faucet off with his/her wet bare hands and then continued to perform kitchen tasks. Observation on 11/29/22 at 10:49 A.M., showed Cook P washed his/her hands at the handwashing sink. Observation showed the cook turned the faucet off with a paper towel and then used the same paper towel to dry his/her hands before he/she continued to prepare food items for service at the noon meal. Observation on 11/29/22 at 11:04 A.M., showed DA O washed his/her hands at the handwashing sink. Observation showed the DA turned the faucet off with his/her wet bare hands and then assisted with preparation of food trays for meal service. Observation on 11/29/22 at 11:39 A.M., showed Cook P washed his/her hands at the handwashing sink. Observation showed the cook turned the faucet off with a paper towel and and then used the same paper towel to dry his/her hands before he/she returned to the steamtable to continue meal service. During an interview on 11/29/22 at 11:41 A.M., the Cook P said staff are to turn the faucet off with a paper towel so you do not get your hands dirty again. The cook said once the paper towel touches the faucet then it would be considered dirty too and he/she did not think about the paper towel being dirty when he/she used it to dry his/her hands. Observation on 11/29/22 at 12:31 P.M., showed DA O washed soiled dishes at the mechanical dishwashing station and then washed his/her hands at the handwashing sink. Observation showed the DA turned the faucet off with his/her wet bare hands, poured him/herself a drink from the reach-in refrigerator, took a drink and then, without performing hand hygiene, put away sanitized dishes from the clean side of the station. Observation on 11/29/22 at 12:36 P.M., showed Cook Q washed his/her hands at the handwashing sink. Observation showed the cook turned the faucet off with his/her wet bare hands and then continued to prepare food for service to residents at the meal. Observation on 11/29/22 at 12:43 P.M., showed DA O washed soiled dishes at the mechanical dishwashing station. Observation showed, without performing hand hygiene, the DA put away sanitized dishes from the clean side of the station. Observation on 11/29/22 at 12:52 P.M., showed DA O washed soiled dishes at the mechanical dishwashing station and then washed his/her hands at the handwashing sink. Observation showed the DA turned the faucet off with his/her wet bare hands and then put away sanitized dishes from the clean side of the station. During an interview on 11/29/22 at 12:55 P.M., DA O said he/she had not been trained on handwashing procedures, but staff should wash their hands between doing dirty and clean things, which would include washing dishes. The DA said after hands are washed, staff should turn off the faucet with their hands and no had ever told him/her that he/she could not use his/her bare hands to turn off the faucet. During an interview on 11/29/22 at 1:00 P.M., the Dietary Manager (DM) said staff are expected to wash their hands in accordance with the facility policy and staff should be trained on handwashing procedures by their trainer. The DM said staff should wash their hands when they come in the kitchen and between handling dirty and clean dishes. The DM said staff should turn the faucet off with anything other than their bare hands after they wash their hands and staff should not use the same paper towel they used to turn off the faucet to dry their hands. Interview on 11/29/22 at 1:12 P.M., the administrator said all staff are trained on handwashing procedures upon hire during their orientation. The administrator said staff should wash their hands every time they touch something dirty before they touch anything clean. The administrator said staff should turn the faucet off with a paper towel after they wash their hands and they should not use the same paper towel they used to turn the faucet off to dry their hands.

Based on observation, interviews, and record review the facility staff failed to ensure the resident's call lights were answered in a timely manner. The facility's census was 54. 1. Review of the facility's Call light Accessibility and Response policy dated, [DATE], showed staff were directed as follows: -All staff will be educated on the proper use of the resident call system, including how the system works and ensuring resident access to the call light; -Staff will report problems with a call light or the call light system immediately to the supervisor and/or the maintenance director and will provide immediate or alternative solutions until the problem can be remedied ; -All staff members who see or hear an activated call light are responsible for responding. If the staff member cannot provide what the resident desires, the appropriate personnel should be notified. Review of the facility's electronic call light report between [DATE] at 12:15 P.M. and [DATE] at 10:17 P.M., showed the following: - [DATE] at 1:17 P.M., room [ROOM NUMBER] bed call light response of 18:05 minutes, with 4 repages; - [DATE] at 1:21 P.M., room [ROOM NUMBER] bed call light response of 20:38 minutes, with 5 repages - [DATE] at 2:24 P.M., room [ROOM NUMBER] bath call light response of 31:24 minutes, with 7 repages; - [DATE] at 2:23 P.M., room [ROOM NUMBER] bed call light response of 18:45 minutes, with 4 repages; - [DATE] at 3:18 P.M., room [ROOM NUMBER] bed call light response of 30:42 minutes, with 7 repages; - [DATE] at 3:15 P.M., room [ROOM NUMBER] bed call light response of 20:53 minutes, with 5 repages; - ,d+[DATE] at 5:18 P.M., room [ROOM NUMBER] bed call light response of 17:44 minutes, with 4 repages; - [DATE] at 6:46 P.M., room [ROOM NUMBER] bed call light response of 1 hour and 11 minutes, with 15 repages; - [DATE] at 6:19 P.M., room [ROOM NUMBER] bed call light response of 24:04 minutes, with 5 repages; - [DATE] at 7:02 P.M., room [ROOM NUMBER] bed call light response of 1 hour and 2 minutes, with 13 repages; - [DATE] at 7:03 P.M., room [ROOM NUMBER] bed call light response of 1 hour and 27 minutes, with 18 repages; - [DATE] at 7:03 P.M., room [ROOM NUMBER] bed call light response of 18:01 minutes, with 4 repages; - [DATE] at 7:46 P.M., room [ROOM NUMBER] bed call light response of 56:07 minutes, with 12 repages; - [DATE] at 7:37 P.M., room [ROOM NUMBER] bed call light response of 37:59 minutes, with 8 repages; - [DATE] at 7:38 P.M., room [ROOM NUMBER] bath call light response of 21:31 minutes, with 5 repages; - [DATE] at 7:37 P.M., room [ROOM NUMBER] bed call light response of 19:09 minutes, with 4 repages; - [DATE] at 8:18 P.M., room [ROOM NUMBER] bed call light response of 21:05 minutes, with 5 repages; - [DATE] at 1:33 A.M., room [ROOM NUMBER] bed call light response of 44:52 minutes, with 9 repages; - [DATE] at 3:15 A.M., room [ROOM NUMBER] bed call light response of 37:59 minutes, with 8 repages; - [DATE] at 3:57 A.M., room [ROOM NUMBER] bath call light response of 24:22 minutes, with 5 repages; - [DATE] at 7:23 A.M., room [ROOM NUMBER] bed call light response of 1 hour and 38 minutes, with 20 repages; - [DATE] at 7:19 A.M., room [ROOM NUMBER] bed