**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, and facility policy review, the facility failed to report an allegation of verbal abuse to the State Survey Agency (SSA) for one out of four residents (Resident (R) 37) reviewed for abuse out of 25 sample residents. This failure had the potential to affect resident safety at the facility. Findings include: Review of the facility's policy titled ABUSE, PREVENTION AND PROHIBITION POLICY, revised 01/24, revealed The facility employee or agent, who becomes aware of abuse or neglect, including injuries of unknown origin or alleged misappropriation of resident property, shall immediately report the matter to the facility Administrator or his/her designated representative in the Administrators absence. An employee or agent or any Covered individual will make or cause a report to be made to law enforcement and the facility. The Administrator, or his/her designated representative if Administrator is not present, will notify the Regional Corporate Nurse (if unavailable, the Director of Clinical Operations will be contacted). The facility Administrator, employee, or agent who is made aware of any allegation of abuse or neglect shall report or cause a report to be made to the mandated state agency per reporting criteria. Such reports may also be made to the local law enforcement agency in the same manner. All alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property will be reported immediately to the Administrator. The person made aware of allegations of abuse or neglect OR the Administrator will report the allegations of abuse and neglect to the mandated state agency and law enforcement. The allegation will be reported no later than 2 hours, or per state regulations, after the allegation is made. Review of R37's admission Record located in the Profile tab of the electronic medical record (EMR), revealed admission to the facility on [DATE] with diagnoses including depression and anxiety. Review of R37's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/24/24 revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated intact cognition. During an interview on 06/25/24 11:31 AM, R37 stated she was abused by a staff member in the past. She stated that she had a procedure on her head to relieve swelling and that has affected her memory. But she stated the staff was Certified Nursing Assistant (CNA) 7 and after the incident occurred she wrote a four-page report about what happened on a yellow note pad and gave it to the former Assistant Director of Nursing (FADON) who then gave it to the former Administrator. She stated she asked that CNA7 was allowed to remain in her hall but was not allowed to come into her room to provide care for her or the roommate. She stated CNA7 used foul language towards her specifically the f-bomb, and she remembered it was physical, but she was unable to remember the specifics due to effects of stroke. R37 stated she still saw CNA7 all the time in passing and it did bother her sometimes because seeing her brought back unpleasant memories. She stated all she heard was how wonderful CNA7 was but then why did she have to be abusive towards her. During an interview on 06/27/24 at 10:39 AM, FADON stated she was the former ADON until April of 2024. She stated that R37 gave her a post it notes that CNA7 was rude to her and R37 did not want her to be her CNA anymore. FADON stated she thought it was around Summertime 2023. She stated she reported it to the Administrator at the time, but she did not think it was reported to the state. She stated she spoke with R37, but she could not remember what she meant by the staff was rude but there was nothing documented. She stated there was no documentation to show that the allegations were investigated. During an interview on 06/27/24 at 12:18 PM, CNA7 stated she had provided care to R37 in the past, but it had been a long time. She stated she was asked by a charge nurse not to provide care to R37, but she was unable to remember which charge nurse it was. She stated that she was told by other residents that R37 made allegations that she called the resident a bitch and that she reported that to a charge nurse, but she was not sure who. She stated she was never interviewed about any of the allegations or asked to write a statement. She stated there was never any follow-up after she was removed from providing care to R37, but she was still allowed to work in the hall where R37's room was located. During an interview on 06/28/24 at 2:54 PM, the Director of Nursing (DON) stated the allegations should have been reported to ensure the safety for all the residents. She stated after any allegation of abuse involving staff, that staff should be immediately removed from the care area and suspended pending the outcome of the investigation. She stated the charge nurse would be responsible for reporting the allegations of verbal abuse to management.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, and facility policy review, the facility failed to thoroughly investigate an allegation of verbal abuse for one of four residents (Resident (R) 37) reviewed for abuse out of 25 sample residents. This had the potential to affect resident safety in the facility. Findings include: Review of the facility's policy titled, ABUSE, PREVENTION AND PROHIBITION POLICY, revised 01/24, revealed Resident abuse must be reported immediately to the Administrator', The facility Administrator will ensure a thorough investigation of alleged violations of resident rights and document appropriate action While a facility investigation is under way steps will be taken to prevent further abuse. If a person is identified in the allegation of abuse, that person will not be allowed to have access to the facility while the investigation is in Progress' except to meet with the administrator, as part of the investigation process. The person identified in the allegation of abuse will have no contact with residents or employees during the investigation process. Review of R37's admission Record located in the Profile tab of the electronic medical record (EMR) revealed admission to the facility on [DATE] with diagnoses including depression and anxiety. Review of R37's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/24/24 revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated intact cognition. During an interview on 06/25/24 11:31 AM, R37 stated she was abused by a staff member in the past. She stated that she had a procedure on her head to relieve swelling and that has affected her memory. But she stated the staff was Certified Nursing Assistant (CNA) 7 and after the incident occurred she wrote a four-page report about what happened on a yellow note pad and gave it to the former Assistant Director of Nursing (FADON) who then gave it to the former Administrator. She stated she asked that CNA7 was allowed to remain on her hall but was not allowed to come into her room to provide care for her or her roommate. She stated CNA7 used foul language towards her specifically the f-bomb, and she remembered it was physical, but she was unable to remember the specifics due to effects of stroke. She stated she still saw CNA7 all the time in passing and it did bother her sometimes because seeing her brought back unpleasant memories. She stated all she heard was how wonderful CNA7 was but then why did she have to be abusive towards her. During an interview on 06/27/24 at 10:39 AM, FADON stated she was the former ADON until April of 2024. She stated that R37 gave her a post it notes that CNA7 was rude to her and R37 did not want her to be her CNA anymore. FADON stated she thought it was around Summertime 2023. She stated she reported it to the Administrator. She stated she spoke with R37, but she could not remember what she meant by the staff was rude but there was nothing documented. She stated there was no documentation to show that the allegations were investigated. During an interview on 06/27/24 at 12:18 PM, CNA7 stated she provided care to R37 in the past, but it had been a long time. She stated she was asked by a charge nurse not to provide care to R37, but she was unable to remember which charge nurse it was. She stated that she was told by other residents that R37 made allegations that she called the resident a bitch and that she reported that to a charge nurse, but she was not sure who. She stated she was never interviewed about any of the allegations or asked to write a statement. She stated there was never any follow-up after she was removed from providing care to R37, but she was still allowed to work in the hall where R37's room was located. During an interview on 06/28/24 at 2:54 PM, the Director of Nursing (DON) stated the allegations should have been investigated to ensure safety for all the residents.