Based on observation, interview, and record review, the facility failed to establish and maintain a comprehensive infection prevention and control program designed to help prevent the development and transmission of water-borne pathogens (a bacterium, virus, or other microorganism that can cause disease), and failed to provide documented assessments for such an outbreak with accepted response protocols, in accordance with Centers for Medicare and Medicaid Services (CMS) guidelines. This deficient practice had the potential to affect all residents, visitors, volunteers, and staff who resided, visited, used, or worked in the facility. The facility census was 24 residents with a licensed capacity for 26 residents at the time of the survey. 1. Observation on 2/21/24 between 1:38 P.M. and 1:49 P.M. during the initial facility Life Safety Code (LSC) inspections with the Maintenance Contractor (MC) showed there were water heaters and hot water storage in the first floor Mechanical Room that served the third floor. Observation on 2/22/24 between 1:15 P.M. and 2:19 P.M. during the 3rd floor room-by-room facility LSC inspections with the MC showed the following: -There was a facility-wide fire sprinkler system. -There were public restrooms and a beauty shop with toilets and/or sinks. -There were at least 20 resident rooms with sinks and toilets, two bathhouses, and janitor's closets with mop hopper sinks. Review of the facility's emergency preparedness (EP) manual entitled Emergency Preparedness Manual, last reviewed on 2/23/23 and obtained from the front nurses station, with a 23-page section, Water Management Program to Reduce Legionella Growth and Spread in the Facility, last reviewed on 5/10/23 by the Director of Nursing (DON) and obtained from a wall rack by Elevator #2 on the first floor, showed the following: -Their Legionella Outbreak & Water Management Policy was a 5-page document last revised 3/2022 that consisted of two explanatory pages, a water-systems flow diagram, an outline of the program's elements, and a blank Water Systems Log Sheet. -There was no facility-specific risk assessment that considered the American Society of Heating, Refrigerating, and Air Conditioning Engineers (ASHRAE) industry standard #188. -There was no completed Centers for Disease Control (CDC) toolkit including control measures such as physical controls, temperature management, disinfectant level control, visual inspections, and environmental testing for pathogens. -There was no facility-specific infection prevention program or plan to deal with outbreaks of Legionella and/or other waterborne pathogens. -There were no facility-specific testing protocols and acceptable ranges for control measures with a method of monitoring them at this facility, with interventions or action plans for when control limits were not met. -There was no documentation of any site log book being maintained with any cleanings, sanitizings, descalings, and inspections mentioned. During an interview on 2/23/24 at 2:33 P.M., the MC said that the DON was responsible for the water-borne pathogen program. During an interview on 2/26/24 at 9:29 A.M., the DON said the following: -The Legionella policy in the EP manual was the only paperwork on it they had. -It was usually the maintenance people who handled the actual testing and temperature measuring. During an interview on 2/26/24 at 11:07 A.M., the Assistant Administrator said the following: -He/She helped to update the EP manual when necessary. -They added the Legionella policy about two years ago when told to do so. -They turned to the State of Missouri and the internet for its requirements. -The Maintenance Department was responsible for implementing it. During an interview on 2/26/24 at 1:58 P.M., the MC said the following: -He/She had not been completely educated on a water-borne pathogen program. -He/She did have some information on it though.

Based on interview and record review, the facility failed to act in the best interests of their residents who held a Resident Trust Fund (RTF) by not securing their monies in an interest bearing bank account. The deficient practice affected 19 residents who authorized the facility to manage their monies and funds. The facility census was 24 residents. 1. Record review of the facility's individual RTF bank statements dated, August 2021 to July 2022, showed these bank accounts to be non-interest bearing accounts for all of the residents who had a RTF with the facility. The average 12-month balance of these statements was $83,146.55. Record review of the residents' quarterly statements dated, January 2022, March 2022 and June 2022, showed no banking money interest accumulating in any of the 19 residents' RTF accounts. Record review of the facility's Current Account Balance dated 8/16/22, showed 19 residents who held a RTF with individual money balances over $50.00. This bookkeeping document also showed these residents to be Medicaid residents with money balances ranging from $57.42 to $4895.18. Record review of a facility's email initiating from the Business Office Manager (BOM) dated 8/18/22, showed the BOM asking for the banking representative to change over the facility's RTF account into an interest-bearing account. Also available on that email was a hand-written response from the BOM indicating he/she spoke with a banking representative/official who said it was going to take several weeks to change over the RTF account to an interest bearing account. During an interview on 8/16/22 at 11:46 A.M., the Business Office Manager said: -The facility was informed that their RTF bank account was going to be changed to a non-interest bearing account to have the bank's monthly service fee waived. -The monthly bank service fee was ranging from approximately eight to eleven dollars, which was more than the accumulated interest paid to the individual residents' or the RTF account.

Based on observation, interview, and record review, the facility failed to post required nurse staffing information, which included the total and actual hours worked by direct care staff who were directly responsible for resident care, per shift on a daily basis and visible for residents, visitors, and staff to view. The facility census was 24 residents. Record review of the facility's policy Posting Direct Care Staffing Numbers dated 7/2005 showed: -The number of nursing personnel responsible for providing direct care to residents would be posted on a daily basis for each shift. -The number of licensed nurses and Certified Nursing Assistants (CNAs) who provide direct care would be posted. 1. Record review of the facility's Daily Staffing Census form dated 8/2/22 through 8/15/22 showed: -The total resident census. -The number of licensed nursing staff and CNAs on each shift. -There was no documentation showing the number of hours worked by licensed nurses or CNAs. Observation on 8/15/22 at 1:59 P.M. showed: -The Daily Staffing Census form was hanging to the left of reception desk in a hallway not visible to visitors and residents. -The number of licensed staff and CNAs were on the form. -There were no number of hours worked on the form. Observation on 8/16/22 at 7:30 A.M. showed there was no staffing posted on the third floor resident living area of the building. Observation on 8/16/22 at 8:15 A.M. showed: -The Daily Staffing Census form was hanging to the left of reception desk in a hallway not visible to visitors and residents. -The number of licensed staff and CNAs were on the form. -There were no number of hours worked on the form. Observation on 8/17/22 at 8:00 A.M. showed: -The Daily Staffing Census form was hanging to the left of reception desk in a hallway not visible to visitors and residents. -The number of licensed staff and CNAs were on the form. -There were no number of hours worked on the form. Observation on 8/17/22 at 1:43 P.M. showed there was no staffing posted on the third floor resident living area of the building. During an interview on 8/18/22 at 8:18 A.M. the Care Coordinator said: -The Director of Nursing (DON) was responsible for posting the staffing daily. -He/She helped the DON out as needed. -The Daily Staffing Census form did not show the actual hours worked by the nursing staff. -The form was posted around the corner of the reception desk. -The form was not posted on the third floor resident living area. -The form was not visible to visitors and residents. During an interview on 8/18/22 at 8:25 A.M. the Director of Nursing (DON) said: -He/she was responsible for posting the daily staffing. -The Daily Staffing Census form was posted by the front desk at the entrance. -The visitors would stop and sign in so they should be able to see the form around the corner. -The form was not posted on the third floor resident living area. -The form was not visible to visitors and residents. -The Daily Staffing Census form did not show the actual hours worked by the nursing staff for each shift.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to obtain authorization from the Durable Power of Attorney (DPOA- a trusted person who a resident may choose to act in that resident's place for medical care and finances if that resident became mentally incapacitated) for two transactions of one severely cognitively impaired sampled resident (Resident #4) out of four residents sampled for the resident funds' review. The facility census was 51 residents. 1. Record review of Resident #4's Financial and Health Care DPOA paperwork dated 4/29/16, showed the resident had a friend as the financial POA. Record review of the resident's Minimum Data Sets (MDS-a federally mandated assessment tool required to be completed by facility staff for care planning) with the following dates showed: - The quarterly MDS dated [DATE], showed the resident was never/rarely understood so a Brief Interview for Mental Status (BIMS) score was not done and the resident was severely impaired in cognitive skills for daily decision-making. - An annual MDS dated [DATE], showed a BIMS score was a zero, and - The quarterly MDS dated [DATE], showed the Resident was never/rarely understood and the Resident was severely impaired in cognitive skills for daily decision-making, so a BIMS score was not done. Record review of the resident's financial transactions dated 11/19, showed two transactions dated 11/8/19 for $110.80 and $237.84 and the absence of a signature by the resident or the Resident's DPOA to authorize those transactions. During an interview on 12/11/19 at 11:54 A.M., the Business Office Manager (BOM) said he/she needed to contact the Social Worker (SW) regarding obtaining someone to look out for this resident's best interest. During an interview on 12/13/19 at 9:47 A.M., the Social Worker said: - The resident had a DPOA as stated in the signed paperwork; and - That DPOA decided on a day to day basis to what happened on behalf of Resident #4.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to complete and send a Third Party Liability (TPL) form (a form which is sent to MO Healthnet which gives an accounting of the remaining balance of that resident's funds in the resident trust account), which is required to be sent within 30 days after the death of three deceased sampled residents (Residents #1000, #1001, and#1002). This practice affected three residents whose resident fund records were reviewed for the purpose of conducting the resident fund investigation for the completion of the TPL forms. The facility census was 51 residents. 1. Record review of Resident #1000's records showed the resident died on [DATE] with a balance of $1, 414.64 in his/her account. During an interview on [DATE] at 12:22 P.M., the Business Office Manager (BOM) said he/she did not send a TPL form for that resident. 2. Record review of Resident #1001's records showed the resident died on [DATE] with a balance of $640.31 in his/her account. During an interview on [DATE] at 12:26 P.M., the BOM said a TPL form was not sent. 3. Record review of Resident #1002's records showed the resident died on [DATE] with a balance of $1159.35 in his/her account. During an interview on [DATE] at 12:29 P.M., the BOM was not sure of who paid for a funeral for that resident, but that burial plan was paid in full.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to complete a comprehensive assessment within 14 calendar days after the resident's admission for one sampled resident (Resident #346) out of 14 sampled residents. The facility census was 51 residents. Record review of the Centers for Medicare and Medicaid Services (CMS) Resident Assessment Instrument (RAI - helps the facility staff to gather definitive information on a resident's strengths and needs, which must be addressed in an individualized care plan) User's Manual dated October 2019 showed: -Federal statute and regulations require nursing homes to conduct initial and periodic assessments for all their residents. -Comprehensive Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff for care planning) assessments include the completion of the MDS as well as completion of the Care Area Assessment (CAA - a problem-oriented framework for arranging MDS information and additional clinically relevant information about an individual ' s health problems or functional status) process and care planning. -Comprehensive MDSs include Admission, Annual, Significant Change in Status, and Significant Correction to Prior Comprehensive Assessment. -Completion of an admission assessment must occur when the resident was in the facility previously and was discharged return anticipated and did not return within 30 days of discharge. -The required admission MDS completion date is no later than the 14th calendar day of the resident's admission (admission date + 13 calendar days). Record review of the facility's MDS Nursing Assessment policy revised August 2017 showed: -A nursing assessment is completed on each new admission, quarterly, annually, and when a change in condition occurs. The MDS form is used to record information obtained during the nursing assessment and is a permanent part of the medical record. --Its purpose is to provide a comprehensive assessment of each resident's ability to perform the activities of daily living (ADL - dressing, grooming, bathing, eating, and toileting). -The MDS Form is used as baseline information for initiation of the resident care plan and serves as the interim (temporary) care plan until the care plan conference. -MDS forms must be completed within fourteen (14) days of admission. -The CAA is completed and placed in the medical record with the MDS form. -The Trigger Indicator List (areas needing additional assessment) of the MDS is completed within the first fourteen (14) days by the nurse admitting the resident. -A copy of the Trigger Indicator List is distributed to the social work services, rehabilitation, dietary, and activity departments when appropriate. 1. Record review of Resident #346's assessments and tracking forms showed he/she: -Was admitted to the facility on [DATE]. -discharged from the facility with return anticipated on 5/31/19. -Was admitted to the facility on [DATE]. Record review of the facility's Electronic Health Records (EHR) showed: -An admission MDS dated [DATE] was present in the EHR with the status of Export Ready. -The 7/27/19 assessment was never added to a batch for submission. Record review of the resident's medical record included the following diagnoses and medical conditions: -Dementia (a chronic or persistent disorder of the mental processes caused by brain disease or injury and marked by memory disorders, personality changes, and impaired reasoning) Without Behavioral Disturbance. -Major Depressive Disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest in life). -Anxiety Disorder. -Altered Mental Status. -Dysphagia (difficulty swallowing). -Type 2 Diabetes Mellitus (a chronic disease characterized by high levels of sugar in the blood and insulin resistance) with Diabetic Neuropathy (nerve damage caused by diabetes). -Difficulty in Walking. -Hypokalemia (low potassium). -Hyperlipidemia (high concentration of fats or lipids in the blood). -Anemia (low iron levels). -Atrial Fibrillation (irregular, rapid heart rate). -High Blood Pressure. -Kidney Failure. -Catheter (a sterile tube inserted into the bladder to drain urine). -Pressure ulcers (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction). -Significant weight loss. During an interview on 12/13/19 at 3:18 P.M., the MDS/Care Plan Coordinator said: -He/she had been in the MDS/Care Plan Coordinator position for approximately three months. -He/she knew that some assessments and care plans were late when he/she took the position, and had worked with other departments to catch up. -His/her goal was to submit MDS assessments by the due date. -MDS assessments should be comprehensive, accurate, and completed according to required timelines. During an interview on 12/13/19 at 3:58 P.M., the Director of Nursing (DON) said: -Significant weight loss, pressure ulcers, and dementia care are examples of important areas that should be included and accurate in the comprehensive MDS assessment. -MDS assessments should reflect residents' needs and current status. -MDS assessments should be completed according to required timelines.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Record review of Resident #4's Face Sheet showed he/she was admitted to the facility on [DATE] with diagnoses including: -Parkinson's Disease (a progressive nervous system disorder that affects movement, characterized by tremors, speech difficulty, muscle weakness, muscle stiffness, and poor balance and coordination). -Psychotic Disorder (a mental state involving loss of contact with reality, causing deterioration of normal social functioning) with Delusions related to Parkinson's disease. -Stroke. -Unspecified Dementia (a chronic or persistent disorder of the mental processes caused by brain disease or injury and marked by memory disorders, personality changes, and impaired reasoning) With Behavioral Disturbance. -Insomnia (difficulty sleeping). -Underactive thyroid. -High Blood Pressure. -Asthma. Record review of the resident's Annual MDS dated [DATE] showed he/she: -Had severe cognitive impairment. -Had difficulty with communication. -Displayed some behavioral symptoms. -Required extensive assistance with all areas of activities of daily living (ADLs). -Had no falls since the previous assessment. -Had significant weight loss. Record review of the resident's Medical Record showed the resident's Quarterly MDS dated [DATE] was in process and was not completed (the MDS was past due). 3. Record review of Resident #346's assessments and tracking forms showed he/she was admitted to the facility on [DATE] with diagnoses and medical conditions that included: -Dementia (a chronic or persistent disorder of the mental processes caused by brain disease or injury and marked by memory disorders, personality changes, and impaired reasoning) Without Behavioral Disturbance. -Major Depressive Disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest in life). -Anxiety Disorder. -Altered Mental Status. -Dysphagia (difficulty swallowing). -Type 2 Diabetes Mellitus (a chronic disease characterized by high levels of sugar in the blood and insulin resistance) with Diabetic Neuropathy (nerve damage caused by diabetes). -Difficulty in Walking. -Hypokalemia (low potassium). -Hyperlipidemia (high concentration of fats or lipids in the blood). -Anemia (low iron levels). -Atrial Fibrillation (irregular, rapid heart rate). -High Blood Pressure. -Kidney Failure. Record review of the resident's December 2019 Physician's Orders showed the following medical conditions: -Use of an indwelling catheter (a sterile tube inserted into the bladder to drain urine). -Presence of pressure ulcers. -Issues with significant weight loss. Record review of the resident's Medical Record showed the resident's Quarterly MDS dated [DATE] was in process and was not completed (the MDS was past due). 4. During an interview on 12/13/19 at 4:00 P.M., the MDS Coordinator said: -He/She had been in the position for about three months. -He/She was new to MDS submissions and found out he/she had been putting in incorrect dates causing some MDSs and care plans to be late. -He/She received error reports related to late MDS submissions. During an interview on 12/13/19 at 4:43 P.M., the DON said: -He/She used to be the facility MDS Coordinator. -He/She transitioned to the role of the DON sometime in June 2019. -He/She was responsible to monitor MDS submissions to ensure they are submitted timely. -He/She did an audit after the new MDS Coordinator assumed his/her role to see what MDSs were late. -The MDS Coordinator did not understand the MDS, care plan, and Care Area Assessment (CAA - a problem-oriented framework for arranging MDS information and additional clinically relevant information about an individual's health problems or functional status) and was inputting the incorrect date. -The MDS Coordinator used to work as a clinical manager in the facility and does sometimes still do clinical manager duties. -The MDS Coordinator will not be performing clinical manager duties in the future so that he/she will have more time to work on MDS submissions. Based on interview and record review, the facility failed to ensure a resident's Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff for care planning) was completed quarterly for three sampled residents (Resident #196, #346, and #4) out of 14 sampled residents. The facility census was 51 residents. Record review of the Centers for Medicare and Medicaid Services (CMS) Resident Assessment Instrument (RAI - helps the facility staff to gather definitive information on a resident's strengths and needs, which must be addressed in an individualized care plan) User's Manual dated October 2019 showed: -Federal statute and regulations require nursing homes to conduct initial and periodic assessments for all their residents. -The Quarterly MDS assessment is used to track a resident's status between comprehensive assessments to ensure critical indicators of gradual change in status are monitored. -The Quarterly MDS assessment must be completed at least every 92 days following the previous assessment. Record review of the facility's Minimum Data Set Nursing Assessment policy revised August 2017 showed: -A nursing assessment is completed on each new admission, quarterly, annually, and when a change in condition occurs. The MDS form is used to record information obtained during the nursing assessment and is a permanent part of the medical record. -The MDS Form is used as baseline information for initiation of the resident care plan and serves as the interim (temporary) care plan until the care plan conference. -Information which must be obtained over a period of several hours to several days is added to the assessment form by the nurse obtaining the information. -Nurses on all shifts are requested to participate in the resident assessment process as needed. -For each ninety (90) days Care Conference meeting, the quarterly MDS review must be completed. The resident care plans are updated and review notes are written by each discipline. -For each change in level of care, the portion of the MDS form relevant to the change is completed by the appropriate discipline. 1. Record review of Resident #196's Face Sheet showed he/she was admitted to the facility on [DATE]. Record review of the resident's MDS submissions showed: -An admission MDS was submitted and accepted on 5/13/19. -No other MDS records were on file for the resident. --The resident should have had a quarterly MDS in August 2019 and November 2019. During an interview on 12/13/19 at 4:00 P.M., the MDS Coordinator said: -He/She did not know why two quarterly MDSs were not submitted for the resident. During an interview on 12/13/19 at 4:43 P.M., the Director of Nursing (DON) said: -At the time he/she did the MDS submission audit, he/she found three residents who had missing MDSs, but this resident was not one he/she had identified in his/her audit.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure the resident's Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff for care planning) was completed timely for one sampled resident (Resident #5) out of 14 sampled residents. The facility census was 51 residents. Record review of the Centers for Medicare and Medicaid Services (CMS) Resident Assessment Instrument (RAI - helps the facility staff to gather definitive information on a resident's strengths and needs, which must be addressed in an individualized care plan) User's Manual dated October 2019 showed: -Federal statute and regulations require nursing homes to conduct initial and periodic assessments for all their residents. -The Quarterly MDS assessment is used to track a resident's status between comprehensive assessments to ensure critical indicators of gradual change in status are monitored. -The Quarterly MDS assessment must be completed at least every 92 days following the previous assessment. Record review of the facility's Minimum Data Set Nursing Assessment policy revised August 2017 showed: -A nursing assessment is completed on each new admission, quarterly, annually, and when a change in condition occurs. The MDS form is used to record information obtained during the nursing assessment and is a permanent part of the medical record. -The MDS Form is used as baseline information for initiation of the resident care plan and serves as the interim (temporary) care plan until the care plan conference. -Information which must be obtained over a period of several hours to several days is added to the assessment form by the nurse obtaining the information. -Nurses on all shifts are requested to participate in the resident assessment process as needed. -For each ninety (90) days Care Conference meeting, the quarterly MDS review must be completed. The resident care plans are updated and review notes are written by each discipline. -For each change in level of care, the portion of the MDS form relevant to the change is completed by the appropriate discipline. 1. Record review of Resident #5's Face Sheet showed he/she was admitted on [DATE], with diagnoses including diabetes, obesity, depression, high blood pressure, asthma, allergies, and chronic pain. Record review of the resident's quarterly MDS dated [DATE], showed he/she: -Was cognitively intact with no memory loss and no behaviors. -Was independent with bed mobility, transfers, eating and toileting and needed limited assistance with bathing and dressing. -Had an upper extremity impairment on both sides (neck, shoulders). -Did not receive respiratory therapy. -Had pain and received pain medication. Record review of the resident's Medical Record showed the resident's quarterly MDS, dated [DATE] was in process and was not completed (the MDS was past due). Observation on 12/11/19 at 7:16 A.M., showed the resident was sitting in his/her recliner with his/her eyes closed resting comfortably. He/she was wearing a nasal cannula (a device used to deliver supplemental oxygen or increased airflow to a patient or person in need of respiratory help-the device consists of a lightweight tube which on one end splits into two prongs which are placed in the nostrils and from which a mixture of air and oxygen flows) that was attached to an oxygen concentrator and the oxygen concentrator was on at 2 liters per minute. The resident seemed to be resting comfortably without sign or symptom of shortness of breath, pain or discomfort. During an interview on 12/13/19 at 3:18 P.M., the MDS/Care Plan Coordinator said: -He/she had been in the MDS/Care Plan Coordinator position for approximately three months. -He/she knew that some assessments and care plans were late when he/she took the position, and had worked with other departments to catch up. -His/her goal was to submit MDS assessments by the due date. -MDS assessments should be comprehensive, accurate, and completed according to required timelines. During an interview on 12/13/19 at 3:58 P.M., the Director of Nursing (DON) said: -MDS assessments should reflect residents' needs and current status. -MDS assessments should be completed according to required timelines.