call light response of 1 hour and 24 minutes, with 19 repages; - [DATE] at 6:56 A.M., room [ROOM NUMBER] bed call light response of 1 hour and 9 minutes, with 14 repages; - [DATE] at 6:39 A.M., room [ROOM NUMBER] bed call light response of 49:04 minutes, with 10 repages; - [DATE] at 6:51 A.M., room [ROOM NUMBER] bed call light response of 17:47 minutes, with 4 repages; - [DATE] at 7:24 A.M., room [ROOM NUMBER] bed call light response of 49:12 minutes, with 10 repages; - [DATE] at 7:55 A.M., room [ROOM NUMBER] bed call light response of 44:28 minutes, with 9 repages; - [DATE] at 8:17 A.M., room [ROOM NUMBER] bed call light response of 46:24 minutes, with 10 repages; - [DATE] at 8:44 A.M., room [ROOM NUMBER] bed call light response of 49:09 minutes, with 10 repages; - [DATE] at 8:44 A.M., room [ROOM NUMBER] bath call light response of 17:02 minutes, with 4 repages; - [DATE] at 10:54 A.M., room [ROOM NUMBER] bed call light response of 16:54 minutes, with 4 repages; - [DATE] at 11:28 A.M., room [ROOM NUMBER] bed call light response of 18:37 minutes, with 4 repages; - [DATE] at 12:04 P.M., room [ROOM NUMBER] bed call light response of 27:59 minutes, with 6 repages; - [DATE] at 1:03 P.M., room [ROOM NUMBER] bed call light response of 16:25 minutes, with 4 repages; - [DATE] at 2:13 P.M., room [ROOM NUMBER] bed call light response of 1 hour and 3 minutes, with 13 repages; - [DATE] at 1:42 P.M., room [ROOM NUMBER] bed call light response of 24:51 minutes, with 5 repages; - [DATE] at 2:56 P.M., room [ROOM NUMBER] bed call light response of 18:32 minutes, with 4 repages; - [DATE] at 3:17 P.M., room [ROOM NUMBER] bed call light response of 20:10 minutes, with 5 repages; - [DATE] at 3:36 P.M., room [ROOM NUMBER] bed call light response of 26:03 minutes, with 6 repages; - [DATE] at 3:37 P.M., room [ROOM NUMBER] bed call light response of 20:09 minutes, with 5 repages; - [DATE] at 3:46 P.M., room [ROOM NUMBER] bed call light response of 17: 39 minutes, with 4 repages; - [DATE] at 4:12 P.M., room [ROOM NUMBER] bed call light response of 39:16 minutes, with 8 repages; - [DATE] at 3:57 P.M., room [ROOM NUMBER] bed call light response of 24:43 minutes, with 5 repages; - [DATE] at 4:06 P.M., room [ROOM NUMBER] bed call light response of 23:17 minutes, with 5 repages; - [DATE] at 4:13 P.M., room [ROOM NUMBER] bed call light response of 30:14 minutes, with 7 repages; - [DATE] at 7:15 P.M., room [ROOM NUMBER] bed call light response of 1 hour and 30 minutes, with 19 repages; - [DATE] at 7:23 P.M., room [ROOM NUMBER] bed call light response of 1 hour and 36 minutes, with 20 repages; - [DATE] at 6:41 P.M., room [ROOM NUMBER] bed call light response of 47:49 minutes, with 10 repages; - [DATE] at 7:15 P.M., room [ROOM NUMBER] bed call light response of 1 hour and 16 minutes, with 16 repages; - [DATE] at 7:15 P.M., room [ROOM NUMBER] bed call light response of 1 hour and 12 minutes, with 15 repages; - [DATE] at 7:18 P.M., room [ROOM NUMBER] bed call light response of 1 hour and 6 minutes, with 14 repages; - [DATE] at 7:15 P.M., room [ROOM NUMBER] bed call light response of 48:32 minutes, with 10 repages; - [DATE] at 7:26 P.M., room [ROOM NUMBER] bed call light response of 57:13 minutes with 12 repages; - [DATE] at 7:17 P.M., room [ROOM NUMBER] bed call light response of 40:52 minutes, with 9 repages; - [DATE] at 7:24 P.M., room [ROOM NUMBER] bed call light response of 44:53 minutes, with 9 repages; - [DATE] at 7:19 P.M., room [ROOM NUMBER] bed call light response of 40:09 minutes, with 9 repages; - [DATE] at 7:05 P.M., room [ROOM NUMBER] bed call light response of 21:09 minutes, with 5 repages; - [DATE] at 8:28 P.M., room [ROOM NUMBER] bed call light response of 1 hour and 4 minutes, with 13 repages; - [DATE] at 8:40 P.M., room [ROOM NUMBER] bed call light response of 57:36 minutes, with 12 repages; - [DATE] at 8:11 P.M., room [ROOM NUMBER] bed call light response of 18:32 minutes, with 4 repages; - [DATE] at 8:36 P.M., room [ROOM NUMBER] bed call light response of 18:06 minutes, with 4 repages; - [DATE] at 10:17 P.M., room [ROOM NUMBER] bed call light response of 17:36 minutes, with 4 repages. 2. Observation on [DATE] at 10:15 A.M., showed the monitor in 200 hall used for call lights was not on and in standby mode showing no display. 3. During an interview on [DATE] at 3:03 P.M., Resident #11's family member said call light responses can take over one hour. He/She feels this has caused a decline in the resident's care and overall health. During an interview on [DATE] at 8:47 A.M., Resident #51 said call lights take a while to be answered; they are supposed to be answered within 30 minutes but it can be longer. During and interview on [DATE] at 11:58 A.M., Resident #23 said he/she had to wait up to on hour to get a response to a call light. He/She added that is too long to wait and he/she has urinated in their clothing requiring a change of clothing. During an interview on [DATE] at 1:28 P.M., Resident #54 said he/she has defecated in their clothing due to waiting an hour for staff to respond to a call light request. During an interview on [DATE] at 9:50 A.M., Licensed Practical Nurse (LPN) G said the call lights above the rooms do not light up and the pagers malfunction a lot so staff just look at the monitors in the hallway or at nurse's desk frequently to check if a call light is going off. During an interview on [DATE] at 10:17 A.M., Certified Nurse Assistant (CNA) A said call lights show up on a monitor and pagers. He/She said they don't use the pagers because they are either lost or not functioning so they check the monitors. During an interview on [DATE] at 3:38 P.M., Certified Medication Technician (CMT) K said staff watch the monitors to see when a call light is on. They used to have pagers but they are not used anymore. During an interview on [DATE] at 3:42 P.M., Registered Nurse (RN) S said they have a monitor system they watch for call lights and CNAs have pagers they should be using but he/she was not aware if the pagers were being used or not. During an interview on [DATE] at 3:40 P.M., CNA B said staff use the monitors in the halls and behind the nurses station to check for call lights. He/She said there are pagers but they do not used them, he/she was not aware of the pagers until after being employed for three months. During an interview on [DATE] at 3:45 P.M., CNA C said staff have told supervisors about the pagers being lost or broken. During an interview on [DATE] at 8:26 A.M., the maintenance director said call lights are shown on the monitors in the halls and at the nurse station and are to also go to pagers. He/She had orders in for replacement pagers and parts for the ones still in the facility but the company that makes them is not providing them. During an interview on [DATE] at 9:22 A.M., the administrator said call lights go to monitors in the hall and are to go to staff pagers. Pagers have not been available due to the company that makes them having supply issues. The monitors are being used at this time as the call light system. Call lights should be answered in five minutes.