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure the care plan was revised for two of three residents (Resident (R) 345 and R3) reviewed for care plan accuracy of 25 sample residents. Specifically, the facility failed to identify the inaccurate medical diagnosis for R345 and did not revise the care plan to address hospice services for R3. Failure to update the care plan could result in the residents not receiving care to meet their specific needs. Findings include: 1. Review of R345's admission Record in the Profile tab of the electronic medical record (EMR) revealed an admission date of 06/10/24. The admission Record revealed a diagnosis of dehydration. Review of R345's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 06/16/24 and located in the MDS tab of the EMR, revealed a Brief Interview for Mental Status (BIMS) score of 14 out of 15 which indicated the resident was cognitively intact. Review of R345's Care Plan under the Care Plan tab of the EMR, revealed [R345] has dehydration or potential fluid deficit as a focus area with an initiation date and revision date of 06/10/24. R345's Care Plan revealed Monitor and document intake and output as per facility policy, and Lab work: blood urea nitrogen (BUN), (test that measures the amount of urea nitrogen that's in blood), and creatinine, (waste product that comes from the digestion of protein in food and the normal breakdown of muscle tissue), as ordered, as interventions related to the focus area. Review of R345's EMR revealed there was no order for monitoring or documentation of fluid intake and urine output. Review of R345's EMR revealed there was no BUN and creatinine lab work ordered or having been completed and documented. During an interview on 06/27/24 at 1:54 PM, the Director of Nursing (DON) stated, His care plan could just be stating what we would do if there were no orders, to monitor labs and Input and Output (I/O's) and labs. He may have diagnosis for it, but it could be an old diagnosis. We will monitor it and see if it is an actual diagnosis, but like I said, it could be an old one. During an interview on 06/27/24 at 2:35 PM, the DON stated, He was here before. The previous care plan triggered dehydration. He had it as a diagnosis during his last stay and on his care plan then. We just haven't updated his care plan, yet which would not include the diagnosis of dehydration. Like I said, things have changed so much in the last two weeks. I don't know how things were run before, but we did things differently where I worked before. During an interview on 06/28/24 at 12:20 PM, Licensed Practical Nurse (LPN) 3 stated, Assistant Director of Nursing (ADON) 1, MDS Coordinator LPN (MDSCL), and MDS Coordinator RN (MDSCR) . enter the meds, treatments, MDS, and care plan on new admissions. If it's a previous resident, we have to do the same process as they're a new resident . If I see a diagnosis that is inaccurate (such as dehydration), I call the Dr. During an interview on 06/28/24 at 12:36 PM, the ADON1 stated, MDS does the initial care plans and baseline care plans if they have been a previous patient. The nurses implement the interventions and make any changes that day . MDS checks the accuracy. During an interview on 06/28/24 at 12:47 PM, the Assistant Director of Nursing (ADON) 2 stated, MDS is responsible for entering the diagnosis. They enter it in the EMR when they get the referral information. Then after they're admitted , it uploads as a new admission into the EMR. The care plan populates right away . The clinical team, (DON, ADONs, and MDS) verify the changes during the daily clinical meeting along with social services and therapy. Readmissions are treated the same way as a new admission MDS should check to be sure they're accurate. During an interview on 06/28/24 at 1:05 PM, MDSCL stated, MDSCR and I enter the diagnosis and baseline care plan . If they are a prior resident, we restart the old care plan . We still have within the five days to update the old care plans when they are readmitted . We should have gone through the old care plan and double checked it for accuracy, but it got missed. During an interview on 06/28/24 at 2:19 PM, the DON stated, The immediate care plans are done upon admission and automatically populate . Until [R345] was brought up, I didn't know MDS repopulated the old care plans and used them. They have five days to review them and correct them after admission. 2. Review of R3's admission Record, located in the Profile tab of the EMR, revealed she was admitted to the facility on [DATE] with diagnoses including Alzheimer's disease/dementia with agitation. Review of R3's significant change MDS assessment, with an ARD of 05/21/24 and located in the MDS tab of the EMR, revealed she was rarely/never able to understand others or make herself understood and had severely impaired cognition. She received hospice services. Review of R3's June 2024 Administration Record under the Orders tab of the EMR revealed a physician's order, dated 05/08/24, to admit R3 to hospice services for a diagnosis of dementia. Review of R3's Care Plan, dated 06/05/24 and located in the Care Plan tab of the EMR, revealed, [R3] has a terminal prognosis r/t [related to] Alzheimer's Disease. However, there were no goals or interventions documented to address the terminal prognosis. The Care Plan also documented, Advanced Directive/End of Life Care Plan. [R3] is approaching the end of life at this time. However, the approaches only addressed her code status of Do Not Resuscitate and did not include the provision of hospice services. Review of the Collaborative Care Plan, dated 05/07/24 and located in R3's hospice binder at the Nurses' Station, revealed the plan was to provide nurse visits once per week, aide visits twice per week, and social work and chaplain visits once per month. Under Other treatment plans documented, Foley Cath [catheter] change, diet/feedings, lab tests/diagnostic tests (with hospice approval), medication - see medication list. The section to list the party responsible for providing the necessary treatment plan (whether hospice staff or facility staff) was left incomplete. During an interview on 06/28/24 at 8:23 AM, the Administrator stated the facility did not have a policy addressing coordination of care between the facility staff and the hospice provider. During an interview on 06/28/24 at 9:02 AM, Certified Nurse Aide (CNA) 4 stated she provided the care R3 needed on a daily basis and hospice provided extra care beyond the standard care the facility provided. She stated the hospice staff used a communication binder and communicated during each visit regarding the care provided. She stated the Care Plan would populate R3's [NAME] to indicate what care needed to be provided. During an interview on 06/28/24 at 1:19 PM, the MDSCL stated the nursing staff communicated to her when a resident went on hospice, and the Care Plan should have been updated right away to address coordination of care with hospice. The MDSCL stated she noticed last night that R3's Care Plan did not include hospice services, so she had added that R3 was on hospice. She stated, however, that she had not yet seen the hospice documents and so had not included any information yet regarding coordination of care with hospice. During an interview on 06/28/24 at 1:58 PM, the DON stated coordination of care with hospice providers should have been included in the Care Plan, which would then populate the [NAME] to communicate to the direct care staff. The DON stated the MDSC was responsible for inputting the hospice Care Plan as soon as hospice services were implemented, and the Care Plan should have reflected the services hospice was providing for R3.