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to complete a baseline care plan reflective of the resident's needs within 48 hours for two sampled residents (Residents #346 and Resident #15) out of 14 sampled residents. The facility census was 51 residents. Record review of the Centers for Medicare and Medicaid Services (CMS) Resident Assessment Instrument (RAI - helps the facility staff to gather definitive information on a resident's strengths and needs, which must be addressed in an individualized care plan) User's Manual dated October 2019 showed: -Federal statute and regulations require nursing homes to conduct initial and periodic assessments for all their residents. -Within 48 hours of admission, the facility must develop and implement a Baseline Care Plan for the resident that includes the instructions needed to provide effective and person-centered care of the resident that meets professional standards of care. Record review of the facility's Baseline Care Plan policy dated 10/2017 showed: -The objective is the completion and implementation of the baseline care plan within 48 hours of a resident's admission. It is intended to: --Promote continuity of care and communication among nursing home staff. --Increase resident safety. --Safeguard against adverse events that are most likely to occur right after admission. --Ensure the resident and/or the resident's representative, if applicable, are informed of the initial plan for delivery of care and services by receiving a written summary of the baseline care plan. -Upon admission, the home will begin the process of developing a baseline care plan and this care plan will be implemented within 48 hours of admission. -Information for the baseline care plan will be based upon admission orders, information from the transferring provider, and discussion with the resident and/or the resident's representative, if applicable and the resident so chooses. -The care plan will include at the minimum the following: --Initial goals based on admission orders. --Physician orders. --Dietary orders. --Therapy services. --Social services. --Instructions needed to provide effective and person-centered care that meets professional standards of quality care. --Address resident health and safety concerns to prevent decline or injury, such as elopement or fall risk. --Identify needs for supervision, behavioral interventions and assistance with activities of daily living (ADL - dressing, grooming, bathing, eating, and toileting) as necessary. -The care plan will reflect the resident's stated goals and objectives and include interventions that address his/her current needs. -The baseline care plan will include conditions and risks affecting the resident's health and safety. -Changes will be made as necessary, resulting from significant changes in condition or needs occurring prior to the development of the comprehensive care plan. --The facility staff or those acting on behalf of the facility will implement the interventions to assist the resident to achieve care plan goals and objectives. --Direct care staff will be educated about the care plan interventions. -The resident and/or the resident's representative will be provided with a written summary of the baseline care plan in a manner he/she can understand. The summary will include: --Initial goals for the resident. --A list of current medications. --Dietary instructions. --Services (i.e., therapy) and treatments to be administered by the facility and personnel acting on behalf of the facility. --Any updated information based on details of the admission comprehensive assessment as necessary. -The home may decide to present the baseline care plan as the summary as long as it meets the requirements listed. -There will be documentation in the clinical record that the baseline care plan summary was given to the resident and/or the resident's representative. -The home has the option of completing a comprehensive care plan instead of a baseline care plan as long as the comprehensive care plan is completed within 48 hours and follows the Resident Assessment Instrument process/requirements. --In this case, a written summary of the comprehensive care plan will be provided to the resident and/or the resident's representative in a language they can understand. 1. Record review of Resident #346's assessments and tracking forms showed he/she: -Was admitted to the facility on [DATE]. -discharged from the facility with return anticipated on 5/31/19. -Was readmitted to the facility on [DATE] with diagnoses and medical conditions that included: --Dementia (a chronic or persistent disorder of the mental processes caused by brain disease or injury and marked by memory disorders, personality changes, and impaired reasoning) Without Behavioral Disturbance. --Major Depressive Disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest in life). --Anxiety Disorder. --Altered Mental Status. --Dysphagia (difficulty swallowing). --Type 2 Diabetes Mellitus (a chronic disease characterized by high levels of sugar in the blood and insulin resistance) with Diabetic Neuropathy (nerve damage caused by diabetes). --Difficulty in Walking. --Hypokalemia (low potassium). --Hyperlipidemia (high concentration of fats or lipids in the blood). --Anemia (low iron levels). --Atrial Fibrillation (irregular, rapid heart rate). --High Blood Pressure. --Kidney Failure. --Catheter (a sterile tube inserted into the bladder to drain urine). --Pressure ulcers (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction). --Significant weight loss. Record review of the facility's Electronic Health Records (EHR) showed no baseline care plan was completed the resident's readmission to the facility on 7/19/19. Record review of the resident's December 2019 Physician's Orders Sheet (POS) included orders for the following medical conditions: -Altered diet related to swallowing difficulties. -Dietary Supplements related to poor appetite/weight loss. -Pressure ulcer prevention, care, and treatment. -Diabetes treatment. -Urinary catheter care and treatment. -Medication therapy for depression. 2. During an interview on 12/13/19 at 3:18 P.M., the MDS/Care Plan Coordinator said: -He/she had been in the MDS/Care Plan Coordinator position for approximately three months. -He/she knew that some assessments and care plans were late when he/she took the position, and had worked with other departments to catch up. -The MDS/Care Plan Coordinator is responsible for initiating baseline care plans. -Care plans should be updated and reflect the residents' needs. During an interview on 12/13/19 at 3:58 P.M., the Director of Nursing (DON) said: -Significant weight loss, pressure ulcers, and dementia care are examples of important areas that should be included and accurate in the care plan. -Care plans should reflect residents' needs and current status. -The baseline care plan is expected to be completed within 48 hours of admission. 3. Record review of Resident #15's admission Nurse's Notes dated 6/12/2019 at 10:30 A.M., showed the resident: -Was ambulatory via wheelchair (w/c) and he/she was accompanied by his/her daughter and family. -Usually ambulated with a walker but had tired with the distance. The resident's gait (manner of walking) with the walker was unsteady. -admitted he/she fell easily and had fallen several times in the past week. 911 had been called to help get him/her up. -Was instructed to call for assist to get up to go anywhere at all times, even during the night. Understanding was verbalized. -Was unable to get his/her balance when he/she attempted to get out of the chair. The resident kept leaning to the left and backwards, even after adjusting his/her feet. He/she started going backwards towards the chair and staff stopped him/her from falling. -Was alert and oriented x 3 (to person, place, and time) with some long term forgetfulness noted. Record review of the resident's admission Fall Risk assessment dated [DATE] at 12:13 P.M. showed the resident scored 17.0 and was at high risk for falls. Record review of the resident's Baseline Care Plan, admission date 06/12/19, showed he/she: -Communicated easily with and understood the staff. -Had diagnoses which included: --Stress incontinence (having no or insufficient control over urination or defecation). --Repeated falls. --Parkinson's disease (a chronic nervous disease characterized by a fine slowly spreading tremor, muscle weakness, muscle stiffness and a peculiar gait). --Restless legs syndrome (irresistible urge to move the legs). -The summary showed the resident: --Had a primary diagnosis of Parkinson's Disease. --Was alert and oriented. --Required the assist of one staff member for his/her activities of daily living (ADL - dressing, grooming, bathing, eating, and toileting). --Came from an apartment setting and had a recent rehab stay related to her diagnosis of Parkinson's disease and recurrent falls. ---The form was signed by the staff, but it was undated. The section for the resident and/or representative signatures and associated dates was left blank. ----There were no resident stated goals or objectives identified, no goals/objectives identified by the facility on this care plan, nor did it identify any interventions staff was to use to address the resident's safety needs, i.e., to prevent falls. It did not identify the resident suffered lack of balance and had a near fall with staff present when the resident stood up from his/her w/c on admission, or the need to reinforce information provided due to the resident's identified forgetfulness. Record review of the resident's Nurse's Notes 6/13/19 at 4:30 A.M. showed: -The resident was found kneeling on the floor on his/her left knee. He/she was barefoot and hanging on to his/her bed rail. The resident stated I did not fall. I slid out of the bed. I was trying to find my call button. I didn't. There were no apparent injuries at that time. The resident offered no complaints of pain or discomfort. Non-skid socks were placed on resident's feet prior to assisting resident to her feet. Record review of the resident's Baseline Care Plan showed it had not been updated to reflect the resident was weak, had slid out of bed, where the call light should be located as the resident had been unable to find his/her call light. Record review of the resident's Fall Care Plan on the resident's comprehensive care plan form dated 6/14/19 showed: -The resident was identified at risk for falls related to his/her diagnosis of frequent falls. -The resident's goal was to not have any injuries related to a fall through the next review time. -Interventions included: --PT/OT orders were obtained for the resident after his/her non-injury fall on 6/13/19. --Staff was to add bright colored tape to the resident's call light to make it easier for the resident to find. --Staff was to leave the resident's bathroom light on and the door partially open to all him/her to see where he/she was in the dark. ---The resident's Fall Care Plan did not identify his/her level of risk for falling, i.e., high risk due to a score of 17, did not identify the resident was weak, couldn't walk long distances and needed a w/c for such activity due to weakness, that he/she had balance issues when moving from a seated to a standing position and had almost fallen with staff present (as had been noted in the resident's nurse's notes), that he/she had slid out of bed on 6/13/19, that he/she needed reminders to use his/her call light when he/she needed/wanted to get up or that he/she needed to wear appropriate footwear (i.e., non-skid socks/shoes) when up. During an interview on 12/13/19 at 11:10 A.M., CNA G said staff used the [NAME] (a medical information system used by nursing staff as a way to communicate important information about their patients) in the computer to find out how to care for a resident. During an interview on 12/13/19 at 11:35 A.M., CNA E said the staff knew how to care for the resident by getting report from co-workers and through the [NAME] in the computer. During an interview on 12/13/19 at 11:34 A.M., Licensed Practical Nurse (LPN) A said: -Staff learned of new interventions either by being told by the nurses or by reading the resident's care plan. -Staff could update the resident's care plans but usually it was the MDS or DON who did that. During an interview on 12/13/19 at 3:50 P.M., the DON said: -A new resident's baseline care plan was to be completed within 48 hours. It was in the computer under Assessments. If a resident was at risk for falls, a fall care plan would be done before the MDS. -If a resident was at risk for falls or had a fall, they would huddle with the staff to inform them why the resident was at risk. -A resident's care plan should be individualized and should have interventions that were appropriate for them. -If a resident had no safety awareness, they should be checked every 30 or 60 minutes. --The resident's [NAME] were not provided by the facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop a comprehensive care plan for one sampled resident (Resident #346) out of 14 sampled residents. The facility census was 51 residents. Record review of the Centers for Medicare and Medicaid Services (CMS) Resident Assessment Instrument (RAI - helps the facility staff to gather definitive information on a resident's strengths and needs, which must be addressed in an individualized care plan) User's Manual dated October 2019 showed: -Federal statute and regulations require nursing homes to conduct initial and periodic assessments for all their residents. -The results of the Minimum Data Set (MDS- a federally mandated assessment tool to be completed by facility staff for care planning), which must accurately reflect the resident's status and needs, are to be used to develop, review, and revise each resident's comprehensive plan of care. -The care plan must be completed within seven days of the completion of the comprehensive assessment (MDS and Care Area Assessments (CAAs - a process to guide the Interdisciplinary Team (IDT) through a comprehensive assessment of a resident's functional status). Record review of the facility's Care Plan policy dated revised 08/2017 showed: -Every resident has a comprehensive care plan as part of his/her medical record. -The care plan contains quantifiable objectives for the highest level of function the resident may be able to attain. -The comprehensive care plan includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychosocial needs as identified in the comprehensive assessment. -The care plan is written within seven (7) days after the completion of the resident assessment and reflects intermediate steps for each outcome objective. -Staff uses these objectives to follow resident progress. -The care plan is prepared by the Interdisciplinary Care Plan Team (IDT - team members from different disciplines working together) which includes the attending physician, MDS Coordinator, the staff nurse responsible for the resident, the supervisor, the social worker, the activities department staff, and other appropriate staff as determined by the resident's need. -To the extent practical the resident and/or family or resident representative participates. -The social service department is responsible for sending a care conference notice to each resident and/or family member inviting participation. -At least every ninety (90) days the nurse, social worker, dietary staff, activities staff, and other staff as determined by the resident's need update the comprehensive care plan. 1. Record review of Resident #346's assessments and tracking forms showed he/she: -Was admitted to the facility on [DATE]. -discharged from the facility with return anticipated on 5/31/19. -Was readmitted to the facility on [DATE] with diagnoses and medical conditions that included: --Dementia (a chronic or persistent disorder of the mental processes caused by brain disease or injury and marked by memory disorders, personality changes, and impaired reasoning) Without Behavioral Disturbance. --Major Depressive Disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest in life). --Anxiety Disorder. --Altered Mental Status. --Dysphagia (difficulty swallowing). --Type 2 Diabetes Mellitus (a chronic disease characterized by high levels of sugar in the blood and insulin resistance) with Diabetic Neuropathy (nerve damage caused by diabetes). --Difficulty in Walking. --Hypokalemia (low potassium). --Hyperlipidemia (high concentration of fats or lipids in the blood). --Anemia (low iron levels). --Atrial Fibrillation (irregular, rapid heart rate). --High Blood Pressure. --Kidney Failure. --Catheter (a sterile tube inserted into the bladder to drain urine). --Pressure ulcers (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction). --Significant weight loss. Record review of the resident's Care Plan Progress Notes showed the last documented care plan meeting was held on 4/4/19 during a previous stay at the facility. Record review of the facility's Electronic Health Records (EHR) showed no care plan had been completed since the resident was readmitted the facility on 7/19/19. Record review of the resident's December 2019 Physician's Orders Sheet (POS) included orders for the following medical conditions: -Altered diet related to swallowing difficulties. -Dietary Supplements related to poor appetite/weight loss. -Pressure ulcer prevention, care, and treatment. -Diabetes treatment. -Urinary catheter care and treatment. -Medication therapy for depression. During an interview on 12/13/19 at 3:18 P.M., the MDS/Care Plan Coordinator said: -He/she had been in the MDS/Care Plan Coordinator position for approximately three months. -He/she knew that some assessments and care plans were late when he/she took the position, and had worked with other departments to catch up. -The MDS/Care Plan Coordinator is responsible completion of care plans. -Care plans should be comprehensive and reflect the residents' needs. During an interview on 12/13/19 at 3:58 P.M., the Director of Nursing (DON) said: -Significant weight loss, pressure ulcers, and dementia care are examples of important areas that should be included and accurate in the care plan. -Care plans should be comprehensive and reflect residents' needs and current status.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure the resident's care plan was updated to reflect the current status of the resident regarding his/her pain for one sampled resident (Resident #5) and skin care for one sampled resident (Resident #45) out of 14 sampled residents. The facility census was 51 residents. 1. Record review of Resident #5's Face Sheet showed he/she was admitted on [DATE], with diagnoses including diabetes, obesity, depression, high blood pressure, asthma, allergies, and chronic pain. Record review of the resident's quarterly Minimum Data Set (MDS-a federally mandated assessment tool to be completed by facility staff for care planning) dated 8/31/19, showed he/she: -Was cognitively intact with no memory loss and no behaviors. -Was independent with bed mobility, transfers, eating and toileting and needed limited assistance with bathing and dressing. -Had an upper extremity impairment on both sides (neck, shoulders). -Did not receive respiratory therapy. -Had pain and received pain medication. Record review of the resident's Care Plan last updated on 8/31/19, showed the resident had chronic pain related to a history of arthritis. The resident's arthritis pain increases with weather changes such as rain, snow, and cold. Interventions showed: -The resident will verbalize adequate relief of pain or ability to cope with incompletely relieved pain through the review date. -The resident will not have discomfort related to side effects of pain through the review date. -Nursing staff was to administer pain medication per physician's orders. -Obtain a referral for the resident to go to a pain clinic. -Nursing staff would monitor/document for side effects of pain medication and observe for constipation; new onset or increased agitation, restlessness, confusion, hallucinations, nausea, vomiting, dizziness and falls. Report occurrences to the physician. -Nursing staff would monitor/record pain characteristics each shift and as needed: Quality (e.g. sharp, burning); Severity (1 to 10 scale); Anatomical location; Onset; Duration (e.g., continuous, intermittent); Aggravating factors; Relieving factors. -Nursing staff would report to the nurse any change in usual activity attendance patterns or refusal to attend activities related to signs/symptoms or complaint of pain or discomfort. -The resident has a soft cervical collar that he/she wears as needed for neck pain. He/She states it is helpful. Record review of the resident's Physician's Note dated 9/4/19, showed a recommendation to follow up with pain management. Record review of the resident's Physician's Telephone Order 9/20/19, showed a physician's order for Oxycodone (narcotic pain medication) 10 milligrams (mg) daily. Record review of the resident's Physician's Note from the Pain Clinic dated 9/20/19, showed the resident had chronic pain in his/her upper extremities. Orders showed the resident found the Transcutaneous Electrical Nerve Stimulation unit (TENS - a small battery operated device placed on the skin to deliver low-voltage electrical current to relieve pain) to be effective and to continue as tolerated. It showed to continue Oxycodone 10 mg daily to maintain pain control, and water therapy. It showed the resident may use Bio-freeze (a topical pain control gel) as needed. Record review of the resident's Nursing Notes showed: -On 9/20/2019, the resident returned from the pain clinic with orders to continue with Oxycontin 10 mg daily to help maintain pain control, to continue with water therapy and to use Bio-freeze three times daily. Physician's orders were noted and fax to the pharmacy. -On 11/13/2019, the resident's primary care physician visited the resident and ordered that it was okay for the resident to keep Blue Emu cream (a topical pain relieving cream) at bedside and apply as directed for pain. The resident stated that his/her family will supply this. Record review of the resident's Physician's Order Sheet (POS) dated December 2019, showed physician's orders for: -Oxycontin (Oxycodone) Extended Release 12 Hour 10 mg, give 1 tablet one time a day for pain related to osteoarthritis, prescribed by the pain management clinic (ordered on 4/11/19, reordered on 9/20/19). -Bio-freeze Gel 4 % Menthol, Apply to shoulders and arms topically every shift for muscle aches (ordered on 10/22/19). -Meloxicam (Nonsteroidal anti-inflammatory drug used to treat pain) 15 mg give 1 tablet once daily for pain (ordered on 12/17/16). -Oxycodone 5 mg, give 1 capsule every 6 hours as needed for moderate to severe pain (ordered on 2/21/19). -Acetaminophen give 650 mg every 6 hours, as needed, for pain, not to exceed 3 grams in 24 hours (ordered on 11/29/18). -Lidocaine pad 5% apply 1 patch daily for 12 hours, off for 12 hours, as needed, for pain (ordered on 11/28/18). -Blue-Emu Super Strength Cream apply to shoulders topically, as needed, for pain, apply as directed. Family will supply. (ordered on 11/13/19). -A TENS unit - staff assists with putting on/off. The resident is able to operate per self as needed for pain relief (ordered 6/12/19). -Orthopedics to follow up regarding pain control (12/1/18). Record review of the resident's Care Plan showed there were no further updates to the resident's pain care plan that showed the resident was currently attending the pain clinic and had additional non-pharmacological interventions (water therapy, topical gel and cream, TENS unit and cervical collar) to assist with pain management. The care plan was not updated to show the resident was able to self-administer topical pain gel and cream and to use the TENS unit. Observation and interview on 12/09/19 at 10:15 A.M., showed the resident was sitting in his/her recliner with his/her walker in front of him/her. The resident was dressed for the weather and groomed without odor. He/she said: -He/She had chronic pain and had gotten his/her pain medication as ordered. -He/She had pain medication he/she used as needed and it is also provided as he/she needs it. -He/She took Oxycontin, Oxycodone and Tylenol for pain (from the pain clinic) but his/her physician also authorized him/her to take Glucosamine (an amino acid derivative taken as a supplement to assist in pain relief), which he/she received in a topical gel form, as needed (Blue Emu cream has Glucosamine in it). -He/She used the tub in the shower room for bathing and the water in the tub helped with his/her pain relief. 2. Record review of Resident #45's Face Sheet showed he/she was admitted to the facility on [DATE], with diagnoses including pain, heart failure, heart disease, constipation, shortness of breath, fracture and high blood pressure. Record review of the resident's admission MDS dated [DATE], showed he/she: -Was alert and oriented without cognitive impairment. -Was independent with transfers, walking, eating, toileting and hygiene. -Needed limited assistance with bathing and dressing. -Used a walker for mobility. -Had constant pain that affected his/her daily activities and functioning, and received pain medication as needed. -Had shortness of breath and received oxygen therapy. -Had no skin issues. Record review of the resident's Care Plan dated 11/22/19, showed care plan interventions related to pain, arthritis, fall risk, nutrition, oxygen use and use of anti-anxiety medications. There were no interventions showing the resident was at risk for or had any skin issues. Record review of the resident's Nursing Notes showed: -On 11/24/19, the resident stated he/she had made his/her right arm bleed yesterday and put a band-aid on it. Today when he/she took it off, it tore his/her skin off as well. The nurse documented the resident had a skin tear on his/her right forearm. The nurse cleaned it with normal saline, applied a Vaseline gauze with a gauze wrap. -On 11/27/19 the nurse documented he/she went to the resident's room to complete eye treatment and noted a dressing on his/her right wrist. The resident said a few days ago he/she was getting something out of his/her closet and bumped his/her arm and had a small area on it. The resident said, I put tape on it and when I pulled off the tape I tore off my skin and it would not stop bleeding. The resident said the nurse on the night shift had put the dressing on it and nothing else had been done. The nurse removed the dressing and noted a skin tear. He/she redressed the area and notified the resident's physician. The physician gave new orders to cleanse the area with normal saline, pat dry, apply Vaseline gauze and kerlix (a gauze dressing) and secure it with tape daily until it healed. Record review of the resident's Nursing Skin assessment dated [DATE], showed the resident had an oblong, quarter-sized area of skin off his/her (wrist) area. The resident said he/she bumped it on something in his/her closet a few days ago, see new treatment orders. Record review of the resident's POS dated December 2019, showed physician's orders to cleanse the resident's right wrist with normal saline, pat dry, apply skin prep (a protective ointment) to the area every day shift for a skin tear for one week until healed (ordered on 12/6/19). Record review of the resident's Care Plan showed there were no updates to the resident's care plan that showed the resident had a skin tear and no interventions for treating the resident's skin in order to prevent further skin tears/skin issues. Observation and interview on 12/11/19 at 6:48 A.M., showed the resident was sitting on a stool in his/her bathroom putting makeup on. He/She was fully dressed and was wearing oxygen. He/She was wearing a short sleeved shirt, but his/her skin tear was not seen at this time. The resident said he/she had hit his/her arm on something in his/her closet and tore the skin but the nursing staff cleaned and covered it daily, and it is almost healed. 