Based on observation, interview, and record review, facility staff failed to store and label medication in a safe and effective manor in one of one medication storage rooms and in one of one medication storage carts. The facility census was 54. 1. Review of the facility's Storage of Medications policy dated, [DATE], showed the facility shall not use discontinued, outdated, or deteriorated drugs or biologicals. All such drugs shall be returned to the dispensing pharmacy or destroyed. Observation on [DATE] at 9:03 A.M., showed the 100 and 200 hall medication storage room contained: -Two 90 tablet bottles of 24 hour Loratadine 10 ml, with an expiration date of ,d+[DATE]; -Two 100 capsule bottles of Vitamin E 90 mg, with an expiration date of ,d+[DATE]. Observation on [DATE] at 9:25 A.M., showed the 100 hall medication cart contained: -One loose yellow tablet with a L stamped on it; -One loose brown tablet with 44291 stamped on it; -Two orange tablets with PC1 stamped on it; -One white tablet with 54612 stamped on it ; -One Brown tablet with 250 stamped on it; -One pink tablet with L200 stamped on it; -One Benefiber supplement bottle with an expiration date of ,d+[DATE]. During an interview on [DATE] at 8:18 A.M., Certified Medical Technician (CMT) H said expired medication should be destroyed with a second staff present. Loose medications found are shown to the charge nurse so they can destroy them. During an interview on [DATE] at 8:23 A.M., CMT M said out of date medication should be destroyed or sent back to the pharmacy. Loose medications should be destroyed. During an interview on [DATE] at 8:30 A.M., the assistant director of nursing said out of date medications or loose medication should be destroyed. During an interview on [DATE] at 9:20 A.M., the administrator said out of date medications should be removed and destroyed. Loose medications should also be removed and destroyed.

Based on staff interview and record review, the facility failed to ensure full time employment of a Director of Nursing (DON) since 9/26/22. The facility census was 54. 1. Review of the facility's Director of Nursing Services policy, revised August 2006, showed the following: - The Nursing services department is managed by the Director of Nursing Services. The Director is a Registered Nurse (RN), licensed by this state, and has experience in nursing service administration, rehabilitative and geriatric nursing; - The Director is employed full-time (40 hours per week). Review of the facility's Director of Nursing job description, undated, showed the following: - Interviews, hires, and trains employees; - Oversees facility in absence of higher-ranking management officials; - Maintains administrative authority, responsibility and accountability for the clinical team; - Investigate falls and allegations of abuse. Review of the Facility Assessment, last reviewed 4/28/22, showed the facility uses an infection control and antibiotic stewardship program developed by Pathways. The Quality Assurance and Process Improvement (QAPI) program team analyzes and reviews the data quarterly. Between quarterly QAPI meetings, the DON analyzes the data and develops plans of action as needed to address the issues. Review of the facility's payroll data for the period of 9/25/22 through 12/03/22, showed RN T as being paid as the DON. Review of a handwritten timeline of staff employed as DON, provided by the administrator, showed RN T filled the position from 4/11/22 through the current survey. During an interview on 11/30/22 at 8:38 A.M., the administrator said RN T was the DON and he/she just stepped down and is working the floor as charge nurse. The Minimum Data Set (MDS) coordinator is acting as DON and MDS coordinator. During an interview on 12/01/22 at 10:47 A.M., the administrator said he/she and the MDS coordinator are responsible for DON duties because the facility does not have a full time DON. During an interview on 12/02/22 at 7:42 A.M., Certified Nursing Assistant (CNA) A said they do not have a DON right now, the MDS coordinator is acting as the DON, and it has been a month or two since the last official DON, who stepped down to be a charge nurse only. During an interview on 12/02/22 at 7:53 A.M., CNA I said he/she was not sure who the DON is, most of the time he/she lets the Assistant Director of Nursing (ADON) know of concerns. During an interview on 12/02/22 at 8:07 A.M., Certified Medication Technician (CMT) M said he/she did not think the facility has a DON since the start of November 2022. During an interview on 12/02/22 at 10:21 A.M., the MDS coordinator said he/she has not been told he/she is the interim DON. The MDS coordinator said he/she filled the role of interim DON in the past, but not currently. He/She believes the DON stepped down about a month ago, but was not sure of the exact time. The MDS coordinator said he/she monitors the clinical side of the DON responsibilities, and the administrator does the rest. He/She said the ADON, who is a Licensed Practical Nurse (LPN), also assists him/her with the DON responsibilities. The MDS coordinator said the DON normally completes annual reviews of nursing staff, and he/she has not done a lot of that. He/She further said usually the DON interviews for new hires, but the administrator is doing that now. The MDS coordinator said he/she and the ADON monitor the performance of nursing staff and complete daily rounds and weekly grand rounds. During an interview on 12/02/22 at 10:34 A.M., the administrator said RN T moved to the floor as a charge nurse in mid-November, but was unable to provide an exact date. The administrator said RN T and the MDS coordinator are sharing DON responsibilities, and staff should know to go to the MDS coordinator if they need anything. He/She said he/she is responsible for hiring staff and setting up their schedules, and the Business Office Manager completes their orientation checklist. The administrator said he/she is responsible for investigating abuse and neglect allegations and falls, and talks to the MDS coordinator or ADON for feedback. During an interview on 12/06/2022 at 11:39 A.M., RN T said he/she submitted his/her resignation from the DON position on 8/26/2022 and returned to floor nursing on 9/26/2022. He/She also said he/she only performs floor nursing duties and is not performing any DON duties.

Based on interview and record review, facility staff failed to maintain and follow current guidance and procedures for immunizations of residents against pneumococcal (infection caused by bacteria) pneumonia in accordance with national standards of practice for five (Residents #3, #7, #16, #18 and #25) out of five sampled residents. The facility census was 54. 1. Review of the facility's Pneumococcal Vaccine Program policy, undated showed the following: -The pneumococcal vaccine program as recommended by the Centers for Disease Control and Prevention (CDC) varies for patients by age group. The recommendations were updated in 2016; -In 2016 there are two pneumococcal vaccines available for use in the United States; PCV13 and PPSV23; -Adults [AGE] years old or older who have already received a dose of PPSV23, should also receive a dose of PCV13 a year or more later; 2. Review of the U.S. Department of Health and Human Services - CDC, pneumococcal and influenza vaccine timing for adults, dated 4/01/2022, showed the following: -Four types of pneumonia vaccines are acceptable for adults [AGE] years or older. PCV13: 13-valent pneumococcal conjugate vaccine (Prevnar13), PCV15: 15-valent pneumococcal conjugate vaccine (Vaxneuvanc), PCV20: 20-valent pneumococcal conjugate vaccine (Prevnar20), and PPSV23: 23-valent pneumococcal polysaccharide vaccine (Pneumovax); -For those who previously received PPSV23 but who have not received any pneumococcal conjugate vaccine (e.g., PCV13, PCV15, PCV20) you may administer one dose of PCV15 or PCV20. -Regardless of which vaccine is used (PCV15 or PCV20): - The minimum interval is at least 1 year. - Their pneumococcal vaccinations are complete. 3. Review of Resident #3's medical record showed: -admitted [DATE]; -Age: 87; -received the Pneumovax (PPSV23) vaccine on 3/4/2016; -The record did not contain documentation the resident received, refused, or was offered the pneumococcal vaccine one year after receiving Pneumovax. 4. Review of Resident #7's medical record showed: -admitted [DATE]; -Age: 96; -received the Pneumovax (PPSV23) vaccine on 11/9/2016 ; -The record did not contain documentation the resident received, refused, or was offered the pneumococcal vaccine one year after receiving Pneumovax. 5. Review of Resident #16's medical record showed: -admitted [DATE]; -Age: 66; -received the Pneumovax (PPSV23) vaccine on 5/1/2019; -The record did not contain documentation the resident received, refused, or was offered the pneumococcal vaccine one year after receiving Pneumovax. 6. Review of Resident #18's medical record showed: -admitted [DATE]; -Age: 101; -received the Pneumovax (PPSV23) vaccine on 4/5/2016 ; -The record did not contain documentation the resident received, refused, or was offered the pneumococcal vaccine one year after receiving Pneumovax. 7. Review of Resident #25's medical record showed: -admitted [DATE]; -Age: 92; -received the Pneumovax (PPSV23) vaccine on 3/12/2012; -The record did not contain documentation the resident received, refused, or was offered the pneumococcal vaccine one year after receiving Pneumovax. 8. During an interview on 12/01/22 at 9:36 A.M., the Minimum Data Set (MDS) Coordinator said the Assistant Director of Nursing (ADON) is responsible for resident flu and pneumonia vaccinations. He/She said when a resident is admitted the ADON will gather and review vaccination information. He/She said when a resident turns 65 they need pneumonia vaccination status addressed again. During an interview on 12/01/22 at 9:45 A.M., the ADON said he/she received the new guidelines for pneumonia vaccines a few weeks ago but he/she hasn't had a chance to review yet. He/She said the pneumonia vaccination recorded in the electronic health record is the current vaccination. During an interview on 12/02/22 at 8:27 A.M., the administrator said the ADON is responsible for resident pneumonia vaccinations. He/She said the ADON monitors vaccination dates to ensure vaccinations are current.