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, record review, and facility policy review, the facility failed to ensure pressure ulcer treatment orders and pressure ulcer prevention measures were implemented for one of two residents (Resident (R) 3) reviewed for pressure ulcers of 25 sample residents. These failures had the potential to lead to wound deterioration or the development of avoidable pressure ulcers. Findings include: Review of the facility's policy titled, Pressure Ulcer/Pressure Injury Prevention (PUP/PIP) dated March 2022 and provided by the facility, revealed, A pressure ulcer/ injury (PU/PI) can occur wherever pressure has impaired circulation to the tissue. A facility must . implement, monitor, and modify interventions to attempt to stabilize, reduce, or remove underlying risk factors; and if a PU/PI is present, provide treatment to heal it and prevent the development of additional PU/Pl's [sic]. Review of R3's admission Record, located in the Profile tab of the electronic medical record (EMR), revealed she was admitted to the facility on [DATE] with diagnoses including dementia, venous insufficiency, muscle weakness, and peripheral vascular disease. Review of R3's significant change Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 05/21/24 and located in the MDS tab of the EMR, revealed she was rarely/never able to understand others or make herself understood and staff assessed her with severely impaired cognition. She was at risk for the development of pressure ulcers but had no current pressure ulcer. She received a pressure-reducing device for her chair and bed. R3 required substantial to maximal assistance with bed mobility and moving from lying to sitting or sitting to lying. Review of R3's Care Plan, dated 06/05/24, revealed, [R3] has actual impairment to skin integrity r/t [related to] diagnosis of PVD [peripheral vascular disease], fragile skin to BLE [bilateral lower extremities], lymphedema. The approaches included, Float heels while in bed as tolerated .Follow orders for treatment of injuries .Administer treatments as ordered and monitor for effectiveness .[and] Monitor pressure areas for changes in color, sensation, temperature and report any change to nurse. 1. Review of R3's Skin Check Weekly & [and] PRN [as needed] assessments, located in the Assessments tab of the EMR, revealed: -On 05/17/24, there were no skin issues. -On 05/24/24, Open area noted to outer left foot measures 1.5 [centimeters (cm)] x [by] 1 [cm] x US [unstageable] with slough to center and peri wound intact. Treatment order obtained, care plan reviewed and update not needed. -On 05/31/24, there were no skin issues. -On 06/07/24, there were no skin issues. Review of R3's Health Status Note, written by Licensed Practical Nurse (LPN) 2, dated 05/24/24 and located in the Progress Notes tab of the EMR, revealed [R3] noted to have open area to outer left foot measures 1.5 [cm] x 1 [cm] and US with slough to wound bed and peri wound intact . New order noted - Cleanse area with wound cleanser, pat dry, apply nickel-thick Santyl, cover with calcium alginate [wound dressing] cut to fit, then border gauze. Change daily and PRN [as needed] if soiled. Order processed. Review of R3's May 2024 and June 2024 Treatment Administration Record (TAR) under the Orders tab of the EMR revealed a physician's order, dated 05/24/24, to Cleanse wound to outer left foot with wound cleanser, pat dry, apply nickel-thick Santyl [ointment used to promote healing] to wound bed, then calcium alginate cut to fit. Cover with border gauze. Change daily et [and] PRN if soiled. The order for the left outer foot wound was documented in the Unscheduled Other Orders section at the top of the page but did not show up in the scheduled orders to be provided. The TARs did not indicate the treatment had been performed for R3's left outer foot wound since it was ordered. Review of R3's Monthly Skin Check, dated 05/28/24 and located in the Assessments tab of the EMR, revealed the skin issue was a skin tear to the top of the left foot measuring 2cm long, 2cm wide, and 0.1cm deep. The assessment did not address the unstageable wound to the left outer foot. Review of R3's EMR revealed no additional documentation of the left outer foot wound, including measurements or assessments. Review of a hospice Progress Note, located in R3's paper hospice binder and dated 06/07/24, revealed, Patient's left foot wound is healed. During an interview on 06/27/24 at 2:02 PM, Licensed Practical Nurse (LPN) 2 stated R3's hospice nurse had notified of a wound to her left outer foot on 05/24/24. He stated the wound was superficial and looked like a blister that popped. LPN2 stated the wound was completely healed and the treatment should have been discontinued. LPN2 stated he did not know if the wound treatment order obtained on 05/24/24 was implemented, as it had been entered wrong into the EMR system and did not populate as a scheduled treatment order. He stated, It must have gotten done though since it's healed. During an observation on 06/27/24 at 2:15 PM in R3's room with the Certified Medical Technician (CMT), R3's left foot was observed with a dry, scabbed, and scarred circular area to the left outer foot below the pinky toe. The area was not open. During an interview on 06/28/24 at 1:30 PM, the Infection Preventionist/Wound Care Nurse (IP-WC) stated typically when a new wound was identified, she would complete a weekly wound assessment to describe the measurements, staging, and characteristics of the wound to monitor for progress. She stated, however, that she did not complete any assessments of R3's outer left foot wound as she messed up. The IP-WC stated she was unsure whether R3's wound care treatment order from 05/24/24 was implemented. During an interview on 06/28/24 at 2:07 PM, the Director of Nursing (DON) stated LPN2 did not enter the 05/24/24 treatment order in the EMR system correctly, so she could not see that the treatment had been done. She stated the LPN should have initiated a schedule to include the treatment order in the active TAR. 2. Review of R3's June 2024 TAR under the Orders tab revealed a physician's order, dated 09/20/22, for Heel protectors on when in bed as tolerated every day and night shift for Prevention. During an observation on 06/26/24 at 3:20 PM in R3's room, R3 was lying in bed wearing non-slip socks. Her heels were not floated, nor was she wearing heel protectors. R3's heels were in direct contact with the mattress. During an observation on 06/27/24 at 2:12 PM in R3's room, R3 was lying in bed with bare feet, directly in contact with the mattress. Her heels were not floated, nor was she wearing heel protectors. On 06/27/24, Certified Nursing Assistant (CNA) 4 and the CMT entered the room and verified R3 was not wearing heel protectors and her heels were not floated. The CMT stated R3 did not have any heel protectors (boots) and she had never been instructed to float R3's heels. CNA4 confirmed R3 did not have any heel protectors and she had not been instructed to float R3's heels. During an observation on 06/28/24 at 9:59 AM in R3's room, CNA4, CNA6, and the CMT assisted R3 in a transfer from her chair to her bed. The staff did not offer or attempt to apply heel protectors or float her heels. During an interview on 06/28/24 at 10:24 AM, LPN4 stated R3 had an order to use heel protectors as tolerated. LPN4 observed R3 in bed and verified her heels were not floated and she was not wearing heel protectors. He looked in the room and was unable to locate an extra pillow or heel protectors (boots). During an interview on 06/28/24 at 1:30 PM, the IP-WC stated R3 should have had boots (heel protectors) because she was at risk for skin breakdown to her feet. She stated she just did a sweep the other day to ensure all residents who needed them had boots. The IP-WC stated staff should have been applying heel protectors for R3 when in bed and she would have to do more staff education.