3. During an interview on 12/13/19 at 3:35 P.M., the MDS Coordinator said: -He/she was responsible for ensuring the resident care plans were updated. -He/She would expect care plans to be updated to reflect the resident's current status. During an interview on 12/13/19 at 3:47 P.M., the Director of Nursing (DON) said he/she expected the resident care plans to be comprehensive and updated to reflect the current status of the resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Record review of Resident #13's Face Sheet showed he/she was admitted to the facility on [DATE] with a diagnosis of chronic Rhinitis (inflammation and swelling of the mucous membrane of the nose, characterized by stuffiness or runny nose, usually caused by the common cold or seasonal allergies). Record review of the resident's care plan dated 12/20/16 and updated on 9/14/19 showed no care plan to have medications at his/her bedside. Record review of the resident's quarterly MDS dated [DATE] showed he/she: -Was cognitively intact with a BIMS (Brief Interview for Mental Status) of 15 out of 15. -Was independent with bed mobility, transfers, walking, dressing, toileting, eating, bathing, and personal hygiene. Record review of the resident's September 2019, October 2019, November 2019 and December 2019 POS and Medication Administration Record (MAR) showed: -Flonase Allergy Relief Suspension, one spray in both nostrils every 12 hours as needed for allergies as needed. --No documentation by the facility staff the medication had been administered. --No physician's order for the resident to keep Flonase Allergy Relief Suspension at his/her bedside. -No physician's order for saline nasal spray. Record review of the resident's medical record showed no facility assessment of the resident's ability to self-administer Flonase or saline nasal spray. Observation on 12/10/19 at 12:49 P.M. showed: -One Flonase bottle on the resident's night stand. The bottle did not have a prescription label. -One bottle of saline nasal spray with a prescription label with may keep at bedside, but the date on the prescription label was worn off making it illegible for the prescription date or fill date or prescribing physician. During an interview on 12/10/19 at 12:51 P.M., the resident said: -He/She was not sure where the box for the Flonase bottle was, but that it had been labeled may keep at bedside. -He/She could not remember when he/she received the bottle of saline nasal spray, but the label was on the bottle marked he/she could keep at bedside. -He/She did not think staff had performed an assessment for him/her to keep medications at his/her bedside. -He/She used both medications occasionally, but could not recall the last time he/she had self-administered either medication. During an interview on 12/13/19 at 2:36 P.M., LPN A said: -Residents should have a physician's order to be able to keep a medication at bedside. -If a resident had an order to be able to keep a medication at bedside, he/she should also have an assessment performed to ensure he/she was able to properly self-administer the medication. -If a resident was able to self-administer medications and the medications could be left at bedside, the resident should have a care plan for self-administering medications. -He/She could not find a physician's order for the resident's saline nasal spray. -The resident did have an order for Flonase, but the order did not indicate he/she could keep the medication at bedside. -He/She did not know the resident had the bottle of Flonase or the bottle of saline nasal spray in his/her room. 4. During an interview on 12/13/19 at 3:33 P.M., the MDS Coordinator said a resident who has a valid order to self-administer medications and to keep the medications at bedside should have a care plan for self-administering medications. During an interview on 12/13/19 at 3:55 P.M., the DON said: -He/She expected staff to complete an assessment for a resident to be able to self-administer medications to ensure the resident was able to do so safely. -The resident should have a physician's order to self-administer medications and to leave medications at the resident's bedside. -If a resident had an order to leave medications at bedside and was assessed to be able to self-administer the medication safely, he/she would expect to see a care plan developed for that. Based on observation, interview and record review, the facility failed to ensure an assessment for self-administration of medication was completed, physician's orders were obtained to self-administer medication for two sampled residents (Resident #19 and #45) and one supplemental resident (Resident #13); to follow the care plan for self-administering eye drops for one sampled resident (Resident #19) and one supplemental resident (Resident #13); to ensure the care plan showed interventions for self-administration of breathing treatment medications for one sampled residents (Resident #45), and to ensure a resident had a valid physician's order for a medication found at the resident's bedside for one supplemental resident (Resident #13) out of 14 sampled residents. The facility census was 51 residents. Record review of the facility policy and procedure dated 10/2013, showed any resident wishing to self-administer medication must have a physician's order and a determination in writing that the interdisciplinary team has evaluated the resident for safe practice. The interdisciplinary team reviews the resident's ability to self-administer at least every 90 days. The purpose was to allow residents who are capable of self-administering medication, to do so with the safe-guard of routine re-evaluation by the interdisciplinary team to determine if a resident is no longer capable. -As part of the admission assessment a resident is asked if it is their desire to self-administer medication. -If the resident wishes to self-administer medications, the interdisciplinary team evaluates the resident's cognitive, physical, and visual ability to administer medications. The determination is based on an interview with the resident, agreement by the family, if applicable, and the opinion of the physician. -If the interdisciplinary team determines that the resident is unable to self-administer medications, because this would be a danger to the resident or others, then the interdisciplinary team may deny or withdraw the right to self-administer medications. -When a resident self-administers medications, the nursing staff will monitor the resident and observe the resident administering the medications; review the resident's self-administration medication administration record for accuracy of documentation; observe the resident's ability to see adequately; observe the resident's ability to physically handle medication and medication containers; assess the resident's cognitive function and ability to identify medications and purpose of medications. 1. Record review of Resident #19's Face Sheet showed he/she was admitted on [DATE], with diagnoses including high blood pressure, heart failure, respiratory failure, high cholesterol, stroke, glaucoma, and visual loss in his/her left eye. Record review of the resident's quarterly Minimum Data Set (MDS- a federally mandated assessment tool to be completed by facility staff for care planning) dated 9/27/19, showed he/she: -Was alert with some cognitive impairment. -Was independent with transfers, bathing, dressing, ambulation, toileting, eating and hygiene. -Had no pain. -Did not have shortness of breath but received oxygen therapy. -Had impaired vision and used corrective lenses. Record review of the resident's Physician's Order Review Report dated 8/26/19 and 10/28/19, showed physician's orders for eye drops but did not show any physician's orders for self-administration of eye drops. Record review of the resident's Physician's Order Sheet (POS) dated December 2019, showed physician's orders for: -Lumigan Solution 0.01 %, instill 1 drop in the left eye in the evening for visual loss (ordered on 3/20/19). -Combigan Solution 0.2-0.5 % instill 1 drop in the left eye two times a day for visual loss (ordered on 3/20/19). -Prednisolone Acetate Suspension 1 % instill 1 drop in the left eye two times a day for (ordered on 3/20/19). -Cyclopentolate HCl Solution 1 % instill 1 drop in the left eye two times a day for visual loss (ordered on 3/20/19). -Dorzolamide HCl-Timolol Mal Solution 22.3-6.8 milligrams (mg)/milliliters (ml) instill 1 drop in the left eye two times a day for visual loss (ordered on 3/20/19). -The POS did not show physician's orders showing the resident could self-administer any medications, to include eye drops. Record review of the resident's Nursing Notes showed: -On 9/12/2019, the resident was seen by the Optometrist and showed the resident had a history of blurry vision due to cataracts. The resident was not ready for cataract surgery at this time. The resident was currently happy wearing glasses. The resident has central retinal artery occlusion (a blockage of this vein that causes the vein to leak blood and excess fluid into the retina) that was long-standing and stable. The Optometrist would continue to monitor with no additional recommendations. Record review of the resident's Medical Record did not show any documentation showing the facility had assessed the resident's ability to self-administer eye drops. There were no physician's orders documented in the resident's medical record that showed the resident was able to self-administer eye drops. Record review of the resident's Care Plan updated on 9/27/19, showed he/she has impaired visual function related to blindness in his/her left eye from an occlusion. The resident has normal vision in his/her right eye, but has potential for visual decline related to a diagnosis of Glaucoma. Interventions showed nursing staff would: -Arrange consultation with the eye care practitioner as required. -Monitor/document/report to physician signs/symptoms of acute eye problems: change in ability to perform daily living skills, decline in mobility, sudden visual loss, pupils dilated, gray or milky, complaint of halos around lights, double vision, tunnel vision, blurred or hazy vision. -The resident was unaware of things on his/her left side. Remain on his/her right side or in front of him/her when speaking with him/her. -Provide eye drops as ordered. -The resident likes to put his/her own eye drops in. Hand him/her the bottle and allow him/her to administer. Observe administration to insure eye drops are administered properly. Observation and interview on 12/9/19 at 9:00 A.M., showed the resident was sitting in his/her room on his/her bed. He/she was alert and oriented. There were four prescription boxes sitting on his/her bed and each box contained a bottle of eye drops. The resident said: -He/she had just taken the eye drop medication and had taken them as prescribed on each box. -He/she had to take the eye drops to control eye pressure after his/her stroke. -He/She administered the eye drops twice daily. -He/she had been self-administering his/her eye drops since before he/she was admitted to the facility. Observation and interview on 12/11/19 at 8:01 A.M., showed the resident was sitting on his/her walker seat in the bathroom, fully dressed and grooming himself/herself. The resident said he/she had not gotten his/her eyedrops yet. He/she said the nurse keeps his/her eye drops on the medication cart, and he/she will let the nurse know when he/she is ready to take them, then the nurse will give them to him/her and he/she will administer them himself/herself. He/She said the nurse has not brought them into him/her yet. Observation and interview on 12/11/19 at 8:59 A.M., showed the resident was in his/her room sitting on her/her bed. There were four numbered prescription boxes, each containing a bottle of eye drops sitting on the bed in front of the resident. The resident had just put eye drops in his/her eyes. There were no nursing staff supervising the resident. The resident said: -He/She has been administering her eyedrops for the past four years. -When he/she first started administering his/her eye drops, the nursing staff observed him/her to ensure he/she was able to administer them correctly (according to the orders), but they have not supervised/observed him/her (while he/she self-administered his/her eye drops) in about two years. -They (nursing staff) know that he/she can do it (self-administer his/her eye drops) himself/herself, so they bring the eyedrops in to him/her, he/she administers them then the nurse comes and gets them to put away. Observation and interview on 12/13/19 at 9:46 A.M., showed the resident was standing at the nursing station with a plastic container in his/her hand. There were four prescription boxes containing eyedrops. The resident said that he/she was returning the eyedrops to the nurse. The Director of Nursing (DON) took the container from the resident and took them to the nurse. During an interview on 12/13/19 at 10:40 A.M., Licensed Practical Nurse (LPN) A said: -They keep the resident's eye drops on the medication cart and then they give them to him/her and the resident and the resident self-administers them. -The resident's eye drops were labeled and the boxes are all labeled. -When the resident first came into the facility, they administered his/her eye drops and the resident did not like that. -Currently, he/she will watch the resident self-administer the first eye drop and the resident does okay. -When administering eye drops, the resident was supposed to wait three to five minutes between drops to allow the medication to absorb but the resident will wait 10-15 minutes between drops to ensure they absorb. -He/She was not aware if the resident had an assessment showing that he/she was able to self-administer his/her eye drops, but he/she should have had one. -They should complete an assessment at least yearly, or quarterly when they complete the MDS and care plan. -There should be a physician's order showing the resident can self-administer medications on the resident's POS. He/She said it should also be in the resident's care plan. 2. Record review of Resident #45's Face Sheet showed the resident was admitted to the facility on [DATE], with diagnoses including pain, heart failure, heart disease, constipation, shortness of breath, fracture and high blood pressure. Record review of the resident's admission MDS dated [DATE], showed he/she: -Was alert and oriented without cognitive impairment. -Was independent with transfers, walking, eating, toileting and hygiene. -Needed limited assistance with bathing and dressing. -Used a walker for mobility. -Had constant pain that affected his/her daily activities and functioning, and received pain medication as needed. -Had shortness of breath and received oxygen therapy. -Had no skin issues. Record review of the resident's POS dated December 2019, showed physician's orders for: -Continuous oxygen at 2 liters per minute. -ProAir HFA Aerosol Solution 108 (90 Base) (Albuterol Sulfate HFA) 2 puffs, inhale orally every 4 hours as needed for shortness of breath (ordered on 11/13/19). -Ipratropium Albuterol solution 0.5-2.5 milligram/milliliters (mg/ml) 3 ml inhale orally four times daily for shortness of air (ordered on 11/13/19). -There was no physician's order for the resident to self-administer his/her breathing treatment. Record review of the resident's Care Plan dated 11/22/19, showed he/she received oxygen therapy related to heart failure and shortness of breath. Interventions showed staff would: -Encourage or assist the resident with ambulation as needed. -Provide extension tubing or portable oxygen. -Give cardiac medications as needed. -Monitor the resident for sign/symptoms of respiratory distress and report to the physician. -Monitor and report to the physician any sign/symptom of heart failure. -It showed the resident wore oxygen at 2 liters per minute and was to increase it to 6 liters per minute with exercise, continuously. -The care plan did not show that the resident also used a breathing treatment and there was no documentation showing the resident could/was physically able to self-administer his/her breathing treatment independently. Record review of the resident's Medical Record showed there was no documentation showing an assessment showing the resident was competent and physically able to self-administer his/her breathing treatment and could do so without supervision. Observation on 12/09/19 at 2:45 P.M., showed the resident was not in his/her room but his/her nasal cannula (a device used to deliver supplemental oxygen or increased airflow to a patient or person in need of respiratory help-the device consists of a lightweight tube which on one end splits into two prongs which are placed in the nostrils and from which a mixture of air and oxygen flows) was draped around the oxygen concentrator (a device that concentrates the oxygen from a gas supply (typically ambient air) by selectively removing nitrogen to supply an oxygen-enriched product gas stream) that was on and running. The resident had a breathing treatment machine that was sitting on a dresser and the mouthpiece was uncovered. Observation on 12/11/19 at 7:54 A.M., showed LPN A, wearing gloves; obtained the resident's medications and entered the resident's room. The resident's breathing treatment machine was sitting uncovered on his/her dresser. LPN A rinsed the mouthpiece and cup in the bathroom; returned the equipment; changed gloves; and put the resident's medication into the breathing treatment cup and left the medication at the resident's bedside for the resident to use when he/she returned from breakfast. At 7:59 A.M., LPN A said that he/she fills the resident's Albuterol for his/her breathing treatment, then leaves the treatment in the resident's room and the resident self-administered it after he/she returned from breakfast. Observation on 12/10/19 at 11:51 A.M., showed the resident was ambulating down the hallway using his/her walker. He/she was alert and oriented and was wearing portable oxygen. During an interview on 12/13/19 at 11:08 A.M., LPN A said: -The resident administered his/her breathing treatment himself/herself. -They (the nurse) set up the resident's medication in the cup that is attached to the mouthpiece, in his/her room, right before the resident comes back from the dining room so the resident can administer it, because the resident becomes anxious if it is not ready for him/her to take. -The resident self-administers his/her breathing treatment right after each meal. -Once the resident moved to this floor from the residential care facility, he/she should have been assessed to self-administer his/her breathing treatment during his/her initial assessment. -He/she did not know if the resident was assessed to self-administer his/her breathing treatment once he/she moved to the second floor. -There should be a physician's order for the resident to self-administer his/her breathing treatment on her POS and it should also be care planned. During an interview on 12/13/19 at 3:47 P.M., the DON said: -He/She expected an assessment to be completed for ensuring residents are competent to self-administer medications. -A resident should not self-administer medications until after they have assessed the resident' ability and competency to self-administer medications. -He/She expected there to be a physician's order to self-administer medications for any resident authorized to do so. -He/she expected the resident's care plan to show that they self-administer medications.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Record review of Resident #346's assessments and tracking forms showed he/she: -Was admitted to the facility on [DATE]. -discharged from the facility with return anticipated on 5/31/19. -Was readmitted to the facility on [DATE] with diagnoses and medical conditions that included: --Dysphagia (difficulty swallowing). --Type 2 Diabetes Mellitus (a chronic disease characterized by high levels of sugar in the blood and insulin resistance) with Diabetic Neuropathy (nerve damage caused by diabetes). --Difficulty in Walking. --Hypokalemia (low potassium). --Hyperlipidemia (high concentration of fats or lipids in the blood). --Anemia (low iron levels). --Atrial Fibrillation (irregular, rapid heart rate). --High Blood Pressure. --Kidney Failure. --Catheter (a sterile tube inserted into the bladder to drain urine). --Pressure ulcers (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction). --Significant weight loss. Record review of the Physician's Progress Note/assessment dated [DATE] showed no documentation of the resident's pressure ulcers/wounds or an assessment of the care and treatment of the wounds. Record review of the resident's November 2019 POS showed: -Clean right lower buttocks well with normal saline, dry, and cover with Duoderm (flexible dressing that adheres to skin) until healed, every evening shift for wound (start date 10/31/19; discontinued date: 11/11/19). -Skin Prep (a topical barrier between skin and adhesives) every shift for both heels. Keep heels floated while in bed (start date: 7/19/19). -Nystop Powder (Nystatin) 100000 Unit/Gram - Apply to skin folds and inner thighs topically every shift due to Moisture-Associated Skin Damage (MASD) (start date 7/19/19). Record review of the resident's November 2019 TAR showed: -Clean right lower buttocks well with normal saline, dry, and cover with Duoderm until healed, every evening shift for wound (start date 10/31/19; discontinued date: 11/11/19). --No documentation that this treatment was administered on 11/7/19 and 11/9/19. -Skin Prep every shift for both heels. Keep heels floated while in bed (start date: 7/19/19). --No documentation that this treatment was administered on 11/9/19 evening shift. -Nystop Powder 100000 Unit/Gram - Apply to skin folds and inner thighs topically every shift due to MASD (start date 7/19/19). --No documentation that this treatment was administered on 11/9/19 evening shift. Record review of the resident's December 2019 POS showed: -Clean open area right buttock with normal saline, pat dry, and cover with Duoderm dressing until healed, every day shift every three days and as needed for wound (start date: 11/16/19; discontinued date: 12/11/19). -Clean open area right foot with normal saline, pat dry, and cover with 2 inch by 2 inch Duoderm dressing until healed, every day shift every three days and as needed for wound (start date: 11/17/19). -Clean right lower buttocks well with normal saline, dry, and cover with Duoderm until healed, every day shift every three days for wound (start date: 11/13/19). -Nystop Powder 100000 Unit/Gram - Apply to skin folds and inner thighs topically every shift due to MASD (start date 7/19/19). -Vitamins A & D Ointment - Apply to right and left buttocks topically every shift for prevention of MASD and as needed for soiling (start date 11/13/19). -Skin Prep every shift for both heels. Keep heels floated while in bed (start date: 7/19/19). -Weekly skin assessment every day shift every Tuesday for skin maintenance. Record review of the resident's December 2019 TAR showed: -Clean open area right buttock with normal saline, pat dry, and cover with Duoderm dressing until healed, every day shift every three days and as needed for wound (start date: 11/16/19; discontinued date: 12/11/19). --No documentation that this treatment was administered on 12/7/19 and 12/10/19. -Clean open area right foot with normal saline, pat dry, and cover with 2 inch by 2 inch Duoderm dressing until healed, every day shift every three days and as needed for wound (start date: 11/17/19). --No documentation that this treatment was administered on 12/10/19. -Clean right lower buttocks well with normal saline, dry, and cover with Duoderm until healed, every day shift every three days for wound (start date: 11/13/19). --No documentation that this treatment was administered on 12/7/19 and 12/10/19. -Nystop Powder 100000 Unit/Gram - Apply to skin folds and inner thighs topically every shift due to MASD (start date 7/19/19). --No documentation that this treatment was administered on 12/1/19 evening shift and 12/10/19 day shift. -Vitamins A & D Ointment - Apply to right and left buttocks topically every shift for prevention of MASD and as needed for soiling (start date 11/13/19). --No documentation that this treatment was administered on 12/10/19. -Skin Prep every shift for both heels. Keep heels floated while in bed (start date: 7/19/19). --No documentation that this treatment was administered on 12/1/19 evening shift. -Weekly skin assessment every day shift every Tuesday for skin maintenance. --No documentation that this weekly assessment was completed on 12/3/19 and 12/10/19. Record review of the Weekly Pressure Injury Log showed: -No Weekly Pressure Injury Log completed for the week of 11/17/19 - 11/23/19. -No Weekly Pressure Injury Log completed for the week of 12/1/19 - 12/7/19. 