Based on observation, interview, and record review, facility staff failed to post the required 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, and on a daily basis. The facility staff also failed to keep the required daily staffing records for eighteen months. The facility census was 54. 1. Review of facility Nurse Staff Posting policy, dated September 2022, showed the following: - Our facility will post, on a daily basis for each shift, the number of nursing personnel responsible for providing direct care to residents; - The nurse staffing sheet will be posted on a daily basis and will contain the following information: - Facility name; - The current date; - Facility's current resident census; - The total number and the actual hours worked by the following categories of licensed and unlicensed nursing staff directly responsible for resident care per shift: Registered Nurses (RN), Licensed Practical Nurses/Licensed Vocational Nurses (LPN/LVN), and Certified Nurse Aides (CNA); - The information will posted will be presented in a clear and readable format, and in a prominent place readily accessible to residents and visitors; - Nursing schedules and posting information will be maintained in the Human Resources Department for review for a minimum of 18 months or as required by State law, whichever is greater. Observation on 11/29/22 at 3:35 P.M. showed the nurse staffing information was not posted. Observation on 11/30/22 at 8:44 A.M. showed the nurse staffing information was not posted. Observation on 12/01/22 at 7:59 A.M. showed the nurse staffing information was not posted. Observation on 12/02/22 at 9:34 A.M. showed the nurse staffing information posted was dated 12/01/22. During an interview on 12/02/22 at 9:33 A.M., Certified Medication Technician (CMT) H said the nurse staffing information is supposed to be on wall in main dining room. During an interview on 12/02/22 at 10:19 A.M., the Business Office Manager (BOM) said LPN G is responsible for posting and saving the nurse staffing information. During an interview on 12/02/22 at 10:21 A.M., the Minimum Data Set Coordinator (MDS) said LPN G is responsible for posting and updating the nurse staffing information. During an interview on 12/02/22 at 10:34 A.M., The administrator said the night nurse is responsible for posting nurse staffing information, and LPN G will make sure it is correct, and file it in a binder to keep. The administrator was unable to provide the binder with saved nurse staffing information.

Based on interview, and record review, facility staff failed to administer medication in a safe manner to prevent accidents for one resident (Resident #1) when they did not remove a [MEDICATION(S)] patch (medication used to treat nausea and/or vomiting) from his/her medication cup before he/she swallowed it and required an emergent transfer to the hospital. The facility census was 58. 1. Review of the facility's Administering Medications, Storage of Medications Policy, dated December 2012, showed medications must be administered in accordance with the orders and the individual administering the medication must check to verify the right route before the medication is administered. 2. Review of Resident #1's quarterly Minimum Data Set (MDS), a federally mandated assessment tool, dated 6/1/22, showed staff assessed the resident as: -Mild Cognitive impairment; -Required extensive assistance from one staff member for bed mobility, transfers, locomotion, dressing, and hygiene; -Required set up assistance only for eating; -Has limited Range of Motion (ROM) (movement in joint) in one lower and one upper extremity; -Uses a wheelchair; -Diagnoses of dysphagia (difficulty with swallowing), [CONDITION(S)] ([CONDITION(S)]) (terminology for a stroke which is when the blood flow to a part of your brain is stopped either by a blockage or the rupture of a blood vessel). Review of the resident's nurse's note, dated 7/29/22 at 12:25 P.M., showed staff documented the resident had a pill stuck in his/her throat and was unable to clear it. Review showed staff documented the resident was able to verbalize some but it was gurgled and deep in sound. Review showed staff documented the resident coughing and gagging however he/she held his/her head up. Staff called the resident's physician and 911 to transport the resident to the emergency department. Review of the resident's nurse's note, dated 7/29/22 at 3:21 P.M., showed staff documented emergency department called report on the resident and said he/she had stable vital signs and had coughed up what was lodged in his/her throat. Review showed staff documented the emergency room reported it to be a [MEDICATION(S)] patch with the hard plastic back still attached. Review of the resident's physician's orders sheet, dated 8/22/22, showed an order directed staff to apply a [MEDICATION(S)] Patch topically behind the ear to decrease [MEDICATION(S)]. During an interview on 8/10/22 at 11:48 A.M., the resident said he/she was in the dining room when staff brought his/her medications to the table because he/she has a medication that is supposed to be taken before meals. He/She said, I picked up the cup and tossed them in my mouth as I always do, but when I swallowed them all of a sudden I couldn't breathe and was choking, He/She said it was very scary. During an interview on 8/10/22 at 12:13 P.M., Registered Nurse (RN) A said he/she was at the desk on the phone right before noon that day and saw staff bring the resident out of the dining room and it appeared they were working on him/her. Once off the phone the nurse asked him/her for assistance and he/she assessed the resident as in distress as he/she tried to gag and vomit but couldn't get anything to come up. They thought he/she was choking on a pill so once a few minutes had gone by he/she said the resident needed to go to the hospital. They called the doctor and received orders to send the resident out via ambulance. RN A said later that afternoon the hospital called and reported the resident had choked on a [MEDICATION(S)] Patch and not pills but that he/she had coughed it up while at the hospital. During an interview on 8/10/22 at 12:35 P.M., the Director of Nursing (DON) said when staff reported the incident to him/her an investigation was immediately started to find out what and how this could have occurred. Upon investigation they found that Certified Medication Tech(CMT) B had prepared the resident's medication and when he/she went to give them the resident was going to therapy. He/She placed the [MEDICATION(S)] patch in the resident's medication cup with his/her pills and when the resident returned from therapy, he/she took the pills to him/her but forgot that he/she had put the patch in the cup. The DON said he/she would not expect a patch to ever be put into a cup with resident medications. They are administered through different routes and they should not have ever been put together. During an interview on 8/15/22 at 12:43 P.M., CMT B said he/she had placed the [MEDICATION(S)] Patch in with the resident's pills and placed them in the top drawer of the medication cart because the resident was at therapy when he/she went to administer them. He/She said when the resident returned from therapy he/she took the pills and sat them on the table in front of the resident and had forgot he/she had even put the patch in the cup. CMT B said he/she didn't even remember until he/she was called at home later in the day and questioned about the incident by the DON. During an interview on 8/17/22 at 3:15 P.M., the Administrator said he/she believes it was an accident by CMT B but that he/she would not expect staff to administer medications with a patch inside the cup. MO 740