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure a resident was free from unnecessary medications when one of five residents (Resident (R) 10) was given two separate doses of psychotropic medications without any documented clinical need for either medication of 25 sample residents. This failure had the potential to affect the safety of all residents who received psychotropic medications. Findings include: Review of R10's admission Record located in the Profile tab of the electronic medical record (EMR) revealed admission to the facility on [DATE] and with diagnoses of depression and anxiety disorder. Review of R10's quarterly Minimum Data Set (MDS) under the MDS tab of the EMR with an Assessment Reference Date (ARD) of 04/11/24, revealed a Brief Interview for Mental Status (BIMS) score of six out of 15 which indicated R10 had severe cognitive impairment. The resident was coded as being prescribed antipsychotic medication. Review of R10's Care Plan located under the Care Plan tab of the EMR, dated 01/09/24, revealed Administer Antipsychotic medication as ordered. Review of R10 Physician Orders located under the Orders tab in the EMR, dated 06/03/24, revealed start Lorazepam (anti-anxiety medication) one milligram (mg) by mouth every four hours (PO) (orally), PRN (as needed) for restlessness and/or agitation for 14 days and haloperidol 0.5 ml (milliliter) orally every four hours PRN for agitation for 14 days. Review of Treatment Administration Record (TAR) located under the Records tab in the EMR, dated June 2024, revealed on 06/11/24; one dose of Lorazepam one milligram was administered at 4:46 PM and it was effective. However, a dose of Haloperidol 0.5 ml was also administered at 5:45 PM. Further review revealed no behaviors charted for agitation or restlessness on 06/11/24. Review of a ''Nurse's Notes'' located in the EMR under the ''Notes'' tab and dated 06/11/24, revealed no documentation about any behaviors or justification for use of PRN Lorazepam or Haloperidol. During an interview on 06/28/24 at 9:18 AM, Registered Nurse (RN) 2 stated staff should have documented in progress notes when a resident was having behaviors that would require a PRN medication and it should also be documented on the TAR under the behavior monitoring. She stated after the initial dose was given staff should have checked in about 45 minutes to an hour to see if it was effective or not and if it was effective, staff would not have needed to administer a second dose of anything. She stated a PRN med should not have been given without justification and it would not have been appropriate to administer a second dose of Haldol if the Lorazepam was documented as effective and that would be unnecessary. During an interview on 06/28/24 at 2:48 PM, the Director of Nursing (DON) stated when administering a PRN medication, staff should have put a note into the progress notes justifying what they were administering the PRN for. The DON stated they should have checked within an hour for effectiveness, and if it was effective, another dose should not have been given. She stated it was not appropriate for either of the PRN medications to have been administered without documentation of justification, or for the second dose to have been administered when the first was effective.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, record review, and facility policy review, the facility failed to implement Enhanced Barrier Precautions (EBP) for three of four residents (Resident (R) 247, R14, and R2) reviewed for implementation of EBP with chronic wounds or indwelling devices (intravenous (IV) line, enteral feeding tubes, urinary catheter, or central venous catheter) who were candidates for EBP of 25 sample residents. These failures created the potential to spread multidrug-resistant organisms (MDROs) throughout the facility. Findings include: Review of the facility's undated policy titled, Infection Prevention and Control Manual-Enhanced Barrier Precautions provided by the facility, revealed Enhanced Barrier Precautions involve gown and glove use during high-contact resident care activities for residents known to be colonized or infected with a MDRO as well as those at increased risk for MDRO acquisition (such as residents that have wounds or indwelling medical devices) .Enhanced Barrier Precautions are recommended for residents with any of the following: 1) Infection or colonization with a MDRO or 2) A wound or indwelling medical device, even if the resident is not known to be infected or colonized with a MDRO. Indwelling medical devices include central venous catheters, urinary catheters, feeding tubes, tracheostomies/ventilators. High-contact resident care activities where a gown and gloves should be used include: -Bathing/showering -Transferring residents from one position to another (for example, from bed to wheelchair) -Providing hygiene, -Changing bed linens, -Changing briefs or assisting with toileting, -Caring for or using an indwelling medical device, Performing wound care. 1. Review of R247's admission Record located in the Profile tab of the electronic medical record (EMR), revealed she was admitted to the facility on [DATE] with diagnoses of esophageal obstruction and dysphagia. Since the resident was recently admitted , there was no completed Minimum Data Set (MDS) assessment for review. Review of R247's EMR under the Orders tab, revealed physician's orders, dated 06/13/24, for enteral feeding, enteral tube flushes, and medication administration via enteral feeding tube. Review of R247's Dietician Nutrition Assessment, dated 06/23/24 and located in the Assessment tab of the EMR, revealed She was having difficulty swallowing pta [prior to admission] to hospital and could only tolerate soft foods and liquids. She had a PEG [percutaneous endoscopic gastrostomy] placed and has been on enteral feeding. Review of R247's Care Plan, dated 06/13/24 and located in the Care Plan tab of the EMR, revealed The resident requires tube feeding - Dysphagia, Swallowing problem. During an observation on 06/28/24 at 8:50 AM outside of R247's room, the Hospice Registered Nurse (HRN) entered the room and approached the resident's bedside wearing only a mask. The HRN did not don (put on) a gown and gloves and began to provide care to the resident, including taking vitals and touching the resident's body. The HRN remained in R247's room until approximately 10:00 AM. During an interview on 06/28/24 at 10:08 AM, the HRN confirmed R247 used an enteral feeding tube and stated she had been providing hands-on care to R247, including applying topical medications and examining her. The HRN stated she had donned gloves while applying the topical medication but had not worn a gown during her encounter. The HRN stated the facility had not provided information to her regarding EBP, told her R247 should be on EBP, or asked her to wear a gown and gloves while providing high-contact care