3. During an interview on 12/13/19 at 10:48 A.M., LPN A said: -When they complete the resident's initial skin assessment, they observe the resident's skin and document the measurements, what it feels like, what it looks like, whether there is pain at the site and the treatment orders. They will also stage the wound at that time. -The person that finds the wound will complete this assessment. -The facility used to have a wound nurse but they don't anymore. -Staff should document this information with each skin assessment. -The documentation should be consistent. -If they notice a wound on a resident, the nurse on that shift would assess and measure it and notify the physician and DON. -The facility has a nurse who usually will measure all of the wounds on Wednesdays. -Each nurse completes their own wound care and weekly skin assessments. -On the weekly skin assessment form they can document the description and measurement of the resident's wound. -There was also a body diagram on the skin assessment form where they can identify where the wound is located and also document a description of the wound and the treatment orders. -They will also document, in the nursing notes, information about the resident's wound. -Usually skin assessments are done around the resident's bath days. -The weekly skin assessment should show documentation on any and all wounds on the resident's skin and there may also be documentation in the resident's nursing notes. During an interview on 12/13/19 at 1:51 P.M., the DON said: -Up until the end of 10/2019, the Clinical Care Coordinator was responsible for completing wound assessments and measurements on their floor. -After the Clinical Care Coordinator left the facility, he/she assigned a nurse (who was a former wound nurse) to be responsible for assessing, measuring and monitoring/tracking the wounds weekly. -The nurse has been measuring the wounds weekly and treating all of the pressure sores. -The nurse documents on the Wound Tracking Log and this document is not in the resident's electronic record. -The nurse also documents in the resident's nursing notes (which is in the electronic record). -He/She expects the documentation on the wound log to also be documented in the resident's nursing notes. -He/She said the MDS Coordinator was trained in wound care and all of the nurses have received wound care training. -Wound care training consisted of an online training/education, about a year ago, on identification of wounds/pressure sores, measurements and treatments. -The weekly skin assessments are for the nurses to use to document any new skin issues, and he/she expected the nurses to document on those assessments the wounds that are known. -He/She did not expect the nurses to document wound staging or tracking of wounds/pressure sores on the weekly skin assessments. -The designated nurse should be the only person to document measurements, staging, and the assessment of any wounds/pressure sores on the Wound Tracking Log. -The physician is notified of the progress of the resident's wound. -The Weekly Pressure Injury Log was the document the nurse used to track the resident's pressure sore. -The Weekly Pressure Injury Log was not in the resident's medical record. -Information documented on the Weekly Pressure Injury Log should also be documented in and kept as part of the resident's medical record. -The wound tracking should be consistent, complete and there should not be discrepancies in documentation about the resident's pressure sore in the resident's medical record. Based on observation, interview and record review, the facility failed to ensure pressure sore (a sore area of skin that develops when the blood supply to it is cut off for more than two to three hours due to pressure on it and lack of movement) monitoring and documentation was comprehensive, accurate and consistent for one sampled resident (Resident #16) with a recurrent deep tissue injury (a pressure-related injury to subcutaneous tissues under intact skin. Initially, these lesions have the appearance of a deep bruise), and one sampled resident (Resident #346) with Stage II (partial thickness loss of skin presenting as a shallow open ulcer with a red or pink wound bed, without slough; it may also as an intact or open/ruptured blister) and Stage III (full thickness tissue loss; fat may be visible but bone, tendon, or muscle is not exposed) pressure sores out of 14 sampled residents. The facility census was 51 residents. Record review of the facility Skin Care, Decubitus policy and procedure dated 8/2017, showed the purpose was to identify residents at risk for decubitus (pressure sores), to prevent breakdown of tissue due to pressure such as body weight, irritation or lack of circulation; and to provide treatment that promotes healing of existing (pressure sores). The procedure showed the facility would: -Identify residents who are particularly at risk for the development of pressure sores. -On each shift, examine residents prone to pressure sores for development of redness, discoloration, or blisters over pressure areas that include ears, shoulder blades, spine, elbows, under breasts, sacrum/coccyx (a small triangular bone at the base of the spinal column), greater trochanter (two bony protuberances by which muscles are attached to the upper part of the thigh bone), inner and outer knees, inner and outer ankles, heels and nostrils. -Institute a preventive plan for any resident who has potential for developing a pressure sore or whose condition is deteriorating, including turning and repositioning every two hours; reduction of pressure by placing the resident on a special mattress and pads; use of foam or sheepskin boots to support heels; use of a bed cradle to keep weight of bedding off of the resident's feet; separation of knees with a pillow when the resident is placed on his/her side; use of elbow protectors; maintenance of a clean. dry, and well lubricated skin; avoidance of powders and sedative overuse; provision and assurance that the resident receives optimum nutrition; observation of the resident's skin on each shift; and reduction of shearing force (tissue damage due to friction) by lifting the resident instead of sliding when repositioning. -Stage II defined as a skin blister or superficial break in the skin. Staff should notify the supervisor of a change in condition of the resident, continue preventive measures, prevent infection to the area by cleaning the area with normal saline, rinsing and patting dry the skin and applying protective covering as ordered. If infection is suspected, notify the Director of Nursing (DON) and physician. Massage healthy skin surrounding the pressure sore and reposition the resident every two hours. Never massage skin that has impaired circulation due to possibly causing further tissue destruction. -Stage III defined as a full thickness skin loss exposing subcutaneous tissue. Notify the DON and the physician of a change in condition, continue preventive measures, clean the area with normal saline and follow the treatment plan as ordered. If infection is suspected, notify the DON and physician. -Documentation by the licensed staff member should: record treatment in the Treatment Administration Record (TAR), record in the resident's progress notes as the condition or level of care warrants, inform the physician of adverse reactions as needed and record on the Decubitus (Pressure Sore) Sheet. 1. Record review of Resident #16's Face Sheet showed he/she was admitted on [DATE], with diagnoses including diabetes, heart failure, high blood pressure, kidney disease, and low iron. Record review of the resident's Physician's Notes dated 9/16/19, showed the physician completed a physical exam of the resident, reviewed the resident's medical records and noted the resident was doing okay. He/she had been admitted to the hospital to see a renal (kidney) specialist. There was no documentation showing the resident had a deep tissue injury to his/her left heel and no documentation showing any treatments that were being administered to the resident's left heel. Record review of the resident's quarterly Minimum Data Set (MDS-a federally mandated assessment tool to be completed by facility staff for care planning) dated 9/20/19, showed he/she: -Was alert and oriented with minimal cognitive impairment. -Was independent with dressing, grooming, toileting, and walking. -Needed limited assistance/supervision with transfers and eating. -Used a walker for mobility. -Was not at risk for pressure sores, did not have a pressure sore or an unhealed pressure sores. -Did not have any other wounds or skin issues. -Did not receive any preventive care or interventions. Record review of the resident's Physician's Order Sheet (POS) dated December 2019, showed physician's orders to off load heels with pillows while in recliner or bed to prevent pressure as much as resident will allow and be compliant with treatment every shift for a deep tissue injury to (the resident's) left heel and prevention for right heel, ordered on 7/11/19. Record review of the resident's weekly Skin Assessments showed the weekly skin assessments from 9/19/19 to 10/24/19, showed the nurse documented the resident's left heel was dry, flaky and intact. The resident's skin prep (a liquid that when applied to the skin forms a protective film or barrier) treatment was in place and there were no open skin areas noted. The skin assessment form showed there was no documentation in the pressure sore assessment area of the form. Record review of the resident's Nursing Notes showed on 10/26/19, the resident complained of pain to his/her left heel when staff was putting on his/her shoes. The nurse checked the resident's foot and noted a blackened area that measured 9 centimeters (cm) in length by 7 cm in width with a soft center. Dry, flaky skin was noted (to an unidentified area). The treatment (unidentified) was changed to day and evening shift and nursing staff notified the physician. Record review of the resident's Weekly Pressure Injury Log dated 10/26/19, showed he/she had a facility acquired deep tissue pressure sore to his/her left heel that measured 9 cm in length by 7 cm in width. It was described as a closed, blackened area with a soft center and dry, flaky skin. The pressure sore had no depth, odor, or drainage. Treatment was for skin prep and to off load the resident's heel for one hour after treatment. Treatment was documented. Record review of the resident's weekly Skin Assessments showed: -On 10/26/19, the nurse documented the resident's left heel had a blackened area-center soft, with dry, flaky skin noted. The area was not open. It measured 9 cm in length by 7 cm in width. The resident's treatment order was changed. The order was for staff to off load the resident's heels after treatment for one hour and while in bed. The resident's right heel was clear. There was no further description of the resident's wound. The skin assessment form noted no documentation in the pressure sore assessment area. -On 10/31/19, the nurse documented the resident's left heel had a blackened area, the center was soft, with dry, flaky skin noted. The area was not open. It still measured 9 cm in length by 7 cm in width. The resident's treatment order was for staff to off load the resident's heels after treatment for one hour and while in bed. The resident's right heel was clear. There was no further description of the resident's wound. The skin assessment form noted no documentation in the pressure sore assessment area. Record review of the resident's Care Plan updated 10/28/19, showed he/she had potential for pressure ulcer development related to needing limited assistance with most activities of daily living (bathing, dressing, grooming, toileting, transferring and ambulating) and urinary incontinence. It showed the resident had a deep tissue injury/unstageable (a covered pressure sore where the depth of the sore is unknown) pressure area on his/her left heel. Interventions showed: -The Charge Nurse was to notify the Dietician with any skin issues noted. -The Charge Nurse was to notify the physician and obtain a treatment order if the resident has any skin breakdown, blisters, moisture associated skin damage or discolorations. -Off load the resident's heels with pillows while in his/her recliner or bed to prevent pressure as much as he/she will allow and be compliant with treatment. -Report to the Charge Nurse any skin breakdown, discoloration, blisters noted when giving cares. -The resident had a new treatment order to clean (the pressure sore) with normal saline, then apply skin prep to the deep tissue injury/unstageable pressure sore on his/her left heel. -The resident will have a weekly skin assessment done by a licensed nurse. Record review of the resident's Weekly Pressure Injury Log dated 11/1/19, showed the resident had a facility acquired deep tissue pressure sore to his/her left heel that measured 9 cm length by 7 cm width. It was described as a closed, blackened area with a soft center and dry, flaky skin. The pressure sore had no depth, odor, or drainage. Treatment was skin prep and to off load the resident's heel for one hour after treatment and when in bed. Treatment was documented. Record review of the resident's Nursing Notes showed on 11/6/19, at 10:08 A.M., the nurse assessed the resident's left heel for a deep tissue injury, and the measurement was 8 cm in length by 6 cm in width, blackened; dry and intact; slightly soft, but firmer and smaller in size; and was showing improvement. Treatment was appropriate at this time. Record review of the resident's Weekly Pressure Injury Log dated 11/6/19, showed the resident had a facility acquired deep tissue pressure sore to his/her left heel that measured 8 cm in length by 6 cm in width. It was described as a closed, blackened area with a soft center with dry skin. The pressure sore had no depth, odor, or drainage. Treatment was skin prep and to off load the resident's heel for one hour after treatment. Treatment was documented as appropriate. Record review of the resident's weekly Skin Assessments showed on 11/7/19, the nurse documented the resident's left heel was dark brown, the center was soft, with dry flaky skin noted. It was not open. The resident's treatment order was changed and staff was to off load the resident's heels after treatment for one hour and while in bed. There was no documentation showing the measurements of the area. The skin assessment form noted no documentation in the pressure sore assessment area. Record review of the resident's Nursing Notes showed on 11/13/19 at 2:36 P.M., the nurse assessed residents left heel for a deep tissue injury, and the measurement was 8 cm in length by 4 cm in width; partially blackened; dry, intact; smaller in size with some peeling skin; without no odor or drainage; and was showing improvement. Treatment was appropriate at this time. Record review of the resident's Weekly Pressure Injury Log dated 11/13/19, showed the resident had a facility acquired deep tissue pressure sore to his/her left heel that measured 8 cm in length by 4 cm in width. There was no description of the wound other than there was no depth, odor, or drainage. Treatment was for skin prep and to off load the resident's heel for one hour after treatment. Treatment was documented as appropriate and the pressure had improved. Record review of the resident's weekly Skin Assessments showed on 11/14/19, the nurse documented the resident had a stage II pressure sore (the top layer of skin is broken, creating a shallow, open ulcer with a red/pink wound bed) to his/her left heel. In the pressure sore section on the form, the nurse documented the resident's left heel had pink tissue surrounded by flaky brown skin. There was no necrosis (dead tissue), drainage or odor. The documentation did not show measurements of the area and did not show the treatment order. Record review of the resident's Physician's Telephone Order dated 11/16/19, showed to clean the resident's left heel with normal saline, pat dry and then apply skin prep (a protective skin barrier) every shift for a deep tissue injury and to maintain skin integrity. Off load the resident's left heel after treatment (ordered on 11/16/19). Record review of the resident's Physician's Notes dated 11/18/19, showed the physician saw the resident and completed a physical examination of the resident, but there was no documentation showing the resident had a deep tissue injury to his/her left heel and no documentation showing any treatments that were being administered to the resident's left heel. Record review of the resident's weekly Skin Assessments showed on 11/21/19, the nurse documented the resident had a deep tissue injury to his/her left heel, with improvement and treatment in progress. The description of the resident's pressure sore showed it was brown and purple in color. There were no measurements documented and no further description of the resident's pressure sore or documentation of his/her treatment order. Record review of the resident's Podiatry Evaluation and Treatment dated 11/22/19, showed the resident had a pressure sore to his/her left heel. The podiatrist documented no prescribed treatment or recommendation for treatment. Record review of the resident's Nursing Notes showed on 11/26/19 at 10:57 A.M., the nurse assessed resident's left heel for a deep tissue injury and the measurement was 7 cm in length by 4 cm in width; 60 percent was purplish/black, 40 percent was maroon, with some peeling skin; it was intact, without odor or drainage; and showing slight improvement. Treatment was appropriate at this time. Record review of the resident's Weekly Pressure Injury Log dated 11/26/19, showed the resident had a facility acquired deep tissue pressure sore to his/her left heel that measured 7 cm in length by 4 cm in width. It was described as intact with some peeling skin and was black and maroon in color. The pressure sore had no depth, odor, or drainage. Treatment was for skin prep and to off load the resident's heel. Treatment was documented as appropriate. Record review of the resident's weekly Skin Assessment Sheets showed: -On 11/28/19, the nurse documented the resident had a deep tissue injury to his/her left heel, with improvement and treatment in progress. The description of the resident's pressure sore showed it was brown and purple in color. There were no measurements documented and no further description of the resident's pressure sore or documentation of his/her treatment order. -On 12/5/19, the nurse documented the resident had a deep tissue injury to his/her left heel, with improvement and treatment in progress. The description of the resident's pressure sore showed it was brown and purple in color. There were no measurements documented and no further description of the resident's pressure sore or documentation of his/her treatment order. Record review of the resident's Weekly Pressure Injury Log dated 12/5/19, showed the resident had a facility acquired deep tissue pressure sore to his/her left heel that measured 7 cm in length by 4 cm in width. It was described as fading black/maroon, intact with some peeling, dry skin. The pressure sore had no depth, odor, or drainage. There were no treatment orders documented. Record review of the resident's Nursing Notes showed the most recent nursing note, dated 12/9/19, did not show any notes regarding the resident's deep tissue injury. During an observation and interview on 12/09/19 at 2:41 P.M., showed the resident was sitting in his/her recliner watching television. He/She was wearing shoes and his/her feet were not elevated. The resident was sitting upright in his/her chair with his/her feet on the ground. He/She said he/she was doing okay and had no concerns. He/She said he/she had a wound on his/her left foot that the nurse treated daily. He/She agreed for me to observe his treatment. During an interview on 12/10/19 at 1:17 P.M., the DON said: -The resident had a deep tissue injury to his/her heel that he/she had a history of developing due to the shoes he/she wore prior to his/her being admitted to the facility. -The resident developed a deep tissue injury that heeled and they thought they had gotten rid of the shoes that his/her family said caused the injury to his/her heel, but it came back in the same place the family said it had developed before. -The resident's wound is healing and they continue to treat it daily and assess it weekly. Observation on 12/10/19 at 1:31 P.M., showed the resident was sitting in his/her recliner with his/her shoes on and his/her feet were not elevated. He/she was alert and was watching television. Licensed Practical Nurse (LPN) D had already placed his/her supplies on a sterile tray that was sitting on top of the resident's dresser by his/her television. The following occurred: -LPN D washed his/her hands and gloved, then removed the resident's shoe and sock. The resident's left heel showed a closed area at the resident's heel that was dark in color and was the size of a small [NAME]. The skin at and around the site was dry, flaky and peeling. - LPN D completed treatment to the resident's heel. Observation on 12/11/19 at 9:21 A.M., showed the resident was sitting in his/her recliner with his/her feet elevated and his/her shoes were on. The resident's eyes were closed and he/she was resting comfortably without sign or symptom of pain or discomfort. Record review of the resident's weekly Skin Assessment Sheet showed on 12/13/19, the nurse documented the resident had a deep tissue injury to his/her left heel, which was dry, flaky and measured approximately 10 cm in length by 7 cm in width. It was circular in size and was brown and light purplish in color. Treatment was in progress. The resident's left heel has much improved. There was no odor or drainage noted. There was no documentation of the resident's current treatment order. Record review of the resident's Weekly Pressure Injury Log dated 12/13/19, showed the resident had a facility acquired deep tissue pressure sore to his/her left heel that measured 6.7 cm in length by 4 cm in width. It was described as fading black/maroon, intact with some peeling, dry skin. The pressure sore had no depth, odor, or drainage. There were no treatment orders documented. During an interview on 12/13/19 at 9:34 A.M., Certified Nursing Assistant (CNA) F said: -Whenever they are bathing a resident or giving care, if they see a skin issue, they were supposed to immediately notify the nurse. -With this resident, they try to encourage him/her to elevate his/her feet when he/she is in his/her recliner, but he/she can be non-compliant at times. During an interview on 12/13/19 at 10:48 A.M., LPN A said: -They had been treating Resident #16's heel with skin prep once daily, and they noticed that the resident developed a fluid filled area in the center of his/her wound. -He/She notified the physician and the orders were changed to put skin prep on the resident's heel twice daily and off load the heel when the resident was in bed and in his/her recliner. -They do a good job with floating his heels at night, but the resident does not always agree to float his/her heels when he/she is in his/her recliner. During an interview on 12/13/19 at 1:51 P.M., the DON said: -During the week that the nurse was on vacation, he/she (the DON) measured Resident #16's pressure sore and documented on the Wound Tracking Log, but was not sure if he/she completed a nursing note. -The night nurse completed the skin assessment on Resident #16 yesterday morning, and he/she did not include documentation showing the resident's pressure sore on his/her left heel. When he/she (the DON) came into work this morning, he/she informed the night nurse that he/she did not complete the assessment correctly. -The night nurse documented the measurement of the resident's heel was 10 cm in length by 7 cm in width, and he/she (the DON) disagreed with that measurement. -When he/she re-measured the resident's heel, he/she documented the resident's measurement was 6.7 cm in length by 4 cm in width. -The physician is notified of the progress of the resident's wound. -They have increased the frequency of treatments for Resident #16's deep tissue injury and they float his/her heels in bed and as much as possible. The resident's heel is healing. -The resident's pressure sore was never a stage II pressure sore because it never opened up, it's always been a deep tissue injury. -The night nurse who documented that information on his/her skin assessment sheet was incorrect. -He/She said she will have to do education with the charge nurses regarding who will complete the wound tracking and what information they are to document.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure resident safety was maintained as evidenced by the facility's failure to ensure the plan of care reflected current conditions and needs; to complete a thorough and timely post fall investigation/root cause analysis of each fall; to assess and monitor the use and effectiveness of current interventions; and to update interventions to help prevent further falls for one sampled residents (Resident #15) out of 14 sampled residents. The facility census was 51 residents. Record review of the facility's Falls Prevention Guidelines policy dated revised 08/2017 showed: -If Falls were triggered on the Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff for care planning), the MDS Coordinator or designee would determine if there was a need to proceed to care planning. -The Interdisciplinary Care Plan Team (IDT - a group of healthcare providers from different fields who work together or toward the same goal to provide the best care or best outcomes for a patient or group of patients) would discuss the potential need for a Physical Therapy (PT - a branch of rehabilitative services designed to restore mobility and decrease pain) and/or Occupational Therapy (OT - a branch of rehabilitative services designed to help people develop, recover, improve, and/or maintain the skills needed for daily living and working) evaluation. -Items to be considered in the evaluation and discussion included: --Had an actual fall occurred during transfer or ambulation? --Were assistive devices adequate and properly fitted? --Should this individual be referred for a PT screen? --Had the resident fallen out of the chair or bed? --Was the immediate environment a safety risk (shoes, room clutter, lighting, etc.)? --If response to the above questions indicated a problem, OT would screen the resident. -The Charge Nurse (CN) was to assess physical/mental status changes on a continuing basis. -The CN was to provide updates of residents who might need to be added to the Falls Prevention Program to the Director of Nursing (DON) and Administrator. Record review of the facility Baseline Care Plan policy dated 10/2017 showed: -The facility was to complete and implement a baseline care plan within 48 hours of a resident's admission. -It was intended to promote continuity of care and communication among nursing home staff, increase resident safety, and safeguard against adverse events that were most likely to occur right after admission; and to ensure the resident and/or the resident's representative, if applicable, were informed of the initial plan for delivery of care and services by receiving a written summary of the baseline care plan. -Upon admission, the home (facility) was to begin the process of developing a baseline care plan and this care plan was to be implemented within 48 hours of admission. -Information for the baseline care plan would be based upon admission orders, information from the transferring provider and discussion with the resident and/or the resident's representative, if applicable and the resident so chooses. -The care plan was to include at the minimum the following: --Initial goals based on admission orders. --Instructions needed to provide effective and person-centered care that met profession standards of quality care. --Address resident health and safety concerns to prevent decline or injury, such as fall risk. --Identify needs for supervision, behavioral interventions and assistance with activities of daily living (ADL - dressing, grooming, bathing, eating, and toileting) as necessary. -The care plan was to reflect the resident's stated goals and objectives and include interventions that addressed his/her current needs. -Changes were to be made as necessary, resulting from significant changes in condition or needs, occurring prior to the development of the comprehensive care plan. -The facility staff or those acting on behalf of the facility would implement the interventions to assist the resident to achieve his/her care plan goals and objectives. -Direct care staff were to be educated about the care plan interventions. -The baseline care plan summary was to be in a language and conveyed in a manner the resident and/or the resident's representative, if applicable, could understand. The summary was to include: --Initial goals for the resident. --Services (i.e., therapy) and treatments to be administered by the facility and personnel acting on behalf of the facility. --Any updated information based on details of the admission comprehensive assessment as necessary. -The home (facility) might decide to present the baseline care plan as the summary as long as it met the requirements listed. -The home (facility) had the option of completing a comprehensive care plan instead of a baseline care plan as long as the comprehensive care plan was completed within 48 hours and followed the Resident Assessment Instrument (RAI - a tool which helps the facility staff to gather definitive information on a resident's strengths and needs, which must be addressed in an individualized care plan) process/requirements. A written summary of the comprehensive care plan was to be provided to the resident and/or the resident's representative in a language that they could understand. Record review of the facility's Fall Risk Assessment form, dated revised 2/21/13, showed a resident was at: -Low risk for falls if he/she scored 0-4. -Moderate risk for falls if he/she scored 5-9. -High risk for falls if he/she scored 10+. 