Based on observation, interview, and record review, the facility failed to implement interventions, follow facility wound care policy, and follow physicians orders to promote healing for eight dependent resident's facility acquired pressure ulcers (Resident #5, #11, #12, #16, #1, #2, #13 and #10) out of 22 sampled residents. The facility census was 61. 1. Review of Resident # 5's comprehensive Minimum Data Set (MDS), a federally mandated assessment instrument, dated 2/22/11, showed staff assessed the resident as: - Unable to repeat/recall three of three words; - Usually understands others; - Unable to report correct year, month, or day of the week; - Is cooperative with care, is not resistive to care provided; - Requires assistance of one person to assist with transfers; - Extensive assistance by staff for ambulation; - Continent of bowel and bladder; - Not at risk for pressure sores; - Had no venous, arterial, or pressure sores. - Active medical [DIAGNOSES REDACTED]. Review of the resident's Braden Scale (an assessment instrument for predicting pressure sore risk) dated 2/22/11, showed staff assessed with [REDACTED]. Review of the resident's Plan Of Care (POC), dated 2/08/11, showed staff identified the resident was at risk for skin breakdown and directed staff to: - Assist the resident of bed several times daily as tolerated and encourage position changes needed per staff assist. - Assess the resident's skin during daily care and bathing for breakdown and use lotion to hydrate dry, flaky areas. - Assess the resident's skin during showers. - Provide perineal care after each incontinent episode. - Provide the resident with adult incontinence briefs while out of bed, linen incontinence pads while the resident is in bed. - Pressure reducing mattress on bed at all times. - Report any red or open areas. - Apply [MEDICATION NAME] cream to the resident's abdominal folds following doctor's orders. - Apply Skin Prep (a topical medication that helps preserve proper skin integrity) to the resident's right heel (implemented 3/8/11). - Apply [MEDICATION NAME] topical spray (a topical spray that prevents skin breakdown, promotes healing, and fights infection) to the resident's left heel(implemented 3/8/11). Review of the Resident's physician's orders [REDACTED]. - Apply Skin Prep to the resident's right heel once each shift (a total of three times every 24 hours). - Apply [MEDICATION NAME] topical spray to the resident's left heel once each day. Review of the Weekly Skin Summary showed staff assessed the resident's skin as follows: - 1/25/11 "Redness, excoriation (abrasion) in crack of buttock" (Stage I pressure sore). - 2/9/11 "Left heel of foot is soft and painful to touch. "Have resident to elevate heels at all times when in bed". - 2/18/11 "Residents skin conditions have no changes from previous assessment, CPTx "(continue present treatment). - 2/24/11-"CPT for heels, no changes from previous assessment". - 3/5/11- "Heels are soft to touch and red". - 3/11/11- " Bilateral (both) foot heels are soft and red". - 3/17/11- "Resident's foot heels-left has a dime size black spot , right heel is soft, red continue Skin Prep". "Request wound nurse consult to evaluate right heel treatment, heel protectors on place up in pillows". Review of the Weekly Wound Report dated 3/20/11 showed staff documented a pressure sore on the resident's left heel that measured 1.5 centimeters (cm.) long, 0.9 cm. wide. The depth or Stage of the pressure sore was not documented. The narrative notes showed the following assessment by the staff,"L (left) heel presents a soft, dark, purple filled blister, surrounding tissue is pink and blanchable" (an area of red or pink skin that when pressed turns white in color, then upon release returns to it's original color or red or pink). The interventions listed the resident to wear heel protectors on at all times, and the resident's heels "floated" (an intervention by which the lower legs are elevated by means of a cushion ,wedge or pillow, so that the heels of the foot are suspended in the air, and "float" thereby relieving pressure on the heel cause by a solid or semi- solid surface) when the resident is in bed. The resident's treatment consisted of [MEDICATION NAME] topical spray once each day to the heel of the left foot, and Skin Prep to the heel of the right foot three times each day. Record review of the Weekly Wound Reports, completed by the facility's staff showed the following: The resident developed a facility aquired pressure sore on the heel of the right foot which the staff described as "new", "unstageable". The pressure sore measured 1.5 cm. long, 0.9 cm. wide, (no depth recorded). The pressure sore was described as,"100% soft, deep purple filled blister". The treatment listed is [MEDICATION NAME] daily. Preventive measures listed heel protectors to be worn by the resident at all times, and heels "floated" when in bed. Review of Nurse's Notes showed the following: -3/7/11 (7 a-3 p) -"New orders for Skin Prep to both heels each shift". "Noted purple blister on left heel 1.0 cm. long 0.5 cm. wide tender to touch". - 3/8/11(3 p-11 p) -"Resident continues to complain of left heel pain. Heels up with pillows and heel protectors applied". - 3/17/11 (3 p-11 p)-" Resident has a black spot in left heel about the size of a dime in dimension". "When in bed heels up with pillows, resident denies pain, continue treatment of [REDACTED]. Review of the Resident's Treatment Administration Record (TAR)dated 3/01/11-3/31/11 showed the following: - Apply Skin Prep to the resident's right heel once each shift ( a total of three times every 24 hours). Further review showed staff failed to document the treatment was given to the resident on 3/15/11 during the evening shift, and on 3/18/11 3/19/11 during the night shift. - Apply [MEDICATION NAME] topical spray to the resident's left heel once each day. Further review showed staff failed to document the treatment was given to the resident on 3/19/11. Observation on 3/23/11 at 8:00 A.M., showed the resident in his/her wheel chair, with leather shoes on each foot. Both of the resident's shoes lay against the foot rest heel loops of the wheelchair. Observation on 3/23/11 at 10:00 A.M., with Licensed Practical Nurse (LPN) K showed the resident had a dime size unstageable pressure sore. The pressure sore was dark brown in color, without drainage, on the outer side on the heel of the left foot. Further observation showed the skin surrounding the pressure sore to be pink, and blanchable by the staff. The resident's toes of the left foot to be intact, and pink in color. The right foot (heel and toes) did not have additional sores. Observation on 3/22/11 at 3:10 P.M., showed the resident lay on his/her back in bed. The heels of the resident's feet were not elevated and lay on the mattress. The resident's heel protectors were in the wheelchair at the foot of the bed. Observation on 3/22/11 at 4:00 P.M., showed the resident lay on his/her back in bed. The heels of the resident's feet were not elevated and lay directly on the bed mattress. The resident's heel protectors were in the wheelchair at the foot of the bed. Observation on 3/22/11 at 4:50 P.M., showed the resident lay on his/her back in bed. The resident's feet were not elevated, and his/her heels lay directly on the bed mattress resident's heel protectors were in the wheelchair at the foot of the bed. Observation on 3/23/11 at 7:00 A.M., showed the resident lay in bed on his/her right side asleep . The resident did not have heel protectors on in bed. The resident's feet were not elevated, and his/her heels lay directly on the bed mattress. During an interview on 3/23/11 at 10:00 A.M., LPN K said the following: - The resident's main mode of mobility is a wheelchair, either self- propelled or pushed by the staff. - The resident developed the "unstageable" pressure sore on the left heel "while living in the home". - Both of the resident's heels should have heel protectors on, and his/her heels should be "floated" off of the bed mattress while he/she is in bed. - The Resident treatment consisted of [MEDICATION NAME] spray to the left heel, and Skin Prep to the right heel. - The resident's wheelchair does not have a pressure reducing pad in it. Observation on 3/24/11 at 9:00 A.M., showed the resident sat in his/her wheel chair, with leather shoes on each foot. Both of the resident's shoes lay against the foot rest heel loops of the wheelchair. Observation on 3/25/11 at 2:05 P.M., showed the resident in asleep in his/her wheel chair, with leather shoes on each foot. Both of the resident's shoes lay against the foot rest heel loops of the wheelchair. During an interview on 3/25/11 at 2:50 P.M., Certified Nursing Assistant (CNA) L said the following: - Staff are given assignment sheets that direct each resident's daily care needs, the sheet is given to them at the beginning of the shift. - Resident # 5's daily care included heel protectors when in bed or in his/her wheelchair, and to "float" his/her heels off of the bed mattress. 