activities. During an observation of R247 in her room on 06/28/24 at 9:17 AM, Assistant Director of Nursing (ADON) 1 was training Licensed Practical Nurse (LPN) 4 on administering medications and tube feeding via gastrostomy tube (G-tube). LPN4 was assisting ADON1 during resident care. Both staff members performed hand hygiene and donned gloves. Neither staff member wore a gown during resident care. During an interview on 06/28/24 at 10:06 AM, LPN4 stated, Today is my first day here working. The Director of Nursing (DON) gave me verbal training on infection control, and I had to sign off on it this morning . I would have to double check with her if she trained me on EBP. I'm drawing a blank on what that is, but I will ask her and double confirm . I would not need a gown for foley but would do sterile technique. We don't use a gown right now and I'm under the impression that we don't need one for the g-tube . During an interview on 06/28/24 at 10:16 AM, LPN3 stated, I wear full PPE [personal protective equipment] when a resident has COVID, Clostridioides difficile (C-diff), (a bacterium that causes an infection of the colon, the longest part of the large intestine), the flu, or Methicillin-resistant Staphylococcus aureus (MRSA), (difficult-to-treat bacterial infection) in a wound . I wear a gown with g-tube or foley catheter if they are on known quarantine or have other infections going on. I don't wear a gown with normal catheter care or normal g-tube care. During an interview on 06/28/24 at 10:35 AM, LPN4 stated, I asked ADON1 about EBP. She said the protocols are not in place yet. However, they are going to start this week and implement them. During an interview on 06/28/24 at 12:36 PM, ADON1 stated, The protocol to gown up is not in place yet. We are going to start implementing them next week. During an interview on 06/28/24 at 2:19 PM, the Director of Nursing (DON) revealed that she was not aware that CMS [Centers for Medicare and Medicaid Services] had already implemented EBP. The DON stated the facility had purchased EBP signage and put together training materials to begin implementation in the facility next month, July. The DON stated there was currently no policy related to EBP for the facility. 2. Review of R14's admission Record, located in the Profile tab of the EMR, revealed he was admitted to the facility on [DATE] with a diagnosis of neuromuscular dysfunction of the bladder. Review of R14's quarterly MDS located in the MDS tab of the EMR with an Assessment Reference Date (ARD) of 03/13/24, revealed he used an indwelling urinary catheter. Review of R14's EMR under the Orders tab, revealed a physician's order, dated 06/06/24, for use of an indwelling urinary catheter and catheter care. Review of R14's Care Plan, dated 01/24/24 and located in the Care Plan tab of the EMR, revealed, [R14] has a Suprapubic Catheter d/t [due to] Neurogenic Bladder. During an interview on 06/28/24 at 9:50 AM, Certified Nursing Assistant (CNA) 5 described how catheter care was completed. CNA5 stated the staff wore gloves while doing catheter care and then proceeded to list the correct steps in the care process. CNA5 verified the staff always wore gloves during catheter care, but confirmed the staff only put on masks, goggles, or gowns when the staff were aware of something in the resident's urine. During an observation on 06/28/24 at 10:12 AM in R14's room, the Restorative Aide (RA) and CNA4 entered the room to empty R14's catheter bag and provided catheter care. Both the RA and CNA4 donned gloves while providing care; however, neither staff donned a gown. Observation of R14's room entrance revealed no signage or indication that EBP was required, and no PPE supplies were available at the entrance. During an interview on 06/28/24 at 10:21 AM, the RA confirmed neither she nor CNA4 donned a gown while providing catheter care for R14. The RA stated she had been trained in EBP requirements; however, the facility had not yet implemented the use of EBP. During an interview on 06/28/24 at 10:51 AM, the DON stated the facility had not yet implemented EBP and was planning to do so in July. She stated she had already briefly educated the staff, had signs printed, and ordered mounted PPE holders to prepare for implementation of EBP, but staff had not yet implemented the use of EBP. 3. Review of R2's admission Record located in the EMR under the Profile tab, revealed R2 was admitted to the facility on [DATE] with diagnoses that included neuromuscular dysfunction of the bladder. Review of R2's comprehensive Care Plan located in the EMR under the Care Plan tab, dated 04/05/21, revealed the following focus areas: suprapubic catheter. Interventions in place were to provide catheter care every day shift, change catheter PRN (as needed) for blockage or dislodgement, irrigate catheter as needed, check for kinks during care, monitor and report any pain, discomfort, or any signs of urinary tract infection (UTI). Further review revealed there were no EBP interventions. Review of R2's Physician's Orders, dated 06/05/24 and located in the EMR under the Orders tab, revealed orders as follows: Perform Indwelling Catheter Care (Suprapubic catheter wash catheter site with soap and water daily and flush catheter with 30 ml [milliliter] NS [normal saline] at bedtime. During an observation and interview on 06/25/24 11:31 AM, there was no EBP signage on the resident's door and no cart with PPE near or outside of the resident's room. An interview with R2 at this time revealed staff were not wearing gowns when performing catheter care. During an observation and interview on 06/28/24 at 11:37 AM, there was no EBP signage on R2's door and no cart with PPE near or outside of the resident's room. During an interview with the Infection Preventionist/Wound nurse (IP-WC) who was prepped to perform catheter care stated that staff only wore gloves when doing care. She stated that she had heard about EBP but that was not implemented in the facility, and she was aware there was a plan in place. But she was unaware that it became regulatory to have that in place two months ago. She verified there was no signage or PPE placed outside the resident's room. But agreed that any resident who had a chronic wound, indwelling medication device, or central line should have been on EBP.

Based on observations, interviews, and facility policy review, the facility failed to store foods in sealed containers in the freezer, ensure the cleanliness of the ice machine, and use adequate hand hygiene during food service in one of one kitchen. These failures had the potential to cause the spread of foodborne illness to all 96 residents. Findings include: Review of the facility's undated policy titled, Kitchen Sanitation provided by the facility, revealed Guideline: To ensure that food prepared in the facility is done so in a safe and sanitary manner. Procedure: The Food Service Manager will monitor food safety and sanitation of the Dietary Department on a daily basis .The Food Service Manager will develop a cleaning schedule for the department and is responsible for its completion .The Food Service Manager will provide written cleaning instructions for each area and piece of equipment in the kitchen. The instructions specify which chemical should be used for each task. During initial observations of the kitchen on 06/25/24 at 9:07 AM, the following were observed: -In the ice machine, a brownish-yellowish-greenish substance was on the inside of the lid. During a concurrent interview, the Dietary Manager (DM) stated the maintenance department was responsible for cleaning the ice machine and had done it recently. -In the stand-alone freezer, there were bags that were open and unsealed containing chicken nuggets, hash brown patties, and hamburger patties. During a concurrent interview with the DM, she stated foods should