1. Record review of Resident #15's Baseline Care Plan, showed: -He/she was admitted on [DATE]. --Stress incontinence (having no or insufficient control over urination or defecation). --Repeated falls. --Parkinson's disease (a chronic nervous disease characterized by a fine slowly spreading tremor, muscle weakness, muscle stiffness and a peculiar gait). --Restless legs syndrome (irresistible urge to move the legs). -Needed one person to physically assist him/her with personal hygiene, toilet use, dressing, bathing, bed mobility, transfers, while walking in his/her room or in the corridor, and for locomotion on the unit. -Used a walker or a wheelchair for mobility. -Had a history of falls and had fallen within the last month, i.e., the resident had fallen in his/her apartment after rehab. Documentation showed staff was unable to determine if the resident had a fall any time in the 2-6 months prior to his/her admission/entry or re-entry to the facility. -Had a therapy goal to improve his/her functional status. --Therapies identified to help achieve this were PT, OT, and Restorative Nursing. ---There were no resident stated goals or objectives identified, no goals/objectives identified by the facility, nor did it identify any interventions staff was to use to address the resident's safety needs, i.e., to prevent falls on this form. Record review of the resident's admission Nurse's Notes dated 6/12/2019 at 10:30 A.M., showed the resident: -Was ambulatory via wheelchair (w/c) and he/she was accompanied by his/her family. -Usually ambulated with a walker but had tired with the distance. -The resident's gait (manner of walking) with the walker was unsteady. -admitted he/she fell easily and had fallen several times in the past week. -911 had been called to help get him/her up (prior to admission to the facility). -Was instructed to call for assist to get up to go anywhere at all times, even during the night. Understanding was verbalized. -Was unable to get his/her balance when he/she attempted to get out of the chair. The resident kept leaning to the left and backwards, even after adjusting his/her feet. He/she started going backwards towards the chair and staff stopped him/her from falling. -Was alert and oriented x 3 (to person, place, and time) with some long term forgetfulness noted. Record review of the resident's admission Fall Risk assessment dated [DATE] at 12:13 P.M., showed the resident was at high risk for falls with a score of 17. Record review of the resident's Baseline Care Plan dated 6/12/19 showed no updates related to the resident's high risk for falls (per the fall risk assessment), lack of balance and near fall with staff present when the resident stood up from his/her wheel chair, or the need to reinforce information provided due to the resident's identified forgetfulness. 1a. Record review of the resident's Nurse's Notes 6/13/19 at 4:30 A.M., showed: -The resident was found kneeling on the floor on his/her left knee. -He/she was barefoot and hanging on to his/her bed rail. -The resident stated I did not fall. I slid out of the bed. I was trying to find my call button. -There were no apparent injuries at that time. -The resident offered no complaints of pain or discomfort. -Non-skid socks were placed on resident's feet prior to assisting resident to his/her feet. Record review of the resident's Fall Risk assessment dated [DATE] at 4:30 A.M., showed the resident was at moderate risk for falls with a score of 9.0. --The assessment did not identify the resident had changes in his/her gait pattern when walking or that the resident required the use of assistive devices (i.e., cane, w/c, walker or furniture). Record review of the facility's Fall Investigation form dated 6/14/19 at 4:30 A.M., showed: -The resident's call light was sounding. -A Certified Nurse Assistant (CNA) answered the call light and summoned a nurse. -The resident was found kneeling on the floor beside the bed on his/her left knee. -He/she was barefoot and was hanging onto the bed rail. -The resident reported, I did not fall. I slid out of the bed. I was trying to find my call button. -The resident was assessed for injuries. When none were found, the staff assisted the resident to his/her feet and then onto the bed. -The resident was alert and oriented to person, situation, and time. A note showed the resident was new to the facility. -The resident's mobility was marked as ambulatory with assistance. -There were no predisposing environmental or physiological factors identified which might have contributed to the resident's fall. -Predisposing situational factors contributing to the fall included: --The event occurred within 72 hours of admission. --Improper footwear. -Actions taken after the fall: --Non-skid socks were placed on the resident's feet and staff reminded the resident to wear them. ---The investigation did not identify which call light was activated (room or bathroom), did not describe the resident's environment at the time of the event, i.e., if the bed was against the wall or perpendicular to it, from which side of the bed the resident slid, the location and condition of the resident's call light at the time the resident was found or why it had been activated, i.e., the resident said he/she couldn't find it. Record review of the facility's Root Cause Analysis of the fall dated 6/14/19 showed: -The fall was due to the resident being new to the facility, i.e., he/she was disoriented in the new surroundings. -The resident had a history of falls and was weak. -New interventions were identified and included: --Leaving the resident's bathroom light on with the door partially shut. --Bright colored tape was added to assist the resident in finding his/her call light. --PT/OT orders were also obtained from the physician to evaluate and treat, as indicated. ---The analysis did not address the resident's memory issues nor did it show the resident's ability to identify and use the call light appropriately was assessed. Record review of the resident's Baseline Care Plan showed it had not been updated to reflect the resident was weak, had slid out of bed, where the call light should be located as the resident had been unable to find his/her call light, nor were the new interventions identified during the root cause analysis added to the care plan. Record review of the resident's Fall Care Plan on the resident's comprehensive care plan form dated 6/14/19 showed: -The resident was identified at risk for falls related to his/her diagnosis of frequent falls. -The resident's goal was to not have any injuries related to a fall through the next review time. -Interventions included: --PT/OT orders were obtained for the resident after his/her non-injury fall on 6/13/19. --Staff was to add bright colored tape to the resident's call light to make it easier for the resident to find. --Staff was to leave the resident's bathroom light on and the door partially open to all him/her to see where he/she was in the dark. ---The resident's Fall Care Plan did not identify his/her level of risk for falling, i.e., high risk due to a score of 17, did not identify the resident was weak, couldn't walk long distances and needed a wheel chair for such activity due to weakness, that he/she had balance issues when moving from a seated to a standing position and had almost fallen with staff present (as had been noted in the resident's nurse's notes), that he/she had slid out of bed on 6/13/19, that he/she needed reminders to use his/her call light when he/she needed/wanted to get up or that he/she needed to wear appropriate footwear (i.e., non-skid socks/shoes) when up. Record review of the resident's admission MDS dated [DATE] showed the resident: -Required extensive assistance of one staff person with bed mobility. -Required limited assistance of one staff person with transfers, when ambulating in his/her room, when ambulating on and off the unit, with dressing, and toileting. -Required supervision when walking in the hall and for personal hygiene. -Was not steady and only able to stabilize himself/herself with human assistance when moving from a seated to standing position, when moving on and off the toilet and when making surface-to-surface transfers (bed to chair or wheel chair). -Was not steady but was able to stabilize himself/herself without human assistance when walking and when turning around and facing the opposite direction. -Had no limits to his/her range of motion (ROM - the range on which a joint can move) of his arms or legs. -Used a walker or wheel chair for mobility. -Believed he/she was capable of greater independence in at least some of his/her ADLs. Direct care staff did not believe this to be true. -Had a history of falls, had fallen within the month prior to his/her admit. Whether the resident had fallen during the two to six months prior to his/her admission was not determined. -Had fallen once since his/her admission. -Triggered for the Fall Care Area Assessments (CAA - a process to guide the Interdisciplinary Team (IDT) through a comprehensive assessment of a resident's functional status). Documentation showed this area should be included in the resident's care plan. Record review of the resident's Nurse's Notes showed: -The resident fell on 6/19/19 at 4:19 P.M. -The resident was found sitting on the floor in the middle of his/her room. -The resident initially denied pain. Range of Motion (ROM) to all extremities was assessed; resident moved without difficulty or complaints of pain, but said he/she had a headache. -Staff noted a quarter-size raised area with an abrasion on the resident's left forehead. The resident pointed to that area and said that was where his/her headache was. -The resident denied dizziness or nausea and knew who he/she was and where he/she was. Staff transferred the resident from the floor to her w/c using a gait belt (a belt, usually made of heavy canvas with a sturdy buckle, used to help residents move). -The resident didn't know how he/she fell and said he/she was just walking across the floor going to his/her shelf unit. -There was nothing on the floor; it was clean and dry. The resident had appropriate shoes on. -The resident said he/she had not used his/her walker. The walker was behind him/her on the other side of the room and the wheel chair was a ways in front of him/her. -The physician was notified and went to the resident's room (the physician was at the facility). -The Charge Nurse did neurochecks (neurological checkpoints to monitor level of consciousness, ability to move extremities, eye responses and change in pupils and vital signs) and stated they were within normal limits (WNL). -The physician examined the raised area on the resident's forehead and said to continue to monitor the area, continue with routine post fall neurochecks, and notify him/her with changes. -Staff placed the resident on 30 minute checks for 24 hours for safety. Record review of the facility's Fall Investigation form dated 6/19/19 at 3:25 P.M., and revised at 4:32 P.M., showed the resident: -Was found sitting on the floor in the middle of his/her room. -Was alert and oriented, denied dizziness or nausea; his/her neurocheck was within normal limits. -He/she complained of a headache and rated his/her pain 3/10 (0=no pain; 10=pain is unbearable). A quarter-size raised area and abrasion was noted on his/her left forehead. -Reported he/she didn't know how he/she fell; he/she had just been walking across the floor going to his/her shelf unit. -The resident's walker was behind him/her on the other side of the room. His/her wheel chair was a ways in front of him/her. -Reported he/she hit his/her head on the floor when he/she fell. Neurochecks were done. An ice pack was applied to the area. -Was seen by his/her physician (already in the facility). He/she instructed staff to notify him/her of changes. -Was placed on every 30 minute checks for 24 hours for safety. -Had the following issues identified as contributing to the resident's fall: Gait imbalance, Parkinson's Disease, and resident ambulating without assistance. The resident was not using his/her walker and did not call for assistance. --The investigation did not describe the environment in which the resident fell, i.e., position of resident on floor in relation to his/her furniture, position of the walker and wheel chair in relation to the furniture, the location from which the resident started walking, i.e., if he/she had been in lying down in bed or sitting in his/her recliner, or the location of the resident's call light. Record review of the facility's Root Cause Analysis of the resident's fall dated 6/19/19 at 3:25 P.M., showed: -The resident had a history of frequent falls related to his/her poor safety awareness according to his/her family. -Bright colored tape had been added to the resident's walker to help him/her remember to use it. --The analysis was completed on 8/21/19, two months after the resident's fall. The analysis did not address the use of assistive devices or where such items should be placed when the resident was in his/her room. Record review of the resident's comprehensive Fall Care Plan revised on 6/19/19 showed: -The resident had been placed back on post fall every 30 minute safety checks. -Staff was to assist the resident with all transfers and ambulation. -There were no updates which identified the resident had poor safety awareness or that red tape had been placed on his/her walker to make it more visible to the resident. Record review of the resident's Fall Risk Assessments showed no assessment of the resident was completed after his/her fall on 6/19/19. Record review of the resident's comprehensive Fall Care Plan showed: -On 7/2/19, the resident's wheel chair had been changed from the one he/she brought from home with no arms to a facility wheel chair with arms, for safety. -The intervention for 30 minute checks was discontinued (the entry was grayed out and dated revised on this date). Record review of the facility's Fall Investigation form dated 7/12/19 at 3:04 P.M., showed the resident: -Was found laying on his/her left side. His/her legs were together and slightly bent. His/her pants were down around the bottom of his/her legs. He/she had shoes on and the rest of her clothes. The resident's walker was standing beside him/her. -Said he/she was trying to change his/her pants because the pair he/she was wearing was too tight. -Was assessed and then staff assisted the resident with removing his/her shoes and pants. Staff assisted the resident to stand and change his/her pants. -Was alert and oriented and able to move all extremities. He/she complained of left hip pain and an order for an x-ray was obtained. A bruise was noted to the palm of the resident's left hand. -Was ambulatory with assistance. -Had a gait imbalance. --The investigation did not describe the resident's environment at the time of the event, the resident's position in relation to his/her environment, where the resident had been prior to the fall, or the location of the resident's call light. Record review of the resident's Fall Risk assessment dated [DATE] at 6:54 P.M., showed the resident was a high risk for falls (score of 11). Record review of the facility's Root Cause Analysis of the resident's fall on 7/12/19, showed: -The resident's fall was caused by his/her reluctance to realize he/she needed help with his/her ADLs. -The resident chose to believe he/she could do what he/she had always been able to do, but when staff talked to the resident, the resident would say he/she knew he/she needed help. -Staff re-educated the resident to ask for help and reminded him/her that it was the staff's job to assist him/her. -The resident verbalized his/her understanding and said he/she would ask when he/she needed them. --The root cause analysis did not address the resident's clothing which he/she reported was too tight or if this issue had been referred to Social Services. Review of the resident's Fall Care Plan showed the following update on 7/12/19: -The resident was re-educated on the importance of using his/her call light to ask for assistance. The resident verbalized his/her understanding. --There were no updates related to the resident's belief he/she was able to do more than he/she was physically able to do, of his/her reluctance to seek assistance, the need to keep the resident's assistive devices close to the resident, or the staff's need to assess the resident's clothing for proper fit. Record review of the resident's Nurse's Notes showed: -On 7/14/19 at 3:09 P.M., the resident was trying to put on his/her pants this morning. -He/she wasn't wanting to wait for the CNA, so the writer of this note helped him/her and reminded the resident to use his/her call light and wait for the CNA's to assist so that he/she didn't fall again. -Staff explained that they were there to help and that the resident was not a bother; It's our job to help. Staff was directed to monitor the resident frequently. Record review of the resident's comprehensive Fall Care Plan showed no update which directed the staff to monitor the resident frequently because he/she was still trying to complete his/her ADLs on his/her own. Record review of the facility's Fall Investigation form dated 7/23/19 at 8:05 A.M., and revised at 10:48 A.M., showed: -A CNA called for the nurse to see the resident. The resident: --Was sitting on the floor in front of his/her recliner. -His/her back was against the chair and his/her legs were straight out in front of him/her. --Had on a brief, a shirt, and fuzzy slipper socks that were not non-skid. The CNA said he/she had dressed the resident earlier, but the resident now did not have on his/her pants or shoes. -The resident's walker was at his/her side, but the resident was unable to tell staff if he/she had been using it. He/she didn't remember. -Staff documented the resident saying he/she didn't know what he/she was doing was a common reply from him/her. --Was guarding his/her left shoulder/upper arm area. An obvious deformity was noted to the area and there resident was unable to raise it and complained of pain there. All other extremities had normal ROM. --Was assisted with putting on a pair of pants then using a gait belt, the resident was assisted to stand. His/her pants pulled up and the resident sat in a chair. Orders were received to send the resident to the ER. -Was oriented to person and place, and he/she rated his/her pain 4/10. He/she was guarding his/her left shoulder/upper arm. -Predisposing factors for the fall included confusion, gait imbalance and impaired memory. Improper footwear and other were also marked. Documentation showed the resident had on fuzzy slipper socks that were not non-slip. He/she was possibly trying to change his/her pants. The CNA had already assisted the resident with dressing but now the resident didn't have any pants or shoes on. --The investigation did not address where the resident's call light was at the time of the fall, if the resident had been wearing the slipper socks with his/her shoes or what was done with the resident's fluffy socks, i.e., if they were removed from the resident's drawer, given to family, etc. Record review of the resident's Fall Risk assessment dated [DATE] at 8:05 A.M., showed the resident remained a high risk for falls with a score of 15.0. Record review of the resident's Nurse's Notes dated 7/23/19 at 4:07 P.M., showed: -The resident returned by ambulance at 4:00 P.M., and was wearing an immobilizer to his/her left arm. -Had a closed reduction to place the humerus (bone of the upper arm forming joints at the shoulder and elbow) back in place. -The resident denied pain and said he/she didn't remember them fixing it. -No instructions were provided by the hospital. Record review of the resident's comprehensive Fall Care Plan revised on 7/23/19 showed: -Staff was to make sure the resident had on either non-skid socks or shoes while he/she was up in his/her room. --The care plan was not updated to reflect the resident had a fall, did not reflect he/she needed an immobilizer, or information for how staff was to care for the resident during this time. Record review of the resident's PT Daily Treatment Note dated 7/24/19, showed the resident: -Was educated on his/her inability to use a walker due to his/her left arm being in an immobilizer, but the resident attempted to use the walker later in the session. -Didn't remember much about the fall but didn't think it was a bad fall. -Performed sit to stand exercises from a partially elevated recliner with moderate assist. -Demonstrated one episode of retropulsion (walking backwards; a disorder of locomotion associated especially with Parkinson's disease that is marked by a tendency to walk backwards) and falling back onto the bed, but after improved positioning, he/she was able to remain unsupported. -The resident demonstrated significant functional decline related to the fall and required increased frequency with PT to improve transfers, bed mobility, wheel chair mobility, and gait and staff training on most appropriate mobility with staff assist. -Received wheel chair mobility training. Had difficulty due to feet not touching the floor. Request had been submitted for a lower wheel chair height. -Required moderate assist to maintain a straight path due to his/her inability to use his/her feet effectively. He/she is unable to effectively propel the wheel chair at this time. Record review of the resident's PT Daily Treatment Notes dated 7/25/19 showed the resident: -Was not receptive to education provided regarding the recent change in his/her status and the importance of consistently participating in therapy (the resident was at an activity and didn't want to leave). -Later the resident was again going to decline therapy due to his/her inability to use left arm, but then agreed to participate. -Was dependent for stand pivot transfer set-up. On the first attempt to stand, the resident raised his/her lift chair greater than 50% and was retropulsive and unable to maintain standing without maximum assist. -Would freeze halfway into sitting. -Required extensive step-by-step cues to perform transfers. -Was again educated on the need to have staff assist him/her with all transfers. -Needed to use a large base quad cane. Staff was educated, but said the resident often got up on his/her own. -The resident's manual wheel chair was lower and he/she was better able to achieve foot contact on the floor for foot propulsion and received training on its use. He/she needed maximum cues on technique and to continue the task. The resident was easily distracted resulting in the stopping of the task. Record review of the resident's Nurse's Notes dated 7/25/19 at 12:37 P.M., showed the facility staff received paperwork from the hospital emergency room . New orders showed the resident was to wear the immobilizer all of the time. Record review of the resident's comprehensive Fall Care Plan showed there were no updates to reflect the resident's recent fall, his/her injury, or that he/she needed to wear an immobilizer all of the time. Record review of the resident's Nurse's Notes dated 7/25/19 at 10:26 P.M., showed the resident: -Was observed by staff with his/her recliner in a raised position. -Told the nurse he/she was going to try to get in his/her wheel chair alone. -Was re-educated on the dangers of self-transfer and was reinstructed to use his/her call light. -The resident promised he/she would do that. -Required the assistance of two staff members. --The note did not address if the call light was within the resident's reach or if the chair was returned the low position. Record review of the resident's comprehensive Fall Care Plan showed no updates related to the resident's attempt for self-transfer by raising his/her chair. Record review of the facility's Root Cause Analysis dated 7/26/19 (for the resident's fall on 7/23/19), showed the resident: -Had a poor sense of safety awareness as his/her family and staff had noted. -Was again reminded to use his/her call light and was to have non-skid socks or shoes on at all times in her room. --The root cause did not address what happened to the resident's slipper socks. The care plan was not updated to address the resident's poor safety awareness nor did it show the resident had an injury which required an immobilizer. Record review of the resident's Nurse's Notes dated 8/1/19 at 1:02 P.M., showed the resident's immobilizer had been discontinued and he/she was to wear a sling for two weeks. There was also an order for the resident to begin PT. Record review of the resident's Nurse's Notes dated 8/7/19 at 11:28 P.M., showed the resident: -Was found on the floor by staff during rounds. -The resident was found to be kneeling down in front of his/her chair. The resident said he/she had been reaching for something. -Was assessed and assisted back into bed. Documentation showed the resident displayed ROM actively in all extremities. --Documentation does not show if the resident was wearing his/her sling, appropriate footwear, the location of the resident's call light or what the resident was reaching for. Record review of the resident's comprehensive Fall Care Plan showed the following update on 8/8/19 the resident will be given a reacher (an assistive device to retrieve things out of arm's reach) by therapy to assist him/her with reaching for things. Record review of the resident's Medical Record showed no Fall Risk Assessment or Fall Investigation form were completed for this fall. Record review of the facility's Fall Investigation form dated 8/24/19 at 11:00 A.M., showed the resident: -Was found on the floor in his/her room by a Certified Medication Technician (CMT). -Was sitting straight up on the floor with his/her legs spread out straight. He/she was a few feet from his/her recliner where he/she had been sitting a few minutes before. -Was wearing app