2. Review of Resident # 11's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument, dated 2/22/11, showed staff assessed the resident as: - Able to repeat/recall three of three words; - Usually understands others, and is usually understood; - No moods or behaviors of resisting care; - Is cooperative with care, is not resistive to care provided; - Requires extensive assistance of two person to assist with transfers; - Extensive assistance by staff for ambulation; - Continent of bowel and bladder; - Has an indwelling urinary catheter; - At risk for pressure sores; - Had one Stage I venous, arterial, or pressure sore upon admission. - Active medical [DIAGNOSES REDACTED]. Review of the resident's Braden Scale (an assessment instrument for predicting pressure sore risk) dated 2/22/11, showed staff assessed with [REDACTED]. Review of the resident's Plan Of Care (POC), dated 10/29/10, showed staff identified the resident had a blister on the heel of the right foot at that time (Stage I ), was at risk for skin breakdown, and directed staff to: - Keep heels of mattress when in bed. - Bilateral heel protector on both feet. - Encourage to keep shoes off as much as possible, use slipper socks. - Weekly checks of heels by the wound nurse. - Regular diet (3/1/11). Review of the Bath Sheets, which the facility staff utilize to monitor residents skin condition showed the following: - 1/25/11- A mushy/discolored heel on the right foot. - 2/1/11 - A mushy/discolored, and open area heel on the right foot. - 2/3/11- An open area heel on the right foot. - 2/11/11- An open area heel on the right foot. - 2/13/11- No mushy/discolored open areas on the right foot. - 2/22/11- No mushy/discolored open areas on the right foot - 2/24/11- An open area heel on the right foot. - 3/1/11- An open area heel on the right foot. - 3/3/11- An open area heel on the right foot. - 3/8/11- An open area heel on the right foot, a "sore"on right heel. - 3/11/11- No mushy/discolored open areas on the right foot. Record review of the Weekly Wound Reports, completed by the facility's staff showed the following: - 11/4 to 11/8/10- The resident developed a facility aquired pressure sore on the heel of the right foot which the staff described as "new". The pressure sore measured 0.5 cm. long, 0.5 cm. wide, (no depth recorded). The pressure sore was described as,"100% soft , brown, eschar (dead skin tissue), and pink in color". treatment is Solosite, (a gelatin solution that aides in removing dead tissue from wounds) and Flexicol (an absorbant bandage wound dressing). Preventive measures listed heel protectors to be worn by the resident. - 12/14- 12/20/10 - The right heel pressure sore measured 0.3 cm. long, 0.4 cm. wide, (no depth recorded). The pressure sore was described as 100% pink with scant, serous, exudate ( pink-colored drainage) and some dry, flaky skin. The treatment was listed as [MEDICATION NAME] (an antibiotic) cream and Flexicol. Preventive measures listed heel protectors to be worn by the resident. - 12/21- 12/27/10 -The right heel pressure sore measured 0.3 cm. long, 0.3 cm. wide, (no depth recorded). The pressure sore was described as 100% pink with exudate. The treatment was listed as [MEDICATION NAME] cream and Flexicol. Preventive measures listed heel protectors to be worn by the resident. - 12/28 - 1/3/11- The right heel pressure sore measured 0.3 cm. long, 0.3 cm. wide, (no depth recorded). The pressure sore was described as 100% pink with exudate. The treatment was listed as [MEDICATION NAME] cream and Flexicol. Preventive measures listed heel protectors to be worn by the resident. - 1/4- 1/10/11- The right heel pressure sore measured 0.3 cm. long, 0.6 cm. wide, (no depth recorded). The pressure sore was described as brownish - red,and soft. The treatment was listed as a Permafoam Cosmopore (an absorbant bandage the allows air and water to pass through it) bandage. Preventive measures listed Pavalon (nylon) boot-heel protectors to be worn by the resident, and removal of the foot board of the bed. - 1/11-1/17/11 - The right heel pressure sore measured 0.5 cm. long, 0.5 cm. wide, (no depth recorded). The pressure sore was described as 100% white. The treatment was listed as [MEDICATION NAME] and a Permafoam Cosmopore bandage. Preventive measures listed Pavalon boot-heel protectors to be worn by the resident, and removal of the foot board of the bed. - 1/24/11- The right heel pressure sore measured 0.4 cm. long, 0.3 cm. wide, (no depth recorded). The pressure sore was described as 100% white. The treatment was listed as [MEDICATION NAME] and a Permafoam Cosmopore bandage. Preventive measures listed Pavalon boot-heel protectors to be worn by the resident, and removal of the foot board of the bed. - 2/7/11- The right heel pressure sore measured 0.3 cm. long, 0.3 cm. wide, (no depth recorded). The pressure sore was described as 100% pink. The treatment was listed as [MEDICATION NAME] and a Permafoam Cosmopore bandage. Preventive measures listed Pavalon boot- heel protectors to be worn by the resident, and removal of the foot board of the bed. -2/13/11-The right heel pressure sore measured 0.3 cm. long, 0.2 cm. wide, (no depth recorded). The pressure sore was described as 100% pink. The treatment was listed as [MEDICATION NAME] and a Permafoam Cosmopore bandage. Preventive measures listed Pavalon boot-heel protectors to be worn by the resident, and removal of the foot board of the bed. - 2/20/11- The right heel pressure sore was described as 100% dry callous, and scabbed. The treatment was listed as [MEDICATION NAME] and a Permafoam Cosmopore bandage. Preventive measures listed Pavalon boot- heel protectors to be worn by the resident, and removal of the foot board of the bed. -2/27/11- The right heel pressure sore was described as healed, 100% dry callous, and scabbed. The treatment was listed as a Permafoam Cosmopore bandage changed two times each day. Preventive measures listed Pavalon boot- heel protectors to be worn by the resident, and removal of the foot board of the bed. Review of the Weekly Skin Summary dated 2/19/11 showed staff assessed the resident's the right foot as, "a small open area on the right heel" Observation on 3/24/11 at 2:30 P.M., with LPN N showed the resident in his/her recliner chair wearing slipper socks on both feet, and a cloth heel protector around the right foot, "floating" off the chair's foot rest. The resident's foot, heel, and all the toes had no open areas, (healed Stage II) and was pink in color. Further observation showed the left foot, heel and all toes to be pink in color, with no open areas. During an interview on 3/24/11 at 2:30 P.M., LPN N said the resident had a blister that opened up" (Stage II pressure sore) on the heel of the right foot that the resident aquired while living in the facility. 