never be open and unsealed in the freezer. The DM confirmed the chicken nuggets, hash brown patties, and hamburger patties were open and unsealed. She removed the observed items and discarded them. The DM stated she was new to the position and had been focusing on cleaning up the walk-in refrigerator and freezer and had not noticed the open and unsealed items in the stand-alone freezer. During observation of lunch service on 06/27/24 from 11:40 AM to 1:00 PM in the kitchen, the following were observed: -At 11:40 AM, the ice machine was again observed with a yellowish-greenish-brownish substance inside the lid. The plate device was observed with crumbs on the outside. -At 12:03 PM, a breadstick fell from a pan onto the top of the steam table. Dietary cook (DC) 2 put the breadstick back in the pan to be served. -At 12:14 PM, DC2 began to serve meals from the steam table. She donned gloves, then opened the plate warming device and grabbed several plate warmers and plates with her gloved hands. Then, she began plating squares of lasagna using a spatula in one hand, and the other hand in the same glove to slide the lasagna off the spatula. -Throughout lunch service, DC used her gloved hands to open the plate warming device and remove the plate warmers, touched carts holding meal trays, touched oven handles, and donned oven mitts over the gloves, then used the same gloves to pick up breadsticks or pieces of bread for plating. -At 12:32 PM, a meal tray card that had been handled and written on in pen dropped into the pan of breadsticks. DC1 removed the meal tray card using her gloved hands and continued to serve the breadsticks that touched the meal tray card. -At 12:33 PM, DC1 used the same gloved hands to pick up a piece of bread out of the bag for serving. During an interview on 06/28/24 at 2:34 PM, the DM stated she had noticed DC1 and DC2 were using unsanitary gloves to pick up bread and breadsticks during lunch service on 06/27/24. She stated she even tried to correct the staff during service to no avail. The DM stated she expected the cooks to use tongs or utensils to serve all foods and should never touch ready-to-eat foods, even with gloves on, because gloves could become contaminated. The DM also confirmed there was a yellowish-brownish-greenish substance on the inside of the ice machine on the lid. She stated she had not noticed it because she was focused on the ice compartment below. The DM stated the maintenance department had just cleaned the ice machine the week before. During an interview on 06/28/24 at 2:45 PM, the Maintenance Director (MD) stated he cleaned the ice machine monthly and just cleaned it last week. He stated, however, that he did not notice the substance on the inside of the lid, as he was focused more on the ice compartment below. He stated the cleaning involved the entire machine, including removing the ice and changing the filter.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to ensure staff obtained physician's orders and assessed residents for safe administration of medication to be kept at the bedside for two of four sampled residents (Resident #1 and #2). The facility census was 96. The facility provided no policy on medication administration. 1. Review of Resident #1's Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 11/6/23, showed: -Cognitive skills intact; -Diagnoses included diverticulitis (an inflammation or infection in one or more pouches in digestive tract), diabetes (a disease that occurs when your blood sugar is too high), and rhabdomyolysis (a breakdown of muscle tissue that releases a damaging protein in blood). Review of care plan, dated 11/6/23, showed the staff were to administer medications as ordered. Review of physician's orders, dated 11/8/23, showed no orders for medications at bedside. Review of electronic medical record on 11/8/23 showed no assessments for self-administration of medications. During an interview and observation on 11/8/23 at 9:45 A.M., Resident #1 was lying in his/her bed with two clear pill cups on his/her bedside table. One pill cup showed a blue pill and the other cup had a white pill. The resident said the blue pill was his/her antibiotic and he/she thought the nurse brought in his/her medications around 9:00 A.M. 2. Review of Resident #2's MDS, dated [DATE], showed: -Cognitive skills intact; -Diagnoses included generalized muscle weakness, chronic obstructive pulmonary disorder (COPD), dysphagia (difficulty in swallowing), and unsteadiness on feet, cognitive communication deficit (difficulty with thinking and how someone uses language). Review of care plan, dated 9/17/23, showed the staff were to administer medications as ordered. Review of physician's orders, dated 11/8/23 , showed: -no orders for medications at bedside; -1.0 cal/cc supplement one time a day for protein supplement -Blood glucose monitoring before meals and at bedtime -Apixaban oral tablet 5 mg, give 1 tablet by mouth two times a day for deep vein thrombosis -Artificial teals ophthalmic solution, instill 1 drop in both eyes one time a day for dry eyes -Budesonide-Formoterol Fumearate inhalation aerosol 160-4.5 mcg/act, 2 puff inhale orally two times a day for COPD rinse mouth with water after use, do not swallow -Carvedilol tablet 3.125 mg, give 1 tablet by mouth two times a day for hypertension -Famotidine tablet 20 mg, give 1 tablet by mouth in morning for acid indigestion -Fluticasone Propionate nasal suspension 50 mcg/act, 1 spray in both nostrils two times a day for allergies -Gabapentin oral capsule 300 mg (give 1 capsule by mouth one time a day for neuropathy -Incruse ellipta inhalation aerosol powder breath activated 62.5 mcg/act, 1 puff inhale orally one time a day for COPD, rinse mouth with water after use, do not swallow -Insulin Lispro (1 Unit Dial) Subcutaneous Solution Pen-Injector 100 Unit/ml, inject as per sliding scale: if 151-200 = 3, 201-250 = 5, 251-300 = 8, 301-350 = 10, 351-400 =12, 401-450 = 15, subcutaneous before meals and at bedtime. Notify doctor if lower than 70 or higher than 350. -Lasix oral tablet 20 mg (furosemide), give 1 tablet by mouth one time a day for congestive heart failure -Levalbuterol HCl inhalation nebulization solution 0.63 mg/3 ml, 3 ml inhale orally via nebulizer two times a day for COPD, rinse mouth with water after use, do not swallow -Lidocaine external patch 4%, apply to sternum topically one time a day for pain and remove per schedule -Losartan potassium oral tablet 25 mg, give 0.5 tablet by mouth one time a day for hypertension. -tizanidine hcl oral tablet 2 mg, give 0.5 tablet by mouth in the morning for spasms Review of Medication administration record on 11/8/23, showed: -7:00 A.M. medication pass included administration of following: -1.0 cal/cc supplement one time a day for protein supplement -Artificial tears ophthalmic solution, instill 1 drop in both eyes one time a day for dry eyes; -Famotidine Tablet 20 mg, give 1 tablet by mouth in the morning for acid indigestion -Gabapentin oral capsule 300 mg, give 1 capsule by mouth one time a day for neuropathy -Incruse Ellipta Inhalation Aerosol Powder Breath Activated 62.5 MCG/ACT, 1 puff inhale orally one time a day for COPD rinse mouth with water after use, do not swallow -Lasix oral table 20 mg (furosemide), give 1 tablet by mouth one time a day for congestive heart failure -Levalbuterol Hcl Inhalation Nebulization solution 0.63 mg/3 ML, 3 ml inhale orally via equalizer in the after afternoon for COPD rinse mouth with water after use, do not swallow -Lidocaine External Patch 4% (lidocaine), apply to sternum topically one time a day for pain and remove per schedule -Losartan Potassium oral tablet 25 mg, give 0.5 tablet by mouth one time a day for high blood pressure -Tizanidine Hcl oral tablet 2mg, give 0.5 tablet by mouth in the morning for spasms -Apixaban oral tablet 5mg, give 1 