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure to complete a comprehensive assessment and document the detailed ongoing monitoring of the resident's respiratory status to include lung sounds for a resident who was suspected to have Pertussis (whooping cough - a highly contagious Upper Respiratory Infection (URI) spread by airborne respiratory droplets such as from coughing and sneezing or by skin to skin contact) and later confirmed to have Pertussis for one sampled resident (Resident #36); and to ensure to assess and document a change in condition of the resident's respiratory system prior to and after diagnosis of URI for one sampled resident (Resident #347) out of 14 sampled residents. The facility census was 51 residents. Record reference review of the CDC.org from the National Center for Immunization and Respiratory Diseases, Division of Bacterial Diseases showed: -Pertussis, commonly known as whooping cough, is caused by a bacterium, Bordetella Pertussis. -Pertussis is spread through the air by infectious droplets and is highly contagious. -The incubation period of Pertussis is commonly 7 to 10 days, with a range of 4-21 days. -People with Pertussis are most infectious during the catarrhal (runny nose) period and during the first two weeks after onset of the cough (approximately 21 days). Review of the facility Infection Control policy revised on 8/2017 showed: -Residents with clinical evidence of a respiratory infection are reported to their attending physician and placed on appropriate medication. -The resident's physician will order and terminate any respiratory precautions. -The resident will have a private room with the door kept closed if necessary. -Masks should be worn and hands washed by all persons upon entering and leaving the resident's room. -When an infectious disease is diagnosed, the Director of Nursing (DON) will ensure that proper techniques and reporting are employed. 1. Record review of Resident #36's admission Face Sheet showed he/she was admitted to the facility on [DATE] with diagnosis of: -Asthma (a respiratory disorder characterized by recurring episodes of shortness of breath, wheezing on expiration and/or inspiration caused by constriction of the bronchi, coughing, and thick secretions). -Bronchitis (infection of the lungs). -Chronic Obstructive Pulmonary Disease (COPD, is a chronic inflammatory lung disease that causes obstructed airflow from the lungs). -Parkinson's disease (a chronic nervous disease characterized by a fine slowly spreading tremor, muscle weakness, muscle stiffness and a peculiar gait). Record review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff for care planning) dated 11/4/19 showed he/she: -Was cognitively intact. -Had diagnoses of COPD and Parkinson's. -Had a Flu shot on 10/15/19. Record review of the resident's Plan of Care review date of 11/4/19 showed: -Continue his/her plan of care through next review. -His/her history of Asthma related to COPD and allergies. -The staff to encourage the resident for prompt treatment of any respiratory infection. -A referral to a pulmonologist as needed. -The staff to monitor the resident for signs and symptoms of impending asthma attack to include: coughing spells, decreased energy, rapid breathing, complaint of chest tightness or hurting, wheezing, shortness of breath, tightness of neck or chest muscles, malaise or fatigue and to report to his/her physician those signs and symptoms. Record review of the resident's Nursing Progress Notes dated 11/10/19 at 6:40 A.M. showed the resident: -Had been coughing more than usual with a runny nose. -That morning he/she had a temperature of 99.0 degrees. -Had received Tylenol with his/her morning medications, as well as needed Promethazine (cough medication) for his/her cough. -He/she also had a breathing treatment for shortness of breath. -Nursing was to pass the information on to the on-coming nursing during shift change report for further monitoring. -No documentation by the facility staff of respiratory precautions found in the resident's progress notes. -Review of the resident's progress note and medical record did not find a detail respiratory assessment to include lung sounds documented by the nursing staff. Record review of the resident's Nursing Progress Notes dated 11/13/19 showed: -At 2:48 P.M., received physician order for Levaquin tablet 500 milligram (mg), give one tablet by mouth in the evening for URI for seven days. --He/she did not have a fever and had no adverse reactions observed that shift. --Nursing staff will continue to monitor the resident. -Review of the resident's progress note did not find a detail respiratory assessment to include lung sounds documented by the nursing staff. Record review of the resident's Nursing Progress Notes dated 11/15/19 to 11/17/19 showed: -On 11/15/19 at 3:57 P.M. the resident continues on antibiotics for an upper respiratory infection with no adverse reactions noted. --Had been given cough medication early in the morning and again at shift change by the evening nurse. --The resident continues to have coughing fit at times. -On 11/16/19 at 6:24 A.M. an Infection Note showed: Resident continues on antibiotics for an upper respiratory infection with no adverse reactions noted. --Given Promethazine syrup (cough medication) at 1:15 A.M. for cough and Tussin DM (cough medication) at 6:00 A.M. for cough. --He/she continues to have coughing fit at times and said that he/she had been coughing up yellow, bloody mucus, but he/she was unable to show a sample. --Nursing staff encouraged the resident to drink fluids. --Nursing staff plan for ongoing monitoring of the resident. -On 11/17/19 at 2:43 P.M. the resident continues on oral antibiotic for URI with no adverse reaction noted. --He/she did not have a fever and continued to have a cough. --The resident reported a productive cough at times. --Staff will continue to monitor the resident. -No documentation of respiratory precautions found in the resident's progress notes. -Review of the resident's progress note did not find a detail respiratory assessment documented by nursing staff. Record review of the resident's Nursing Progress Notes dated 11/18/19 at 4:58 P.M. showed: -The resident continued to have a productive cough at times. -No documentation of any respiratory precaution found in the resident's progress notes. -Review of the resident's progress note did not find a detail respiratory assessment documented by nursing staff. Record review of the resident's Nursing Progress Notes dated 11/21/19 at 6:02 A.M. showed: -The resident had a cough with audible wheezing. -The resident said he/she felt tired and worn out and had a headache related to his/her coughing. -He/she had as needed Promethazine 5 ml and 1 vial of Albuterol (breathing treatment) given at 6:00 A.M. -Oxygen saturation was 98%. (normal 97-100%) -The resident said he/she had been too weak and would like to sleep more. -Nursing staff plan to continue to monitor the resident closely. Record review of the resident's Nursing Progress Notes dated 11/27/19 at 4:59 P.M. showed he/she had been seen today by his/her physician today due to persistent cough and received the following new orders of Medrol dose pack (a steroid used to decrease inflammation). Record review of the resident's Nursing Progress Notes dated 11/29/19 at 7:51 P.M. showed: -The resident had complaints of pain in in his/her left upper side, under his/her armpit due to coughing. -He/she had been started on a Medrol dose pack yesterday for coughing. -Staff called the resident's physician, left a message and was awaiting a call back. -The evening and night nursing staff had been made of aware of the resident's cough, pain and call to his/her physician. -Review of the resident's progress note did not find a detail respiratory assessment documented by nursing staff. Record review of copy of the resident's outside of the facility clinic visit dated 12/2/19 showed: -He/she had a cough for two months. -The resident's chest x-ray was normal. -A Computed Tomography (CAT scan, is a special X-ray tests that produce cross-sectional images of the body using X-rays and a computer) of the sinus was normal. -Diagnosis of suspected adult Pertussis. -The physician recommended two weeks of Azithromycin (an antibiotic) tablet 250 mg for 14 Days. -Give Prednisone has follow: a gradual dose reduction started with 30 mg daily for four days, then 20 mg daily for four days, and then 10 mg for four days. -The facility nurse signed acknowledging the visit summary on 12/2/19. Record review of the resident's Nursing Progress Notes dated 12/2/19 at 3:51 P.M. showed: -The resident had seen by the pulmonologist and had received new orders for coughing. -To give Azithromycin 250 mg daily for 14 days. -To give Prednisone 30 mg for four days, then Prednisone 20 mg for four days, then Prednisone 10 mg for 4 days. -The resident's family member had been notify along with the resident by the nurse of the new orders. -No documentation of respiratory precautions indicated in the resident's progress notes or any further respiratory assessment by nursing staff. Record review of the resident's Nursing Progress Notes dated 12/7/2019 12:36 P.M. showed: -The resident's continues on antibiotics for cough and had no adverse reactions noted. -The resident said It feels good not to cough all the time. -He/she had been resting most of the shift and his/her temperature had been 97.6 degrees; and -Review of the resident's progress note did not find a detailed respiratory assessment documented by nursing staff. During initial tour and interview on 12/09/19 at 8:55 A.M., the resident said -He/she had been on his/her second round of antibiotics for whooping cough. -He/she had a diagnosis of COPD. -He/she had been tired and had a of loss appetite due to the coughing. -Had whooping cough for a while now. During an interview on 12/9/19 at 2:50 P.M., DON said:. -The resident had not been on any respiratory precautions or isolation while at the facility. -He/she was not aware the resident had a positive lab result of Pertussis (whooping cough). -The resident had a chronic cough and had not reported as a croupy cough (a barking cough). -The resident had been without a fever for the past week. -The resident's physician's ordered a chest X-ray that was normal in addition to lab work and tests. -The physician was not able to find the cause of the resident's cough. -The physician ordered a consult at pulmonary specialist for the resident's cough. During an interview on 12/9/19 at 3:00 P.M., RN A said: -The resident had a chronic cough for a while that was thought to be due to allergies. -He/she was not aware of the resident having a croupy cough or cough to the point of vomiting. -He/she expect nursing staff to notify the MDS Coordinator or the DON of a new diagnosis of Upper Respiratory Infection and any communicable disease such as Pertussis. -The resident had several X-rays and been on antibiotics and cough medication. -The cough was not going away so the resident's physician referred him/her to an outside physician. Record review of the resident's Infection Note dated 12/10/2019 at 6:18 A.M., showed the resident: -Continued on antibiotics URI with no adverse reactions noted. -Had been given as needed (PRN) cough syrup as ordered and fluids had been encouraged. -Noted that his/her cough had significantly improved and the resident stated he/she had started to feel much better. -Nursing staff plan for ongoing monitoring; and -Did not have a detail assessment of the resident's respiratory system to include lung sounds. During telephone interview on 12/10/19 3:40 P.M., Licensed Practical Nurse (LPN) C said: -He/She had received a phone call from the resident's pulmonary clinic that his/her test result came back was positive for Pertussis and the resident should continue on antibiotics. -They said the resident was not contagious due to have been coughing for a couple of months. -He/She notified the resident and his/her family member of the test results. -He/She did not complete any other infection report, infection note or document the resident's current lung sounds. -It had been recommended for the resident to wear a mask when he/she first had the URI since he/she had active coughing at the time. -He/She was unsure if staff had documented the resident's use of face mask or if there was a physician's order for the resident to wear a mask. During an interview on 12/11/19 at 6:15 A.M. RN C said: -When the resident had his/her initial URI and had been coughing, the resident wore a mask when outside his/her room and when staff had been in the room. -The resident had been on antibiotics when he/she first started coughing. -He/she has not had fever for a while, his/her normal temperature had been 97 degrees to 98 degrees and -He/she said anything 99 degrees and over was considered a fever. During record review of electronic medical record on 12/11/19 at 3:00 P.M., showed no detailed nursing assessment of the resident's lung sounds, or respiratory status during his/her upper respiratory infection. During an interview on 12/13/19 at 9:14 A.M., the resident said: -He/she thought he/she had started coughing in October and had started cough again over the last two days. -The cough medication had been helping at this time. -When he/she first had an issue with coughing, he/she had a box of face masks and he/she would wear the face mask to help prevent the spread of any diseases. -The mask was not due to a physician order or a nursing request for him/her to wear the mask. -The nursing staff checked his/her oxygen saturation, but had not been performing or monitoring lungs sounds or listened to his/her heart. -The doctor does not always listen to his/her heart and lungs either. 2. Record review of Resident #347's admission Face Sheet showed he/she was admitted to the facility on [DATE] with following diagnoses: -COPD. -Mycosis Fungoides (type of blood cancer) and -Admit resident under the care of Hospice services (end of life care) started 11/4/19. Record review of the resident's medical record found no documentation of lung sounds or respiratory status related to the resident's complaints of a respiratory issue noted prior to visit to outside clinic on 10/17/19. Record review of the resident's Infection Progress Note dated 10/17/2019 at 3:59 P.M. showed: -The resident had been seen today by the pulmonary physician and he/she had wrote the following new orders: -Augmentin 875 mg 1 tab by mouth twice daily (BID) for seven days. -Prednisone 10 mg: 40 mg every day for four days, then 30 mg every day for four days, then 20 mg every day for four days, then 10 mg every day for four days, then stop. -The nurse called the clinic office two times to get clarification on written orders and was still awaiting a call back at that time. -The resident's physician requested for the resident to be reevaluated for hospice. -The resident had received Flu shot while at his/her appointment. -His/her temperature was assessed that shift he/she had no fever and his/her temperature was 98.1 degree; and -No documentation for the resident's respiratory system assessment by nursing staff to include lung sounds. Record review of the resident's Infection Progress Note dated 10/21/2019 at 4:01 A.M. showed: -The resident remains on antibiotics for URI and had no adverse reaction noted. -His/Her cough was sporadic and wet. -The resident had been encouraged to cough and to take deep breaths. -Oxygen saturation remains stable with nasal cannula delivering 3 liters (L) of oxygen. -Staff will continue to monitor the resident. -No documentation of respiratory precaution found in the resident's progress notes; and -Review of the resident's progress note did not find a detail respiratory assessment documented by nursing staff. Record review of the resident Progress Notes dated 10/21/2019 at 12:40 showed: -The resident continued on oral antibiotics due to URI with no adverse reaction noted. -He/she had no fever and had been on continuous oxygen to keep his/her oxygen levels between 92 percent (%) and 96%. -He/she had become short of breath with exertion. -He/She had an occasional cough that had been productive at times; and -Did not find documentation for the resident's respiratory system assessment by nursing staff to include lung sounds. Record review of the resident Infection Progress Notes dated 10/22/19 at 6:24 A.M. showed: -The resident remained on antibiotic for URI and had no adverse reaction noted. -He/she had a sporadic and wet cough. -Resident encouraged to cough and take deep breaths. -His/her oxygen saturation remains stable with nasal cannula in place and delivering of 3 L of air. -Nursing staff will plan to continue to monitor the resident; and -Did not find documentation for the resident's respiratory system assessment by nursing staff to include lung sounds. Record review of the resident Infection Progress Notes dated 10/22/2019 at 2:37 P.M. showed: -The resident continues on antibiotic for URI and had no adverse reactions noted; -The resident had been self propelling around the unit. -His/her oxygen saturation level was 93% via nasal cannula and his/her temperature was 99.2 degrees. -Staff will provide ongoing monitoring; and -Review of the resident's progress note did not find a detail respiratory assessment documented by nursing staff. Record review of the resident's Physician Progress note dated 10/23/19 showed: -His/her ear, nose and throat (ENT) had moist membranes. -The resident's lungs was clear to auscultation (CTA), no crackles is (small clicking, bubbling, or rattling sounds in the lungs) or rhonchi (are coarse rattling respiratory sounds). Observation 12/13/19 at 8:46 A.M. of the resident room showed his/her: -Oxygen concentrator was on and set at a rate of 4.5 L with green extension tubing coiled laying on the ground. -Nasal cannula had been hanging on the bathroom door knob; and -Nebulizer treatment machine had been left uncovered on his/her bedside table. Record review of resident's POS dated December 2019 showed; -Azithromycin Tablet 250 mg, give one tablet by mouth every 48 hours for lungs. -Maintain oxygen saturations between 92% to 96%, titrate as needed to maintain and check every shift related to COPD Pulmonary clinic consult. -DuoNeb Solution 0.5-2.5 (3) mg/3 ml (Ipratropium-Albuterol) 3 ml inhale orally every 4 hours as needed for shortness of breath (SOB) or wheezing via nebulizer can use every 4-6 hours or use Pro air instead, one or the other. -ProAir HFA Aerosol Solution 108 (90 Base) Mcg/ACT (Albuterol Sulfate HFA) 2 puffs inhale orally, every 4 hours as needed for shortness of breath order had been written for every 4-6 hrs; and -May use intermittent/conservator regulator to deliver oxygen while awake and only if awake at night 3. During an interview 12/13/19 at 10:34 A.M., the DON said: -The facility did not have a specific assessment form to document lung or respiratory issues. -He/she would expect nursing staff to document baseline lung assessment and as needed for residents with URI and to document in the resident progress notes; and -He/She reviewed Resident #36 and Resident # 347 medical records and the facility weekly, monthly and quarterly assessments did not have a place to monitor or document lungs condition. During an interview on 12/13/19 at 2:51 P.M., LPN D said: -Nursing should do a head to toe assessment on the resident, to include lung sounds upon admission and readmission. -If the resident was having a respiratory issue or had an URI, nursing staff should had completed a comprehensive assessment to include lung sounds. -Nursing should document all assessment findings in the resident's progress notes under health status or infection note. -The resident's weekly, monthly and quarterly nursing assessments did not include heart and lungs. -Resident's on hospice services, the hospice nurse would document lung sounds on a normal bases and for Resident #347 he/she had end stage COPD. -Resident#36 had been doing his/her preventative measures related to his/her cough by using a face mask; and -Nursing staff did not document in the resident's progress notes any respiratory precaution or the resident's use of the face mask. During an interview on 12/13/19 at 3:50 P.M., DON said: -The resident's do not always return with visit summary of their outside clinic visit. -Would expect nursing staff to follow-up with the clinic to obtain visit record including any test results. -The nurse are expected to make copies of any clinical visit notes or lab results. The original goes medical records, keep one for the nursing staff, one to the nursing Care Coordinator/MDS Coordinator and one to the DON if there are any critical findings. -He/She nor the MDS coordinator/Nursing Care Coordinator had been notified about the suspected adult Pertussis on 12/2/19 or the confirmed lab results of Pertussis on 12/6/19. -He/she was not been made of aware of the positive Pertussis test until 12/9/19 during the interview with the State Surveyor. -With suspected cases of a communicable disease, he/she would expect nursing staff to place the resident on isolation until received further physician's orders and had instruction from the DON on what the next step should had been. -A base line care plan should had been completed within 48 hours under assessment for any upper respiratory issue or infections. -Expect nursing staff to document in the resident nursing notes a comprehensive assessment, notification of the resident's physician, family, and the facility Sisters (nuns) of the resident's change in condition and/or suspected communicable disease. -Would expect nursing staff to complete a nursing comprehensive head to toe assessment for the resident ensuring to address the organ that had been affected; and -Would expect nursing staff to at document lungs sounds in the resident's progress note for residents with upper respiratory infection, new or ongoing lung issue.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Record review of the Resident #3 annual MDS dated [DATE] showed he/she: -Was moderately cognitively impaired; and -Had diagnosis of Diabetes. Record review of the resident's MAR dated December 2019 showed Novolin N 10 units (U) bottle give 10 milliliter (ml) Subcutaneous (sub-Q, means under the skin) daily. Observation and interview during the resident's insulin administration on 12/11/19 at 8:15 A.M. showed: -Novolin N sub-Q 10 ml bottle to give 10 units had been refilled on 7/22/19 had no date on the bottle when had been open and a sticker on the container to keep refrigerated. -The Registered Nurse (RN) B had drawn up 10 ml of insulin from the undated bottle of insulin and administered the insulin in the resident's left deltoid (upper arm muscle) sub-Q. -RN A said he/she was not sure when the resident's insulin had been opened. --He/she should have looked for the date the vial was opened and if the insulin was expired prior to administering it to the resident. --The insulin should had been dated when first opened. --He/she should had not given the undated insulin to the resident; and --Open Insulin bottles are stored in the refrigerator when not in use. During an interview on 12/13/19 at 2:33 P.M., RN A said: -He/she would expect nursing staff to label medication when opened; and -Should not use undated open bottle of insulin with a pharmacy label fill date of 7/22/19. During an interview on 12/13/19 at 3:00 P.M., RN C and LPN D said: -Medication and insulin are to be dated when open and - If an insulin bottle did not have a date on the bottle or container when it was opened, they would expect it would not to be given to the resident by nursing staff. During an interview on 12/13/19 at 3:50 P.M., the DON said: -Expect nursing staff and the Certified Medication Technician (CMT) to check for expired medications daily basis. -Insulin not dated should not be given to a resident; and -Multiuse medications should be marked with the date the medication was opened on the bottle and container. Based on observation, interview, and record review, the facility failed to ensure a medication error rate of less than five (5) percent. Three errors were detected out of 42 opportunities resulting in a medication error rate of 7.14%. The errors were related to the administration of drugs at a higher than prescribed dose for one sampled resident (Resident #15) and for one supplemental resident (Resident #2) and for administering medication from an open vial which was undated for one supplemental resident (Resident #3); out of 14 sampled residents and two residents who were supplemental to the sample. The facility census was 51 residents. Record review of the facility's Medication Administration policy dated 08/2017 showed: -A physician order that included dosage, route, frequency, duration, and other required considerations was required for administration of medication. It was the responsibility of the nursing professional to be aware of the classification, action, correct dosage, and side effects of a medication before administration. -If there was a discrepancy between the eMAR and the label, check physician orders before administering the medication. -If the label is wrong, send the medication to the pharmacy for re-labeling. If the eMAR is wrong, discontinue (d/c) or update the order with the correct information within Orders in the electronic chart. Note: The facility policy did not identify checking for an expiration date prior to dispensing a medication. Record review of Fish Oil on WebMD, 2005-2019 WebMD LLC, last updated November 02, 2016, showed Fish Oil was most often used in supplements for conditions related to the heart and blood system. Record review of the Novolin N (long-acting insulin) web site, showed Novolin N insulin expires 28 days after it is opened. 1. Record review of Resident #2's quarterly Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff for care planning) dated 11/27/19 showed he/she was admitted on [DATE] and had diagnoses which included: -Cerbrovascular Accident (CVA, Transient Ischemic Attack (TIA) or stroke and -Hypertension (abnormally high blood pressure). Observation on 12/11/19 at 07:22 A.M. showed Licensed Practical Nurse (LPN) A dispensed and administered Fish Oil 1200 milligrams (mg) to the resident. Record review of the resident's Physician Order Sheet (POS) and Medication Administration Record (MAR) on 12/12/19 showed the resident had an order for 1000 mg of Fish Oil. 2. Record review of Resident #15's admission MDS dated [DATE] showed he/she was admitted to the facility on [DATE] and had diagnoses including hyperlipidemia (an abnormally high concentration of fats or lipids in the blood). Observation on 12/11/19 at 08:00 A.M. showed LPN A dispensed and administered Fish Oil 1200 mg to the resident. Record review of the resident's POS and MAR on 12/12/19 showed the resident had an order for 1000 mg of Fish Oil. During an interview on 12/13/19 at 3:00 P.M., LPN A said: -Fish oil was house stock at their facility. -Staff needed to watch the bottle for accurate dose; check with the pharmacy if a medication was delivered that didn't correspond with the dose prescribed; and needed to notify the physician if the prescribed dose wasn't available and obtain a new order. -He/she should not have given the medication before checking with the physician since the dose was higher than what the physician had prescribed. During an interview on 12/13/19 at 3:50 P.M., the Director of Nursing (DON) said: -Medications should be given as ordered. -He/she would not expect staff to give 1200 mg of fish oil if 1000 mg had been ordered. -Staff should notify the physician of the situation and let him/her decide what amount he/she wanted the resident to receive, i.e., if it was okay to continue to give 1200 mg which was on hand or wait till the 1000 mg capsules were available. -Staff should inform the DON and Central Supply staff about the discrepancy as they managed the floor stock medication.