3. During an interview on 3/25/11 at 3:15 P.M., the Director Of Nursing (DON) said the following: - Braden Scale are performed on all residents upon admission, each quarter, annually, and with any significant change in condition of the resident. - When a wound is found, the facility's staff are responsible for initiating the wound protocol. - The DON and Resident's physician are notified the same day the wound is discovered. - Nurses are responsible for implementing treatment using the wound protocol, or by obtaining physician orders [REDACTED]. - The wound nurse is responsible for the overall care of the wound when nursing or the DON notify him/her of the resident's wound. - Staff are responsible to assess, treat, and document all pressure sore (s) that are Stage I (reddened, intact skin) or greater severity - Staff are responsible for documentation in the Nurses Notes, and/or Weekly Wound Reports. - Skin Treatments are changed in seven days or less if the pressure sore has not improved. - Any omissions, or "blanks" in the signature areas of the TAR would indicated the treatment had not be given. 4. Review of Resident #12's Minimum Data Set (MDS), a federally mandated assessment instrument, dated 2/28/11, showed staff assessed the resident as: - Short and long term memory problem; - Severely impaired cognitive skills for daily decision making; - Total dependence on two plus persons physical assist for bed mobility, transfers and personal hygiene; - Always incontinent of bowel and bladder; - At risk for the development of pressure sores; - Pressure ulcers were not present on the resident's prior assessment. Review of the resident's plan of care, dated 6/7/10, showed staff were directed to: - Body/skin audit during assist with showers; - During care/dressing/bathing - look at resident's skin - use lotion/hydrate skin as needed - report excessive dryness, flakingess, abarasions, rash if noted; - Turn and reposition resident at least every two hours per nursing staff to releive pressure points - encourage and assist with position change. Review of the resident's Weekly Summary skin assessment sheet showed the licensed staff documented the following information: - 3/9/11 - Bilateral heels red and mushy; - 3/20/11 - The licensed staff did not document information about the resident's heels. Observation on 3/24/11 at 2:00 P.M. showed RN J in the resident's room to apply a protective cream to the resident's buttocks. The resident layed in bed with his/her heels in contact with the mattress. RN J removed the resident's Ted Hose (compression stockings) from his/her feet. The resident had a small blackened area, approximately 1centimeter (cm) by 0.5 cm, underneath the skin on the outer side of his/her right heel. During an interview conducted at the time of the observation, RN J said the small blackened area on the outer side of the resident's right heel was a "callous" (hardened/thickened skin). During an interview on 3/24/11 at 4:00 P.M. Observation on 3/24/11 at 4:00 P.M. showed the Director of Nursing (DON) observed the resident's outer right heel. During an interview conducted at the time of the observation, the DON said: - He/she would not consider the blackened area a "callous"; - The resident's outer right heel felt "mushy"; - The resident did not have a history of skin breakdown over his/her heels; - He/she would bring it to the physician's attention and get some heel protectors; - He/she would describe the area to the physician as "black pigmentation with callous over the top." Further review of the resident's medical record showed the licensed staff did not report the area to the resident's physician. During an interview on 3/25/11 at 2:30 P.M. Licensed Practical Nurse (LPN) A said: - To prevent pressure ulcers in dependent resident he/she would float a resident's heels on a pillow, use pillow protectors for the resident's heels, and turn the residents; - The resident "should have" heel protectors; During an interview on 3/25/11 at 3:06 P.M., the DON said: - Staff are expected to call the resident's physician the day a wound is identified; - Staff are expected to initiate the facility's wound protocol once a wound is identified; - Staff should notify the facility's wound care nurse either by verbal report or by filling out a wound report sheet; - The facility's wound care nurse is at the facility five days a week; - Wound care, including a full assessment of the wound, is done on Sundays; - The licensed staff are responsible to assess, treat, and document all pressure sore (s) that are Stage I (reddened, intact skin) or greater severity; - Staff are responsible for documentation in the Nurses Notes, and/or Weekly Wound Reports; - He/she expects the licensed staff to follow facility protocol, initiate the wound protocol, notify the residents physician, and communicate with hospice. 5. Review of Resident #16's Minimum Data Set (MDS), a federally mandated assessment instrument, dated 3/11/11, showed staff assessed the resident as: - Able to repeat three words; - Able to report correct month; - Unable to recall three words; - Requires extensive assistance of two plus persons physically assist for bed mobility, transfers, toilet use, and personal hygiene; - Always incontinent of bladder and bowel; - Not at risk for the development of pressure ulcers; - No unhealed ulcers at stage I (reddened, intact skin) or higher; - Pressure ulcers were not present on the prior assessment. Review of the resident's plan of care, updated on 1/11/11, showed staff were directed to: - Body/skin audit during assistance with showers; - During care/dressing, bathing, look at the resident's skin; - Incontinent - provide barrier cream as needed per staff; - Report any red or open areas; - (added on 1/11/11) OA (open area) noted to left buttock, dressings per orders; - Start AWC 30cc TID (three times a day); - Continue ensure pudding; - Multivitamin daily; - United Seating to be here 1/19/11 to evaluate for new wheelchair cushion due to open area. Review of the resident's Weekly Summary skin assessments showed: - 2/4/11 Open area to right and left gluteal fold; - 2/10/11 Left buttocks brown scar, left buttock pink- old open area now healed, right buttocks pink- old open area; - 2/17/11 Right and left buttocks red, old open area; - 2/26/11 Left and right old open area on buttocks, scarring; - (no documentation of a weekly skin assessment from 2/26/11 to 3/12/11, 13 days; - 3/12/11 Staff did not document any skin issues to the resident's right or left buttock; - 3/22/11 Staff did not document any skin issues to the resident's right or left buttock. Observation on 3/24/11 showed RN J provided treatment to the resident. RN J and an unidentified LPN cleansed the resident of fecal material. The resident had a small, approximately penny sized stage I pressure ulcer (a defined area of persistent redness, pressure-related alteration of intact skin) on his/her lower left buttocks. During an interview conducted at the time of the observation, RN J said: - The resident did not have the pressure sore prior to today; - The only intervention staff can do is to protect the skin, and use EPC (extra protective cream -a moisture barrier skin protectant) - He/she would measure the wound if he/she has time; - He/she will follow the wound protocol. Review of the resident's nurse's notes, dated 3/24/11 7:00 A.M. to 3:00 P.M. shift, showed the licensed staff documented: - Resident's right buttock is red and tender. Non-blancheable small area about the size of a dime; - Staff did not document actual measurements; - Staff did not document they notified the resident's physician. During an interview on 3/25/11 at 2:30 P.M. LPN A said: - Staff put the resident on his/her sides in bed and provide protective ointment -EPC During an interview on 3/25/11 at 3:06 P.M., the DON said: - Staff are expected to call the resident's physician the day a wound is identified; - Staff are expected to initiate the facility's wound protocol once a wound is identified; - Staff should notify the facility's wound care nurse either by verbal report or by filling out a wound report sheet; - The facility's wound care nurse is at the facility five days a week; - Wound care, including a full assessment of the wound, is done on Sundays; - The licensed staff are responsible to assess, treat, and document all pressure sore (s) that are Stage I (reddened, intact skin) or greater severity; - Staff are responsible for documentation in the Nurses Notes, and/or Weekly Wound Reports; - He/she expects the licensed staff to follow facility protocol, initiate the wound protocol, notify the residents physician, and communicate with hospice. 