tablet my mouth two times a day for deep vein thrombosis -Budesonide-formoterol fumarate inhalation aerosol 160-4.5mcg/act, 2 puff inhale orally two times a day for COPD rinse mouth with water after use, do not swallow -Carvedilol tablet 3.125 mg, give 1 tablet by mouth two times a day for hypertension -Fluticasone Proionate nasal suspension, 50 mcg/act, 1 spray in both nostrils two times a day for allergies; -Levalbuterol Hcl inhalation nebulization solution 0.63 mg/3 ml, inhale orally via nebulizer two times a day for COPD, rinse mouth with water after use, do not swallow -Blood glucose monitoring before meals and at bedtime: 153 at 0600 -Insulin Lispro (1 unit dial) subcutaneous solution pen-injector 100 unit/ml, inject per sliding scale: if 151-200 = 3, 3 units administered. Review of electronic medical record on 11/8/23 showed no assessments for self-administration of medications. During an interview and observation on 11/8/23 at 10:04 A.M., the resident was lying on his/her bed with medications at bedside table. Observation showed a fluticasone 50 mcg nasal spray (a medication used to treat allergies), incruse ellipta 62.5mcg (used to treat COPD), budesonide and formoterol fumactate dehydrate inhalation 160 mg inhalers (used to treat COPD), and two pill cups. One medication cup contained a yellow pill, one white round pill, ½ a white pill, 1 white oval pill and one pink pill. The second medication cup showed a larger pink tablet. During an interview on 11/8/23 at 1:38 P.M., the resident said he/she had other residents wander into his/her room. 3. During an interview on 11/8/23 at 12:49 P.M., Regional Nurse A said: -Facility did not have a medications at bedside policy or self-administration of medications policy. -Facility would allow residents to self-administer medications but a medication administration assessment would have been competed on those residents and located in electronic medical record. During an interview on 11/8/23 at 1:27 P.M., Licensed Practical Nurse (LPN) A said: -The staff should not leave medication on residents bedside table. During an interview on 11/8/23 at 1:33 P.M., Registered Nurse (RN) A said: -He/She passed medications this morning to Resident #1 and Resident #2; -The medication administration practice included watching residents take their medications; -He/She left medications at the bedside for Resident #1 because he/she preferred to take antibiotics over a period of time as his/her medications make them nausea. -He/She did not know if Resident #1 had orders to self-administer his/her medications' -Resident #1 was alert and orientated; -He/She watched Resident #2 take his/her medications. During an interview on 11/8/23 at 1:48 P.M., Certified Medication Technician (CMT) A said: -He/She said it was not okay to leave medications at bedside with a resident; -He/She found residents with medications at his/her bedside who were not cognitively aware and reported it to nurse when he/she found the medications; -He/She has found medications after overnight shift had passed medications. During an interview on 11/8/23 at 1:53 P.M., LPN B said: -Standard practice was to wait with resident while they take their medications to ensure they take the medications; -Inhalers can only be left at bedside if a doctor orders them; -No medications should be left at bedside unless approved by doctor. During an interview on 11/8/23 at 1:56 P.M., the Administrator said: -He/She would expect medications left at beside to have a physician's order; -Residents that self-administer medications should have an assessment completed and a physician's order. During an interview on 11/8/23 at 2:06 P.M., the Assistant Director of Nursing (ADON) said: -He/She expected staff to stay and watch the resident take their medications during the medication pass; -Medications should not be left on the bedside table; -An assessment should be completed on residents who self-administer their own medications. MO226709

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure staff obtained appropriate documentation and signatures related to residents' advanced directives (indicates healthcare wishes, such as whether or not a resident wants CPR, cardio-pulmonary resuscitation, and authorization of an agent to make healthcare decisions for the resident). This affected one out of 19 sampled residents (Resident #38). The facility census was 76. Review of the facility's policy related to advance directives, dated [DATE], showed: -Prior to, or upon admission of a resident, the social services designee (SSD) will inquire of the resident, and/or his/her representative, about the existence of any written advance directives. -Information about whether or not the resident has executed and advance directive shall be placed in the medical record. -Depending on the state requirements, the resident representative may also have the right to refuse or forego treatment. -The Interdisciplinary Team will review for changes to the resident's cognitive status and communicate significant changes to the resident's representative. Such changes will be documented in the care plan and medical record. -Durable Power of Attorney (DPOA) for health care is defined as a document delegating authority to a legal representative to make healthcare decisions in case the individual delegating that authority subsequently becomes incapacitated (inability to make decisions). -Do Not Resuscitate (DNR) indicates that, in case of respiratory or cardiac failure (breathing stops or heart stops beating), the resident, legal guardian, health care proxy, or representative (sponsor) has directed that no CPR or other life-sustaining treatments or methods are to be used. -The policy did not address instructions related to verifying a resident's incapacity. Review of the Missouri Revised Statute 404.825 showed: -Unless the patient expressly authorizes otherwise in the power of attorney, the powers and duties of the attorney in fact to make healthcare decisions shall commence upon a certification by two licensed physicians based upon an examination of the patient that the patient is incapacitated and will continue to be incapacitated for the period of time during which treatment decisions will be required and the powers and duties shall cease upon certification that the patient is no longer incapacitated. One of the certifying physicians may be the patient's attending physician. The certification shall be made according to accepted medical standards. The determination of incapacity shall be periodically reviewed by the attending physician. The certification shall be incorporated into the medical records and shall set forth the facts upon which the determination of incapacity is based and the expected duration of the incapacity. Other provisions of this section to the contrary, notwithstanding, certification of incapacity by at least one physician is required. 