Based on observation, interview and record review, the facility failed to ensure residents were free from significant medication errors by the administration of insulin not dated when opened for one supplemental resident (Resident #3) during the medication pass. The facility census was 51 residents. Record review of the Novolin N (long-acting insulin) web site, showed Novolin N insulin expires 28 days after it is opened. 1. Record review of the Resident #3's annual Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff for care planning) dated 8/20/19 showed he/she: -Was moderately cognitively impaired and -Had diagnosis of Diabetes. Record review of the resident's Medication Administration Record (MAR) dated December 2019 showed a physician order for Novolin N 10 units (U) bottle give 10 milliliter (ml) Subcutaneous (sub-Q, means under the skin) daily. Observation and interview during the resident's insulin administration on 12/11/19 at 8:15 A.M. showed: -Novolin N sub-Q 10 ml bottle to give 10 units had been refilled on 7/22/19 had no date on the bottle when had been open and a sticker on the container to keep refrigerated. -The Registered Nurse (RN) B had drawn up 10 ml of insulin from the undated bottle of insulin and administered the insulin in the resident's left deltoid (upper arm muscle) sub-Q. -RN A said he/she was not sure when the resident's insulin had been opened. --He/she should have looked for the date the vial was opened and if the insulin was expired prior to administering it to the resident. --The insulin should had been dated when first opened. --He/she should had not given the undated insulin to the resident and --Open Insulin bottles are stored in the refrigerator when not in use. During an interview on 12/13/19 at 2:33 P.M., RN A said: -He/she would expect nursing staff to label medication when opened; and -Should not use undated open bottle of insulin with a pharmacy label fill date of 7/22/19 . During an interview on 12/13/19 at 3:00 P.M., RN C and Licensed Practical Nurse (LPN) D said; -Medication and insulin are to be dated when open and - If an insulin bottle did not have a date on the bottle or container when it was opened, they would expect it would not to be given to the resident by nursing staff. During an interview on 12/13/19 at 3:50 P.M., the Director of Nursing (DON) said: -Expect nursing staff and the Certified Medication Technician (CMT) to check for expired medications daily basis. -Insulin not dated should not be given to a resident; and -Multiuse medications should be marked with the date the medication was opened on the bottle and container.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to maintain the hot water temperatures at the handwashing faucets in numerous resident rooms and in the shower rooms across from resident rooms 3222, 3213, 2222, and 2213, at temperatures consistently above 105 degrees Fahrenheit(ºF ) This practice potentially affected residents on who resided on the 3rd and 2nd floor. The facility census was 51 residents. 1. Record review of the facility record of hot water temperatures on rooms located on the 3rd and 2nd floors, showed the water temperatures that were recorded in one resident room per day, were: - On 11/28/19, the hot water temperature in resident room [ROOM NUMBER], was 104 ºF. - On 12/9/19, the hot water temperature in resident room [ROOM NUMBER], was 104 ºF, and - On 12/12/19, the hot water temperature in resident room [ROOM NUMBER], was 102 ºF. ** Note: All water temperatures taken by the Department of Health and Seniors Services (DHSS) were checked after letting the faucet run for 2 minutes or more. 2. Observations of hot water temperatures on 12/9/19, showed: - At 10:46 A.M., the hot water temperature in resident room [ROOM NUMBER] was 100.5 ºF. - At 11:01 A.M., the hot water temperature in resident room [ROOM NUMBER] was 91.8 ºF. - At 11:02 A.M., the hot water temperature in resident room [ROOM NUMBER] was 85.8 ºF. - At 11:09 A.M., the hot water temperature in resident room [ROOM NUMBER] was 92.5 ºF. - At 11:16 A.M., the hot water temperature in resident room [ROOM NUMBER] was 96.4 ºF. - At 11:28 A.M., the hot water temperature in resident room [ROOM NUMBER] was 97.7 ºF. - At 11:32 A.M., the hot water temperature in resident room [ROOM NUMBER] was 83.8 ºF. - At 11:37 A.M., the hot water temperature in resident room [ROOM NUMBER] was 95.5 ºF. - At 11:54 A.M., the hot water temperature in resident room [ROOM NUMBER] was 99.1ºF. - At 11:58 A.M., the hot water temperature in the 3rd floor shower room across from 3222, was 95.1 ºF. - At 12:03 P.M., the hot water temperature in resident room [ROOM NUMBER] was 98.4 ºF. - At 12:14 P.M., the hot water temperature in resident room [ROOM NUMBER] was 97.4 ºF. - At 11:32 A.M., the hot water temperature in resident room [ROOM NUMBER] was 83.8 ºF. - At 11:37 A.M., the hot water temperature in resident room [ROOM NUMBER] was 95.5 ºF, and - At 11:54 A.M., the hot water temperature in resident room [ROOM NUMBER] was 99.1ºF. During an interview on 12/9/19 at 9:11 A.M., Resident #40 with a Brief Interview for Mental Status (BIMS - an assessment tool that shows a score between 3 of 15 which shows the resident's mental status. This tool helps determine the resident's attention, orientation and ability to register and recall new information) score of 14 out of 15, said: - The hot water was not hot enough and he/she could only obtain a sponge bath, and - This issue of lack of hot water, was reported to maintenance. During an interview on 12/9/19 at 10:15 A.M., during the initial pool process, Resident #5 with a BIMS score of 15, said: - The only concern he/she had was in the shower room. - The tub is the issue. - The hot water was not regulating correctly, when they fill the tub. - The shower head temperature did not get hot. - Some residents have brought this up to the nursing and maintenance staff. - Maintenance staff have looked at the temperature, but the temperature was not correct, - This issue has existed for about six weeks. - When the residents brought up the issue of cold water in the previous month the residents were told that the company that makes the tub needed to be called because the maintenance department has tried to fix it and have not been able to fix it. - There have been issues with the water in both shower rooms on the floor, but he/she thought the shower room closest to his/her room had been fixed, and - The nursing staff was also frustrated about this because they had to assist her in bathing with water that was cold. During an interview on 12/9/19 at 12:27 P.M., the Maintenance Director said: -The mixing valve (a plumbing device which mixes cold and hot water to a desired temperature for a large variety of radiant heating and domestic water applications to ensure constant, safe water temperature at faucet and fixture outlets to prevent scalding and thermal shock) for the resident use areas, is set at its highest temperatures which were between 105-106 ºF, and -The mixing valve has been in use, for many years. 3. Observations with the Maintenance Director on 12/9/19 at 12:32 P.M., showed the temperatures of the boilers which provided the water to tanks which subsequently provided the water to the mixing valves were set at 139ºF and 130 ºF respectively and one storage tank was set at 140 ºF and the other was set 130 ºF. Observations and interview related to the water temperatures on 12/9/19, showed: - At 2:20 P.M., the hot water temperature in resident room [ROOM NUMBER] was 82.9 ºF. - At 2:23 P.M., the hot water temperature in resident room [ROOM NUMBER] was 95.3ºF. - At 2:26 P.M., the hot water temperature in resident room [ROOM NUMBER], was 87.1 ºF. - At 2:29 P.M., the Maintenance Director said the mixing valve has been giving trouble for about a month and on some days he/she can get the water temperatures to be to be around 106 ºF to 107 ºF, and on other days it is harder to get those temperatures. - At 2:33 P.M., the hot water temperature in resident room [ROOM NUMBER] was 101.9 ºF. - At 2:44 P.M., the hot water temperature in the shower room across from 2222 was 89.3 ºF, and - At 2:48 P.M., the hot water temperature in resident room [ROOM NUMBER] was 108.5ºF. 4. Observations of hot water temperatures on 12/10/19, showed: - At 8:38 A.M., the hot water temperature in resident room [ROOM NUMBER] was 96.1 ºF. - At 8:44 A.M., the hot water temperature in resident room [ROOM NUMBER], was 93.7ºF. - At 8:47 A.M., the hot water temperature in the shower room across from 2222 was 99.2 ºF. - At 10:07 A.M., the hot water temperature in resident room [ROOM NUMBER], was 97.9 ºF. - At 10:18 A.M., the hot water temperature in resident room [ROOM NUMBER] was 101.4 ºF. - At 10:44 A.M., the hot water temperature in resident room [ROOM NUMBER] was 98 ºF, and - At 11:09 A.M., the hot water temperature in resident room [ROOM NUMBER], was 97.0 ºF 5. Observations of hot water temperatures on 12/11/19, showed: - At 6:36 A.M., the hot water temperature in the shower room across from 2213 was 98.5 ºF. - At 7:39 A.M., Certified Nurse's Assistant (CNA) A said he/she has given baths instead of showers. - At 7:41 A.M., the hot water temperature in the shower room across from 3221 was 99.9 ºF, and - At 7:43 A.M., CNA B said even some of the faucets in the resident rooms, had cold water. Observations with CNAs C and D on 12/11/19 at 8:52 A.M., showed the hot water temperature in the shower room across from 3213 was 95.4 ºF. - At 8:55 A.M., the tub water was 90.1 ºF and - At 8:56 A.M., CNA C said the water has been cold since around the time of Thanksgiving. During the group interview on 12/11/19 at 10:33 A.M., the following was said: - Residents #40 (with a BIMS score of 14) and #29 (with a BIMS score of 12) said there was cold water in the 2nd floor shower room. - Resident #5 said one of the shower rooms had cold water but that was repaired last week. - The other shower room still had a problem with cold water. - Resident #28 (with a BIMS score of 15) said sometimes it depends on the time of day or if there are a lot of residents who are being given showers at the same time, the water will be cooler, and the facility worked on repairing the situation. During interviews on 12/13/19 from 1:29 P.M. through 1:35 P.M., the following was said: - The Maintenance Director said he/she had been working with the mixing valve for about month and a half. - The mixing valve was rebuilt four to five years ago and it had been a struggle to obtain parts for it. - The manufacturer did not make that style anymore. - That was the problem in getting the mixing valve fixed. - The Director of Nursing (DON) said some of the CNAs said there was cold water in the 2nd floor shower room across from 2213. - The Administrator said some of the water temperatures mentioned, were too cold. - The Maintenance Director said the tubs do not heat the water, and - The tubs do not circulate the water, but only heated the air which moved the water.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. During an interview and observation of the medication room on 12/11/19 at 6:45 A.M., showed the following medications were stored in the medication refrigerator: --Three bottles of undated, opened bottles of Latanoprost solution 0.0005% eye drops (for glaucoma). --One undated, opened bottle of Novolin N insulin. During an interview on 12/11/19 at 8:15 A.M., RN B said: -He/she was not sure when the Novolin N insulin had been opened. -The insulin should had been dated when first opened. -Open Insulin bottles are stored in the refrigerator when not in use. During an interview on 12/13/19 at 2:33 P.M., RN A said: -He/she would expect nursing staff to label medication when opened. -Staff should not use an undated open bottle of insulin. During an interview on 12/13/19 at 3:00 P.M., RN C and LPN D said: -Medication and insulin are to be dated when opened. -If a medication did not have a date on the bottle or container when it was opened, he/she would expect the medication not to be given to the resident by nursing staff. During an interview on 12/13/19 at 3:50 P.M., DON said insulin not dated should not been given to the resident. Based on observation, interview and record review, the facility failed to ensure a resident's Fentanyl patch (a powerful narcotic pain medication) was signed by two staff when removed from the resident and destroyed for one sampled resident (Resident #23) out of 14 sampled residents; to ensure medications were dated when they were opened for use and to ensure all outdated medications were removed from the facility's medication delivery system; and to ensure a medication bottle was labeled with the resident's name when stored out of the original medication box. The facility census was 51 residents. Record review of the United States Food and Drug Administration (U.S. FDA) began requiring an expiration date on prescription and over the counter medications in 1979 stating The medicine expiration date is a critical part of deciding if the product is safe to use and will work as intended. Record review of the facility's Medication Storage in the Facility policy dated effective September 2016 showed: -All medications dispensed by the pharmacy are stored in the box, bag or other container with the pharmacy label. -Outdated, contaminated, or deteriorated medications and those in containers that are cracked, soiled, or without secure closures are immediately removed from stock, disposed of according to procedures for medication disposal .and reordered from the pharmacy .if a current order exists. 1. Record review of Resident #23's Face Sheet showed he/she was admitted to the facility on [DATE] with a diagnosis of chronic pain. Record review of the resident's September 2019 Physician Order Sheet (POS) and Medication Administration Record (MAR) showed: -Fentanyl patch 72-hour 50 micrograms per hour (mcg/hr), apply one patch to the skin every 72 hours for pain and remove per schedule. -Verify placement of Fentanyl patch every shift. -One staff documented a new Fentanyl 50 mcg/hr patch was placed every 72 hours nine out of 10 opportunities (one opportunity was left blank). -One staff documented the removal of the previous Fentanyl 50 mcg/hr patch nine out of 10 opportunities (one opportunity was left blank). -Staff documented the verification of the Fentanyl 50 mcg/hr patch 87 out of 90 opportunities. Record review of the resident's Fentanyl 50 mcg/hr Controlled Medication Utilization Record for September 2019 showed one staff documented the destruction of the removed Fentanyl 50 mcg/hr patch one out of nine opportunities. Record review of the resident's October 2019 POS and MAR showed: -Fentanyl patch 72-hour 50 mcg/hr, apply one patch to the skin every 72 hours for pain and remove per schedule. -Verify placement of Fentanyl patch every shift. -One staff documented a new Fentanyl 50 mcg/hr patch was placed every 72 hours eight out of 10 opportunities (two opportunities were left blank). -One staff documented the removal of the previous Fentanyl 50 mcg/hr patch eight out of 10 opportunities (two opportunities were left blank). -Staff documented the verification of the Fentanyl 50 mcg/hr patch 84 out of 93 opportunities. --Staff documented the resident was at the hospital six times, and one opportunity was left blank. The remaining two opportunities staff documented to refer to the resident's Nursing Notes. No notes were documented by the staff on those two opportunities. Record review of the resident's Fentanyl 50 mcg/hr Controlled Medication Utilization Record for October 2019 showed: -One staff documented the destruction of the removed Fentanyl 50 mcg/hr patch five out of eight opportunities. -Two staff documented the destruction of the removed Fentanyl 50 mcg/hr patch two out of eight opportunities. -The remaining one opportunity had one staff signature with a note not there, indicating the patch was not on the resident. --No staff documentation in the resident's medical record the Fentanyl patch was not located on the resident on that date, if staff looked for the missing Fentanyl patch, if staff notified the Director of Nursing (DON) of the missing Fentanyl patch. Record review of the resident's November 2019 POS and MAR showed: -Fentanyl patch 72-hour 50 mcg/hr, apply one patch to the skin every 72 hours for pain and remove per schedule. -Verify placement of Fentanyl patch every shift. -One staff documented a new Fentanyl 50 mcg/hr patch was placed every 72 hours 10 out of 10 opportunities. -One staff documented the removal of the previous Fentanyl 50 mcg/hr patch 10 out of 10 opportunities. -Staff documented the verification of the Fentanyl 50 mcg/hr patch 87 out of 90 opportunities. --The remaining three opportunities were left blank. Record review of the resident's Fentanyl 50 mcg/hr Controlled Medication Utilization Record for November 2019 showed: -One staff documented the destruction of the removed Fentanyl 50 mcg/hr patch three out of 10 opportunities. -No staff documented the destruction of the removed Fentanyl 50 mcg/hr patch one out of 10 opportunities. Record review of the resident's December 2019 POS and MAR showed: -Fentanyl patch 72-hour 50 mcg/hr, apply one patch to the skin every 72 hours for pain and remove per schedule. -Verify placement of Fentanyl patch every shift. -One staff documented a new Fentanyl 50 mcg/hr patch was placed every 72 hours three out of four (one opportunity was left blank). -One staff documented the removal of the previous Fentanyl 50 mcg/hr patch two out of four opportunities (one opportunity was left blank and one opportunity showed review nursing notes). -Staff documented the verification of the Fentanyl 50 mcg/hr patch 30 out of 37 opportunities. --Staff documented to refer to the resident's Nursing Notes seven times. No notes were documented by the staff on six of the seven opportunities. --Staff documented the patch was not on the resident when he/she was checked for patch placement and a new patch was placed. No documentation the staff notified the Director of Nursing of the missing patch. Record review of the resident's Fentanyl 50 mcg/hr Controlled Medication Utilization Record for December 2019 showed: -One staff documented the destruction of the removed Fentanyl 50 mcg/hr patch two out of two opportunities. -The current Controlled Medication Utilization Record was requested and not received by the facility at the time of exit. During an interview on 12/11/19 at 7:00 A.M., Licensed Practical Nurse (LPN) E said: -Two staff sign off on the resident's Controlled Medication Utilization Record the destruction of a Fentanyl patch. -Two staff could also sign off the destruction on the resident's MAR. During an interview on 12/11/19 at 7:10 A.M., LPN A said: -Two staff sign off on the destruction of a resident's Fentanyl patch. -He/She thought staff could sign the destruction on the resident's MAR but could not find a place for it to be documented. -He/She said staff could sign off on the resident's Controlled Medication Utilization Record for the destruction of a Fentanyl patch. -If a Fentanyl patch was missing from the resident, staff should try to look for it. If it could not be found, staff should notify the Director of Nursing (DON). During an interview on 12/13/19 at 3:17 P.M., the DON said: -He/She expected two staff to document somewhere in the resident's medical record the destruction of the resident's Fentanyl patch. -Staff could document the destruction on the resident's MAR, in a nursing note, or on the resident's Controlled Medication Utilization Record. -He/She expected staff to notify him/her if a Fentanyl patch was not found on the resident and not found in the resident's clothing or bedding. -He/She was not aware the resident's Fentanyl patch was missing and not located on 12/7/19. -The facility does not do a formal investigation if a Fentanyl patch was not located on a resident and was not located in the resident's clothing or bedding. 3. Observation and interview on 12/13/19 at 6:55 A.M. showed the 2nd floor medication cart contained: -Beanaid all natural enzyme supplement with a manufacturer's expiration date of 07/19 marked as opened on 09/28/19. -A bottle of Alaway children's ophthalmic drops (used to treat allergies) was open in the medication cart. The bottle had no name on it nor was it dated when it was opened. An empty box for this medication was found in the medication cart. A resident's name was on the box. -LPN A said: --Medication should have a resident's name on it, unless it was floor stock, and it should be dated when it was opened. --Each staff should be checking for expiration dates before dispensing medications to make sure it was okay to use. Staff should not use a medication if it's expiration date has passed. --Staff was supposed to do monthly checks for outdated medications and the pharmacy was supposed to help check that as well. He/she said no one was specifically assigned to do such checks. 4. During and interview on 12/13/19 at 3:50 P.M., the DON said: -Staff was to check the expiration date prior to using a medication to make sure it was still good to use. -He/she would not expect staff to open and use a medication that had already expired. -Medication should be labeled with a resident's name. If a medication was open, unlabeled, and undated, staff should not use it.

Based on observation, interview, and record review, the facility failed to maintain the temperature of the hot cereal at or above 135 degrees Fahrenheit (ºF) at the steam table throughout the meal service and to ensure two thermometers that were available and used for checking the temperature of cooked foods, were calibrated (checked, adjusted, or standardize a measuring instrument, usually by comparing it with an accepted model). This practice potentially affected 25 residents who resided on the 3rd floor. The facility census was 51 residents. 1. Observation on 12/11/19 at 7:59 A.M., around the beginning of breakfast, showed the temperature of the hot cereal was 168.4 ºF. Observation on 12/11/19 at 8:42 A.M., showed the temperature of the hot cereal was 123.8 ºF. During an interview on 12/11/19 at 8:42 A.M., Dietary Aide (DA) A said there were five more residents left to be fed at that point. 2. Observations with DA A on 12/11/19, showed the following comparisons between the facility's thermometer and the surveyor's thermometer: - At 8:17 A.M., facility's thermometer recorded the temperature of the sausage at 92.2 ºF, while the surveyor's thermometer read sausage at 156 ºF. - At 8:18 A.M., the facility's thermometer recorded the temperature of the scrambled eggs between 125-126 ºF, while the surveyor's thermometer recorded the temperature of the scrambled eggs at 139.8 ºF. - At 8:20 A.M., DA A said he/she did not know the last time those thermometers were calibrated. During an interview on 12/11/19 at 8:42 A.M., DA A said if the temperature of the steamtable fell, he/she would not know it because his/her thermometers read a lower temperature to begin with. Record review of the following chapter of the 2017 Food and Drug Administration (FDA) Food Code, showed: Chapter 3-501.16 Time/Temperature Control for Safety Food, Hot and Cold Holding. A) Except during preparation, cooking, or cooling, or when time is used as the public health control as specified under 3-501.19, and except as specified under paragraphs B and C of this section, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD shall be maintained: 1) At 135 ºF or above, except that roasts cooked to a temperature and for a time specified in paragraphs 3-401.11(B) or reheated as specified in paragraph 3-403.11(E) may be held at a temperature of 135 ºF or above. Review of the 2017 Food and Drug Administration (FDA) Food Code and Missouri Food Codes, showed: - In Chapter 4-203.11 Temperature Measuring Devices, Food: (B) Food temperature measuring devices that are scaled only in Fahrenheit shall be accurate to +/- 2 °F in the intended range of use.