6. Record review of Resident #1's Braden Scale, a scale used to determine a person's risk for acquiring pressure ulcers, dated 12/23/10, showed staff assessed the resident to be at moderate risk. Record review of the resident's comprehensive plan of care, dated 1/15/11, showed the following: -The resident had a "fluid filled blister" on the right heel; -The resident had an "open area" on the spine. Further review of the resident's comprehensive plan of care showed staff were instructed to: -Assist resident with dressing and grooming needs; -Assist resident in repositioning while in bed and in chair as resident allows; -Assist resident in and out of bed several times daily as tolerated; -Encourage position change as needed per staff assistance; -Complete body/skin audits during showers; -Provide a cusion in wheelchair for pressure reduction; -Maintain good body alignment with weight distributed evenly; -Report any decline in mobility status and add interventions; -Monitor skin breakdown size and stage, wound granulation, healing status at least weekly per wound rounds; -Administer treatment per physician's orders [REDACTED]. -Provide an air mattress; -Keep heels off-loaded at all times; -Continue follow-up care at wound clinic. Record review of the resident's nurses notes, dated 1/16/11, showed staff documented the resident had a blood blister that covered the right heel, and they placed a heel floater on the resident's foot. Record review of the resident's Weekly Wound Reports showed the following: -Week of 1/11/11-1/17/11 staff documented the resident had two new pressure ulcers. Staff documented the first ulcer was a Stage II pressure ulcer(partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed without slough, may also present as an intact or open/ruptured blister) on the spine that measured 0.6 centimeters (cm) by 0.6 cm and described it as 80% loose adherent yellow slough and 20% pink tissue. Staff documented second ulcer was an unstageable pressure ulcer (known but not stageable due to coverage of wound bed by slough and/or eschar) on the right heel that measured 5.4 cm by 5.8 cm, described it as fluid filled and purple in color. -On 1/24/11 staff documented the resident had a Stage II pressure ulcer on the spine that had worsened. Staff documented the pressure ulcer measured 1.2 cm by 1.0 cm and described as 55% white/gray tissue and 45% pink tissue. Staff documented the resident had a Stage III pressure ulcer (Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon, or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling.) on the right heel that measured 5.0 cm by 2.5cm and described as 100% reddish black and firm. -On 2/7/11 staff documented the resident had a Stage II pressure ulcer on the spine that measured 1.2 cm by 0.9 cm and described as 100% white tissue. Staff documented the resident had a Stage III pressure ulcer to the right heel taht measured 4.8 cm by 3.2 cm and described as 100% reddish black and firm. -On 2/13/11 staff documented the resident had a Stage II pressure ulcer on the spine that measured 1.1 cm by 1.0 cm and described as 100% white tissue. Staff documented the resident had a Stage III pressure ulcer on the right heel that measured 4.7 cm by 3.4 cm, described as 100% reddish black and firm. -On 2/20/11 staff documented the resident had a Stage II pressure ulcer on the spine that measured 2.2 cm by 1.5 cm and decribed as 100% white tissue. Staff documented the resident had a Stage III pressure ulcer on the right heel that measured 4.7 cm by 3.4 cm, described as 100% reddish black and firm. -On 2/27/11 staff documented the resident had a Stage II pressure ulcer that measured 2.1 cm by 1.5 cm, described as 100% white tissue. Staff documented the resident had a Stage III pressure ulcer on the right heel that measured 4.7 cm by 3.4 cm. Staff described the Stage III pressure ulcer as 100% black, firm, and beginning to separate from surrounding tissue. -On 3/6/11 staff documented the resident had a Stage II pressure ulcer on the spine that measured 2.4 cm by 1.8 cm, described as pink granulating (healing) tissue. Staff documented the resident had a Stage III pressure ulcer on the right heel that measured 4.7 cm by 3.4 cm, described as 100% black and hard. -On 3/13/11 staff documented the resident had a Stage II pressure ulcer on the spine that measured 2.0 cm by 1.9 cm, described as 100% pale pink granulating tissue. Staff documented the resident had a Stage III pressure ulcer on the right heel that measured 4.2 cm by 3.3 cm, described as 100% black and hard. -On 3/20/11 staff documented the resident had a Stage II pressure ulcer on the spine that measured 2.4 cm by 1.7 cm, described as 40% pale pink granulating tissue and 60% bright pink granulating tissue. Staff documented the resident had a Stage III pressure ulcer on the right heel that measured 4.0 by 3.1, described as 100% black and hard. Record review of the resident's physician's orders [REDACTED]. -Pro-Stat AWC (a high protein dietary supplement that aids in wound healing); -[MEDICATION NAME] Spray (a topical skin care ointment designed to prevent infection, promote healing, and relieve pain) to the right great toe blister four times a day (ordered 2/4/11); -[MEDICATION NAME] Spray to back ulcer, cut out center of foam dressing and cover with a transparent dressing; -[MEDICATION NAME] Spray to the right heel three or four times a day; -[MEDICATION NAME] Spray to the right third and fourth toes and cover with gauze daily until healed; -Place an inflatable plastic ring behind the resident's back while he/she is sitting in a chair. Record review of the resident's treatment administration record (TAR), dated January 2011, showed the following: -The resident's physician directed staff to cover the resident's pressure ulcer on the spine with a foam dressing and cover with a transparent dressing and change daily. Record review of the TAR showed staff did not document they administered the treatment as ordered on 1/22, 1/23, 1/24, and 1/31. -The resident's physician directed staff to cleanse the resident's right heel pressure ulcer, apply hydrogel (maintains a moiste wound environment which promotes wound healing), cover with a non-adhering dressing and gauze, change daily and as needed. Record review of the TAR showed staff did not document they administered the treatment as ordered on 1/23 and 1/28. Record review of the resident's TAR, dated February 2011, showed the following: -The resident's physician directed staff to cover the resident's pressure ulcer on the spine with a foam dressing and cover with a transparent dressing and change daily until a new order was received on 2/22. Record review of the TAR showed staff did not document they administered the treatment as ordered on 2/7, 2/9, and 2/11. -On 2/22 the resident's physician directed staff to apply [MEDICATION NAME] Spray to the resident's back pressure ulcer with a dry foam dressing, change every shift and as neede