Based on observations, interview and record review, the facility failed to maintain the floors behind and under the convection oven, the large cooking kettles, the steamers and the automated dishwasher free of debris; to ensure the hair of dietary employees (Dietary [NAME] (DC) A and the Assistant Dietary Services Director) were completely covered; and to maintain the cutting boards without numerous nicks and stains and failed to maintain the handles of utensils in an easily cleanable condition because some handles had melted areas. This practice potentially affected all residents. The facility census was 51 residents. 1. Observations during initial kitchen observations on 12/9/19 from 8:35 A.M. through 8:43 A.M., showed the presence of food debris behind the fryer, two large kettles, and the steamers. 2. Observations during the breakfast meal preparations on 12/11/19 from 6:01 A.M. through 7:12 A.M., showed: - The presence of food debris behind the fryer, two large kettles, and the steamers. - DC A and the Assistant Dietary Services Director, cooking omelets, processing eggs, and cooking cereal with hair that was incompletely covered. - Six spatulas with handles which had burnt areas. - At 6:23 A.M., both DC A and the Assistant Dietary Services Director did not have their hair completely covered, and - Eight cutting boards with numerous nicks and stained areas that were not easily cleanable. During interviews on 12/11/19 from 7:23 A.M. through 7:35 A.M., the Director of Nutrition Services, said the following: - He/she could educate dietary staff about not resting the spatulas on hot surfaces. - He/she can look into the get a resurfacer (a device to remove scratches and grooves from cutting boards with a cutting board scraper and helps refinish cutting boards for food safety) for the cutting boards because they go through a lot of cutting boards often. - The dietary staff are supposed to sweep and mop under the stoves/kettles nightly but they missed performing that duty on some nights after he/she saw under the stoves, and - The night shift dishwasher is supposed to sweep and mop the dish room, nightly. During an interview on 12/13/19 at 3:14 P.M., the Dietary Services Director said he/she expected the dietary staff to wear hairnets which completely covered their hair while they were in the kitchen. During an interview on 12/13/19 at 3:28 P.M., DC A said he/she realized then (the time of the interview) that his/her hair cover, did not cover his/her hair completely. Record review of the 1999 and 2009 Food and Drug Administration (FDA) Food Code and Missouri Food Codes, showed: - In Chapter 2-402.11, (A) Except as provided in (B) of this section, food employees shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed food. - In Chapter 4-501.12, Surfaces such as cutting blocks and boards that are subject to scratching and scoring shall be resurfaced if they can no longer be effectively cleaned and sanitized, or discarded if they are not capable of being resurfaced. Surfaces such as cutting blocks and boards that are subject to scratching and scoring shall be resurfaced if they can no longer be effectively cleaned and sanitized, or discarded if they are not capable of being resurfaced. - In Chapter 4-601.11, EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be clean to sight and touch. - In Chapter 4-602.13, non-FOOD-CONTACT SURFACES of EQUIPMENT shall be cleaned at a frequency necessary to preclude accumulation of soil residues - In Chapter 6-501.12, paragraph A, The physical facilities shall be cleaned as often as necessary to keep them clean.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. Record review of Resident #36's admission Face Sheet showed he/she was admitted to the facility on [DATE] with following diagnoses: -Asthma (is when the lungs become progressively smaller as they go deeper into the lungs and if become inflamed cause bronchitis), bronchitis (infection of the lungs). -Cancer of Breast. -Chronic Obstructive Pulmonary Disease (COPD, is a chronic inflammatory lung disease that causes obstructed airflow from the lungs). Record review of the resident's MDS dated [DATE] showed he/she: -Was cognitively intact and -Diagnosis of COPD. Record review of the resident Plan of Care review date of 11/4/19 showed the resident: -Continue his/her plan of care through next review. -His/her history of Asthma related to COPD, allergies. -The staff to encourage the resident for prompt treatment of any respiratory infection. -A referral to a Pulmonologist as needed and -The staff were to monitor the resident for signs and symptoms of impending asthma attack to include: coughing spells, decreased energy, rapid breathing, complaint of chest tightness or hurting, wheezing, shortness of breath, tightness of neck or chest muscles, malaise or fatigue and to report to his/her physician those signs and symptoms. Record review of the resident's clinic visit dated 12/2/19 showed: -He/she had a cough, chest x-ray was normal, Computed Tomography (CAT scan, is a special X-ray tests that produce cross-sectional images of the body using X-rays and a computer) of the sinus was normal, and the resident had been coughing for 2 months. -Diagnosis of Suspected Adult Pertussis. -Recommendation documented for: two weeks of Azithromycin (an antibiotic) Tablet 250 milligrams (mg) for 14 Days. -Give Prednisone (a steroid used to treat inflammation) as follows: a gradual dose reduction started with 30 mg daily for four days, then 20 mg daily for four days, and then 10 mg for four days. -Had been noted by facility nurse signature on 12/2/19. Record review of the resident's Progress Notes dated 12/2/2019 at 3:51 P.M. showed: -The resident had seen by Pulmonologist today and had received new orders for coughing. -To give Azithromycin 250 mg daily for 14 days. -To give Prednisone 30 mg for four days, then Prednisone 20 mg for four days, then Prednisone 10 mg for 4 days. -The resident's family member had been notified along with the resident by the nurse of the new orders. -Did not include documentation related to the diagnosis of suspected adult Pertussis. -No documentation found related to the notification of facility DON, the resident's physician and family member of the suspected diagnosis of a communicable disease of Pertussis. Record review of the resident's POS dated 12/3/2019 showed: -Azithromycin Tablet 250 mg to give one tablet by mouth one time a day for cough for 14 Days. -Prednisone Tablet, give 30 mg by mouth one time a day for cough for 4 Days, then give 20 mg by mouth one time a day for cough for 4 Days, then give 10 mg by mouth one time a day for cough for 4 Days. -No orders for any type of respiratory isolation. Record review of the resident's Progress Notes dated 12/6/2019 at 4:18 P.M. showed: -Nursing staff had received a call from clinic of the Pulmonologist office. -The clinic nurse said the resident's Pertussis swab came back positive for Pertussis. -The resident should continue on oral antibiotics as ordered. -They said the resident's was no longer contagious due to the onset being a couple of months ago. -The nurse documented he/she had notified the resident of test result and had notified a family member. -The resident continued on oral antibiotic due to Pertussis with no adverse reaction noted and no fever. -No documentation been found related to the notification of facility DON or the resident's physician of the confirmed diagnosis of a reportable communicable disease of Pertussis. Record review of the resident's Progress Notes dated 12/7/2019 12:36 P.M. showed: -The resident continues on antibiotics for cough and had no adverse reactions noted. -No documentation had been found related to the notification of facility DON, the resident's physician of the confirmed diagnosis of a reportable communicable disease of Pertussis. During initial tour and interview on 12/09/19 at 8:55 A.M., the resident said -He/she had been on his/her second round antibiotic for whooping cough. -He/she had been tired and had a loss appetite due to the coughing. -He/she said had whooping cough for a while now. During an interview on 12/09/19 at 10:10 A.M. Registered Nurse B (RN) said the facility did not have any residents on respiratory isolation at that time or any other precaution. During an interview on 12/9/19 at 2:31 P.M., Certified Nursing Assistant (CNA) E said: -The unit had not had any resident's recently on isolation or respiratory precautions. -The resident had been coughing a lot. -Had seen the doctor that placed the resident on medication for his/her cough. During an interview on 12/9/19 at 2:40 P.M., RN B said: -No residents were currently on isolation or on respiratory precautions. -He/she was aware with the finding of Pertussis, but the resident is no longer contiguous. -He/she was unsure if the resident had been on isolation this past week/month. -The resident had been without fever for the past week and his/her coughing had decreased. -Had went to specialist for his/her cough and had been antibiotics for several times. During an interview on 12/9/19 at 2:50 P.M., DON said: -He/she said no resident had been reported with any newly or past communicable disease in the facility. -The resident had not been on any respiratory precautions or isolation while at the facility. -He/she was not aware the resident had a positive lab result of Pertussis. -He/she had not been informed by nursing staff or the MDS Care Coordinator of a current Pertussis or a suspected adult Pertussis at the facility. -MDS Coordinator had not reported any new communicable diseases diagnosis. -He/she would had expected nursing staff to notify him/her immediately with any communicable disease or positive lab results. -He/she would have to look up the protocol for Pertussis to see if it was a reportable disease. -The resident had a chronic cough and had not reported the cough as croupy (barking) cough. -The resident had been without a fever for the past week. -The resident's physician's had order chest X-ray, and was normal and other lab work and other test. the physician was not able to find the cause of the cough. -The physician's ordered consult at pulmonary specialist. -He/she was aware the resident was being tested for Pertussis but he/she had not heard any findings from test. -Not aware if the facility had a copy of the lab result or a copy of the clinic visit, he/she would have to follow-up. During an interview on 12/9/19 at 3:00 P.M., RN A said: -He/she had not received notice or documentation related to a new diagnosis for the resident. -The resident had a chronic cough for a while, they thought had been allergies. -He/she was not aware of the resident having a croupy cough or coughing to the point vomiting. -Nothing had been reported related to a suspected or confirmed case of Pertussis. -He/she expect nursing staff to notify MDS Coordinator or the DON of new diagnosis a communicable such as Pertussis. -He/she would have to find the lab reports and read the resident's nurses noted to follow-up on the new finding. -He/she then would have to check CDC protocol on reportable disease and that would tell them if is reportable and who to report the disease to. Record review of the resident's medical record on 12/9/19 at 3:00 P.M. in review of the resident's report findings showed he/she did not have a copy of the final lab result in his/her medical record for the positive Pertussis. During an interview on 12/9/19 at 4:00 P.M., DON said after he/she was notified by the state agency of a positive Pertussis in the facility: -He/she talked to staff at the County Health Department. -He/she was to monitor facility residents, staff, family for any coughing at night not relieved by cough medication. -Preventive treatment of individuals who have been in close contact only and for pregnant women would be to take an antibiotic. Record review of the facility initial paperwork for reporting Pertussis and follow-up for the resident dated 12/9/19 showed: -The facility had faxed a report to County Health Department on 12/9/19 at 5:00 P.M. -Had sent the resident's face sheet with handwritten note on top the paper noting: --Pertussis swab had been obtained on 12/2/19 at the Pulmonologist office. --On 12/6/19 the lab result swab came back as positive. --The Pulmonologist said the resident was no longer contagious, since his/her cough started two months ago. -No other information or lab result sent to the health department. Record review of the resident's medical record on 12/10/19 at 3:00 P.M. in review of the resident's report findings showed: -He/she did not have a copy of the final lab result in his/her medical record for the positive Pertussis. -No other infection control surveillance investigation report offered at this time. During telephone interview on 12/10/19 3:40 P.M., LPN C said: -He/She received a phone call from the resident's pulmonary clinic that the resident's test result came back was positive for Pertussis and the resident should continue on antibiotics. -They said the resident was not contagious due to have been coughing for a couple of months. -He/She notified the resident and his/her family member. -He/she reported the positive lab result to the DON the same day he/she had received call from the clinic. -He/She was not sure if he/she had documented the contact with the DON. -He/she did not notify the resident's physician. -He/she did pass the information on to the next shift nurse. -He/She did not complete any other infection report or infection note. -He/she does not know where to find the list reportable disease, he/she would report to DON. -Has not had training related to process of process of reporting diseases. During an interview on 12/11/19 at 6:30 A.M., the DON said: -The resident's primary care physician had been aware of the resident's pending test for Pertussis. -The physician did not get the final positive lab results until the DON had report to him/her on 12/10/19. -Medical Director, who had been the resident's primary care physician said, since he/she had already been on antibiotic then would covered the treatment of Pertussis. During an interview on 12/13/19 at 2:51 P.M., LPN D said: -When he/she receives a positive communicable disease lab result such as Pertussis, he/she would notified the resident's doctor and the DON to see if any isolation precautions were needed. -All communication received from the resident's clinic, doctor and the DON would be documented in the resident progress notes. During an interview on 12/13/19 at 3:50 P.M., DON said: -The residents do not always return with a visit summary of their outside clinic visit. -Would expect nursing staff to follow-up with the clinic to obtain a visit record to include any test result. -He/She expected the nurse to make a copy of any clinical visit notes or lab results from an outside appointment. The original goes to medical records, keep one for the nursing staff, one to the nursing Care Coordinator/MDS Coordinator, and one to the DON if there were any critical findings. -He/She nor the MDS Coordinator/Nursing Care Coordinator were notified about the suspected adult Pertussis on 12/2/19 or the confirmed lab results of Pertussis on 12/6/19. -He/she was not been made of aware of the positive Pertussis test until 12/9/19 during interview with State Surveyor. -With a suspected case of a communicable disease, he/she would expect nursing staff to place the resident's on isolation until received further physician's orders and had instruction from the DON on what the next step should had been. -He/she would have to look up if a communicable disease should be reported or if need place the resident on isolation. -He/she not aware if the charge nurse or other nursing staff know where to find the reportable communicable disease and the process for it -The nursing staff should had called and report the whooping cough to the DON and then should document in the nurses note who had notified and the outcome. -Expect nursing staff to document in the resident nursing notes a comprehensive assessments, had notified the resident's physician, family, and the facility Sisters (nuns) of the resident's change in condition and suspected communicable disease. 5. Record review of Supplemental Resident #2's quarterly MDS dated [DATE], showed he/she was admitted to the facility on [DATE]. Observations on 12/11/19 at 7:22 A.M., showed LPN A: -Dispensed administered scheduled medications to the resident in his/her room. -Exited the resident's room; wiped a spill from the top of the medication cart; and signed off the resident's medications as given. He/she did not perform hand hygiene upon exiting the resident's room or after cleaning up the spill. -Then opened a trash can liner and placed it into the trash receptacle attached to the medication cart. He/she did not perform hand hygiene after completing this task. 6. Record review of Supplemental Resident #39's quarterly MDS dated [DATE], showed he/she was admitted to the facility on [DATE] and had a diagnosis of diabetes. Observation on 12/11/19 at 7:34 A.M. showed LPN A: -Asked the resident if it was okay to stick his/her finger for a blood sugar sample. The resident consented. -Touched numerous glucometer storage bags stored in the medication cart with his/her bare hands before finding this resident's machine. -Applied gloves without first performing hand hygiene. -Entered the medication drawer for supplies while wearing these gloves. He/she placed the necessary items on a barrier on top of the cart; -Obtained the resident's blood sample. -He/she changed his/her gloves. No hand hygiene was formed after removing his/her soiled gloves. -Prepped and administered the resident's insulin. He/she removed his/her gloves after disposing of the used supplies. Again LPN A failed to perform hand hygiene. -Returned the glucometer into its storage bag without first disinfecting the machine. -He/she used hand sanitizer, locked the cart, and left to find bleach wipes so he/she could clean the machine. -Returned to the cart, and without sanitizing his/her hands, opened the cart and found the bleach wipes in a drawer he/she hadn't previously checked. -Applied gloves without performing hand hygiene. -Removed the soiled glucometer from its storage bag and placed it on the barrier. -He/she applied gloves. No hand hygiene was performed. -Placed another barrier down, obtained a bleach wipe and wiped the machine. He/she then wiped and wrapped the machine in a bleach wipe and placed it in a Styrofoam cup, and allowed it to sit. -After a few minutes, LPN A wiped the machine some more, removed the bleach wipe from the machine and returned the machine to the same cup he/she had used to disinfect the soiled machine. He/she discarded his/her gloves and began preparing to pass another resident's medications. -LPN A did not perform hand hygiene after discarding her gloves. 7. Record review of Resident #16's quarterly MDS dated [DATE], showed he/she was admitted to the facility on [DATE] and had diagnosis of diabetes. Observation on 12/11/19 at 7:45 A.M. showed LPN A: -Prepped the required supplies and completed the blood sugar test for the resident. -Placed the soiled glucometer on a barrier; removed his/her gloves and put on new ones without performing hand hygiene. -Administered the resident's insulin, removed his/her gloves and without performing hand hygiene, returned the medication to its container and put it back into the medication cart. -Applied one glove then obtained a bleach wipe. He/she applied a second glove after opening the container and wiped down the soiled glucometer. He/she placed the glucometer wrapped in a bleach wipe into the same cup the previous glucometer had been in. -Removed his/her gloves and recorded the medication administration into the computer (he/she did not sanitize his/her hands). -He/she put on new gloves, removed a bleach wipe, and placed the glucometer back into same cup in which it had been disinfected. -He/she removed his/her gloves; no hand hygiene was performed. During an interview on 12/13 at 3:00 P.M., LPN A said: -Each resident had his/her own glucometer at the facility and they were stored in a certain area of the medication cart. -Each bag was labeled with the resident's name. -If a soiled glucometer was put back into its protective bag, a new bag should be obtained from the DON. --He/she hadn't done that. -Hand hygiene should be completed: --Before and after medications, eye drops, etc. --After touching soiled items. --Before and after glove use. --After touching garbage. --If staff needed to leave the area and return. ---He/she hadn't performed hand hygiene as he/she should have. -He/She said it was hard being watched. -Bleach wipe contact time should be three minutes, then the item should be allowed to air dry. -Should probably use a clean cup to air dry the glucometer instead of using the same cup in which the glucometer had been disinfected. During an interview on 12/13/19 at 3:50 P.M., the DON said: -Hand hygiene should be performed: --Any time staff went from clean to dirty tasks. --When gloves were removed and before gloves were applied. -Staff could use alcohol-based hand gel if their hands were not visibly soiled. -He/she would expect staff to sanitize before completing a task if they had left the area to get supplies, etc. -Each resident had his/her own glucometer. -Staff was to use two bleach wipes when disinfecting a glucometer. One wipe was used to clean the machine and the second one was used to disinfect the machine. Staff could lay the machine on something on top of the cart or put it in a cup. -A clean cup probably should be used when allowing the machine to air dry to help prevent potential cross-contamination. -He/she would not expect staff to put a soiled glucometer back into its storage bag. The machine should be cleaned first; otherwise you ran the risk of contamination. If that happened, he/she would expect staff to get a clean storage bag from him/her. --The DON said no staff member had asked her for a new storage bag. Based on observation, interview and record review, the facility failed to ensure infection control practices to prevent cross contamination by failing to ensure proper handwashing during wound care for one sampled resident (Resident #16); to store oxygen, nasal cannulas (a device used to deliver supplemental oxygen or increased airflow to a patient or person in need of respiratory help-the device consists of a lightweight tube which on one end splits into two prongs which are placed in the nostrils and from which a mixture of air and oxygen flows) and breathing treatment mouthpieces adequately for two sampled residents (Resident #5 and #45); to report a confirmed case of Pertussis (a reportable communicable disease that is highly contagious lung disease spread by droplets from coughing and/or sneezing, also known as whooping cough) to proper authorities in the required time frame of one day and to report the final positive results of a reportable disease to the resident's primary care physician and to administration staff in a timely manner for one sampled resident (Resident #36 ) who had suspected and confirmed diagnosis of Pertussis; to ensure staff performed hand hygiene during medication pass for one supplemental resident (Resident #2); to ensure staff used good infection control practices when performing blood sugar testing and disinfecting the equipment for one sampled resident (Resident #16) and one supplemental resident (Resident #39); and to develop a written/documented waterborne illness/Legionella sp. (a form of pneumonia, caused by the bacterium Legionella pneumophila found in both potable and nonpotable water systems could grow and spread) prevention plan, which contained the following: text and flow diagrams, areas where Legionella sp. could grow and spread, and documentation that a team has conducted an annual water program out of 14 sampled residents. The facility census was 51 residents. Record review of the facility's Handwashing policy dated revised 08/2017 showed: -All staff providing direct patient care or having any physical contact with the residents or their equipment shall wash their hands frequently. This will include, but is not limited to: --Between contacts with different residents. --Before and after any physical contact with resident's equipment or personal articles that are likely to be contaminated with virulent (extremely severe or harmful in its effects) microorganisms or pathogens (a bacterium, virus, or other microorganism that can cause disease), such as an object or device contaminated with secretions or excretions, e.g., urinary catheter (a tube passed into the bladder to drain urine) systems, endotracheal tubes, etc. --Before and after any procedure with the resident and the collection of specimens, e.g., dressing changes, urine, or blood specimens. --After the removal of gloves. --Whenever hands have become dirty. -Hand washing is essential for the prevention of infection and the control of cross-infection between staff and residents. It is the single most important means of reducing the risks of transmitting microorganisms from one person to another or from one site to another on the same person. -Use soap and warm running water. -Hands may be sanitized with waterless hand cleansers (alcohol gels). Record review of the facility's undated Disinfecting and Cleaning of Blood Glucose Monitors (glucometer - an instrument for measuring the concentration of glucose (a simple sugar) in the blood) policy showed: -The purpose of the policy was to ensure the control of infections by preventing the spread of microorganisms from one resident to another from the use of glucometers or blood glucose monitors. -Staff was to disinfect the exterior of the glucometer after each use with Clorox wipes. Record reference review of the Center of Disease of Control Prevention (CDC.org) from the National Center for Immunization and Respiratory Diseases, Division of Bacterial Diseases last reviewed 11/18/19 showed: -Pertussis, commonly known as whooping cough, is caused by a bacterium, Bordetella Pertussis. -Pertussis is spread through the air by infectious droplets and is highly contagious. -The incubation period of Pertussis is commonly 7 to 10 days, with a range of 4-21 days. -People with Pertussis are most infectious during the catarrhal period and during the first two weeks after onset of the cough (approximately 21 days). -Pertussis is nationally notifiable and clinicians should notify the appropriate health department of all patients with suspected Pertussis. Similarly, diagnostic laboratories should notify health departments of all positive Pertussis laboratory results. State health departments then report confirmed and probable Pertussis cases to CDC through the National Notifiable Diseases Surveillance System (NNDSS). 1. Record review of Resident #16's Face Sheet showed he/she was admitted on [DATE], with diagnoses including diabetes, heart failure, high blood pressure, kidney disease, and low iron. Record review of the resident's quarterly Minimum Data Set (MDS-a federally mandated assessment tool to be completed by facility staff for care planning) dated 9/20/19, showed he/she: -Was alert and oriented with minimal cognitive impairment. -Was independent with dressing, grooming, toileting, and walking. -Needed limited assistance/supervision with transfers and eating. -Used a walker for mobility. -Was not at risk for pressure sores, did not have a pressure sore or an unhealed pressure sores. -Did not have any other wounds or skin issues. -Did not receive any preventive care or interventions. Record review of the resident's Physician's Order Sheet (POS) dated December 2019, showed physician's orders to: -Off load heels with pillows while in recliner or bed to prevent pressure as much as resident will allow and be compliant with treatment every shift for a deep tissue injury to (the resident's) left heel and prevention for right heel. (ordered on 7/11/19). -Clean the resident's left heel with normal saline, pat dry and then apply skin prep (a protective skin barrier) every shift for a deep tissue injury and to maintain skin integrity. Off load the resident's left heel after treatment (ordered on 11/16/19). Observation on 12/10/19 at 1:31 P.M., showed the resident was sitting in his/her recliner with his/her shoes on and his/her feet were not elevated. He/she was alert and was watching television. Licensed Practical Nurse (LPN) D had already placed his/her supplies on a sterile tray that was sitting on top of the resident's dresser by his/her television. The following occurred: -LPN D washed his/her hands and gloved, then removed the resident's shoe and sock. The resident's left heel showed a closed area at the resident's heel that was dark in color and was the size of a small [NAME]. The skin at and around the site was dry, flaky and peeling. -Without de-gloving and re-washing or sanitizing his/her hands, LPN D took a sterile gauze with saline on it out of a cup on the tray, and cleansed the resident's heel. -He/she then de-gloved and without washing or sanitizing his/her hands, he/she gloved, put skin prep on the area then removed his/her gloves. He/she said he/she needed to allow the skin prep to dry before putting his/her sock and shoe on. -LPN D, without washing his/her hands, took the tray and the residents meal tray out of the resident's room. During an interview on 12/10/19 at 1:44 P.M., LPN D said he/she should have washed his/her hands after he/she removed his/her gloves. He/She said he/she could have also used hand sanitizer but was not thinking. During an interview on 12/13/19 at 3:47 P.M.,the Director of Nursing (DON) said: -He/She would expect nursing staff to perform hand hygiene between clean and dirty tasks, before providing care to a resident, before gloving, and whenever they are removing gloves. -The nursing staff can use hand sanitizer if there is no visible soilage. -Nursing staff should wash their hands before leaving the resident's room. 2. Record review of Resident #5's Face Sheet showed he/she was admitted on [DATE], with diagnoses including diabetes, obesity, depression, high blood pressure, asthma, allergies, and chronic pain. Record review of the resident's quarterly MDS dated [DATE], showed he/she: -Was cognitively intact with no memory loss and no behaviors. -Was independent with bed mobility, transfers, eating and toileting and needed limited assistance with bathing and dressing. -Had an upper extremity impairment on both sides (neck, shoulders). -Did not receive respiratory therapy. Record review of the resident's Physician's order Sheet dated December 2019 showed physician's orders for Oxygen at 2 liters per minute. Observation on 12/10/19 at 9:23 A.M., showed the resident was not in his/her room. There was an oxygen concentrator in his/her room. The nasal cannula and tubing was draped around the top of the concentrator, uncovered. Observation on 12/11/19 at 7:16 A.M., showed the resident was sitting in his/her recliner with his/her eyes closed resting comfortably. He/she was wearing a nasal cannula that was attached to an oxygen concentrator and the oxygen concentrator was on at 2 liters per minute. The resident seemed to be resting comfortably without sign or symptom of shortness of breath, pain or discomfort. 3. Record review of Resident #45's Face Sheet showed he/she was admitted to the facility on [DATE], with diagnoses including pain, heart failure, heart disease, constipation, shortness of breath, fracture and high blood pressure. Record review of the resident's admission MDS dated [DATE], showed he/she: -Was alert and oriented without cognitive impairment. -Was independent with transfers, walking, eating, toileting and hygiene. -Needed limited assistance with bathing and dressing. -Used a walker for mobility. -Had constant pain that affected his/her daily activities and functioning, and received pain medication as needed. -Had shortness of breath and received oxygen therapy. Record review of the resident's POS dated December 2019, showed physician's orders for: -Continuous oxygen at 2 liters per minute and -Ipratropium Albuterol solution 0.5-2.5 milligram/milliliters (mg/ml) 3 ml inhale orally four times daily for shortness of air (11/13/19). Observation on 12/09/19 at 2:45 P.M., showed the resident was not in his/her room, but his/her nasal cannula was draped around the oxygen concentrator that was on and running. The resident had a breathing treatment machine that was sitting on a dresser and the mouthpiece was uncovered. Observation on 12/10/19 at 9:34 A.M., showed the resident was not in his/her room at this time, but his/her nasal cannula was draped around the oxygen concentrator that was on and running. The resident's breathing treatment machine was sitting on a dresser above his/her oxygen concentrator and the mouthpiece was uncovered. Observation on 12/10/19 at 11:30 A.M., showed the resident was in the Chapel participating in Mass. Observation in his/her room showed the resident's oxygen concentrator was sitting on the floor and his/her nasal cannula was draped around the handle of the oxygen concentrator that was on and running. The resident's breathing treatment machine was sitting on the dresser above the oxygen concentrator, and the mouthpiece was uncovered. During an interview on 12/13/19 at 3:47 P.M., the DON said oxygen nasal cannulas and mouthpieces for breathing treatment machines should be stored in bags when the equipment is not in use. 8. Record review of the Centers for Medicare and Medicaid Services (CMS) Survey and Certification letter dated 6/2/17, showed the facility should develop and implement a water management program that considers the American Society of Heating Refrigerating and Air Conditioning Engineers (ASHRAE) industry standard and the CDC toolkit. The toolkit should contain the following: text and flow diagrams, identify areas where Legionella could grow and spread, that the team has conducted a water program review at least annually, as stated. The annual review should: 1) be implemented; 2) record findings and updates; 3) record participants; and 4) be submitted to the Executive Director. During interviews on 12/13/19 at 1:40 P.M. through 2:00 P.M., the following was said: - The Maintenance Director said oxygen concentrators were discussed as an a potential reservoir for waterborne illness. - The Maintenance Director said there were no text flow diagrams at this time. - The Administrator said the facility has the bottled water and the bottled water was located on the 2nd floor, in response to a question about how the facility would account for changes in water quality such as water main breaks and construction. - The Maintenance Director said the facility staff would flush the system and all holding tanks, while the residents and staff would drink bottled water in response to a question about actions that would be taken in response to a legionella positive water sample. - The Maintenance Director said they do not have one at this t