1. Review of Resident #38's DPOA for healthcare, signed by the resident, and notarized on [DATE], showed: -Named Family Member (FM) A as an agent; -Directed that the agent's authority to make all healthcare and related decisions for the resident is effective when and only when I cannot make my own healthcare decisions; -Did not specify how many physicians should verify the resident's incapacity in order to allow the DPOA agent to begin making decisions for the resident. Review of the resident's Outside the Hospital DNR (OHDNR) request form showed: -Signed by FM A on [DATE], with a witness, on the same date; -Signed by a physician on [DATE]. Review of the resident's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated [DATE], showed: -Long- and short-term memory deficits; -Moderately impaired decision-making skills; -Had a disease or condition that resulted in a life expectancy of less than six months; -Was on hospice care. Review of the resident's admission record/face sheet showed: -admitted [DATE]; -FM A was the responsible person; -Had a DNR status. Review of the resident's care plan, last updated on [DATE], showed: -Had a terminal prognosis related to multiple sclerosis and was on hospice care; -Ensure the resident's wishes are honored in regard to any advance directive; -Code status: DNR (in chart). Review of the resident's electronic physician order sheet (e-POS) for active orders as of [DATE], showed: -Diagnoses that included multiple sclerosis (a progressive neuromuscular disease) and encounter for palliative care (specialized medical care to provide relief from the symptoms and stress of the illness for people living with a serious illness); -A DNR order dated [DATE]. Review of the resident's electronic medical record on [DATE], at 1:48 P.M., showed no DNR form in the record and the DPOA paperwork in the resident's electronic record had another resident's name on it. During an interview and record review on [DATE] at 3:35 P.M., the SSD stated he/she found the resident's OHDNR, signed by FM A, and found the resident's DPOA paperwork. The SSD did not find any verifications of incapacity by any physicians. He/she said the charge nurses and assistant director of nurses (ADON) should help the SSD obtain and verify appropriate paperwork for advance directives. During an interview on [DATE] at 5:28 P.M., the DON said: -The SSD should obtain advance directive information and verify accuracy. -Charge nurses can obtain advance directive information during the admission process, but the SSD should follow-up and verify the information. -Medical record staff scans advance directive information into resident records, and the SSD enters the resident's code status onto the admission/face sheet and care plan.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of Resident #43's comprehensive Minimum Data Set (MD), a federally mandated assessment tool completed by facility staff, dated 9/5/19 showed: - Date of admission [DATE]; - Severe cognitive impairment; - Diagnoses included Dementia; - Received hospice services; - At risk for pressure ulcers. Observation on 10/16/19 at 8:27 A.M. showed the resident's LAL mattress was set on 200, with a range of 50 to 350, with normal pressure; - The resident had just been transferred to his/her wheelchair. Observation on 10/17/19 at 8:12 A.M. showed the LAL mattress was at the same setting; - The resident was not in his/her bed at this time. Review of the resident's medical record showed: - Pressure Ulcer Weekly Wound Evaluation forms dated 10/14/19 showed the resident had two pressure ulcers; - October 2019 Physician Orders Sheet (POS) showed the following orders: o Coccyx and right gluteal wound, cleanse with wound cleanser, pat dry, apply Nurtrashield Calazime (used to protect the skin) to perineal wound skin. Apply Hydrogel to open area. Cover with Abdominal (ABD) pad so covers both wounds, every day shift for coccyx wound and as needed; o Hospice to order/provide Low Air Loss Mattress with perimeter overlay; o The order did not show any setting to be maintained. Review of the resident's Care Plan dated 10/15/19 included the intervention to use pressure reduction mattress on the bed but did not specify the setting to be maintained; - The resident weighed 122.4 pounds in September 2019; - Review of the owner's manual of the LAL mattress did not show any recommendations on the settings; - There was no documentation found with any recommended settings of the LAL mattress in the resident's medical record. During an interview on 10/17/19 at 9:00 A.M. Certified Nurse Aide (CNA) B said CNA's did not do anything with the LAL mattresses. During an interview on 10/17/19 at 8:19 A.M. The Long Term Care Assistant Director of Nursing (ADON) said: - Hospice brought in the LAL mattress; - Staff should make sure it is on but if there is technical difficulties they contact the hospice company; - She was not sure who determined the settings or who monitored the settings. During an interview at the same time the MDS Coordinator said: - Hospice provided the LAL mattress; - It was brought in and set by the Durable Medical Equipment (DME) company according to the manufacture recommendations which were according to the resident's weight; - She was not sure if it was periodically checked on or by whom. During an interview on 10/17/19 at 3:45 P.M. the DON said: - The facility did not have a policy for LAL mattresses but they were set according to the resident's weight and manufacture guidelines; - The DME company told the facility to set it according to the resident's weight; - The firmness is increased when staff provide care; - When she and the ADON have checked the mattress, it had been lower than 200; - CNA's monitor the LAL settings when they provide care; - Desirable settings were communicated verbally to the CNA's or through the care plans. Based on observations, interviews and record review, the facility failed to ensure staff followed professional standards of care when staff failed to establish a correct setting and monitor a Low Air Loss (LAL) mattress for one sampled resident (Resident #43) and failed to prime (wasting two units of insulin) a NovoLog (fast acting) flexpen before administration of 25 units of insulin to Resident #44, also staff did not ensure the resident had a meal timely following administration of the fast acting insulin. The facility census was 76. The facility furnished Competency Checklists as their facility policies. The Regional Nurse stated during the exit conference the facility used the Competency Checklists as their policy for what staff should do. Review of the Competency Checklist for Insulin Flexpen, revised 6/12, showed: - Check the flow with an air shot; - Must be completed before each injection to clear air bubbles and prime the needle; - After the needle is in place, turn the dose selector to two units; - Hold the pen with needle pointing up, tap the cartridge gently with fingers to force air to the top of cartridge; - Press the button all the way in, a drop of insulin should appear at the needle tip (if not, repeat the procedure us to six times; do not use the pen if no success after six attempts. Review of https://www.drugs.com/Drugs.com > novolog, dated 4/26/19, showed: - Since NovoLog is used before meals, you may not be on a timed dosing schedule. Whenever you use NovoLog, be sure to eat a meal within 5 to 10 minutes. 1. Review of Resident #44's current physician order sheet for 10/19, showed the physician ordered: - Accu check monitoring before meals and at bedtime; - NovoLog Inject 20 units before meals for diabetes mellitus; - Give prior to meals and ensure the resident is eating; - Inject NovoLog per sliding scale if accu check is 251 to 300, inject five units. Observation on 10/14/19 at 11:24 A.M., showed Licensed Practical Nurse (LPN) B completed an accu check on the resident, returned to his/her medication cart, cleaned the port on the flexpen, added a new needle and without priming he/she dialed up 25 units of Novolog insulin and administered the 25 units to the resident. Observation on 10:14/19 at 12:02 P.M., showed staff served the resident his/her meal, 38 minutes after the insulin injection. During an interview on 10/17/10 at 11:11 A.M., the DON said: - Staff should prime the flexpen needle by using two units of insulin or until all the air was out of the cartridge; - Staff should prime the flexpen before each injection; - Staff should only administer fast acting insulin 15 to 20 minutes prior to a meal. - Did not have a policy for fast acting insulin administration in relationship to how soon a meal should be served.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure staff provided complete peri care and catheter (sterile tube inserted into the bladder to drain urine) care in a manner to prevent infection, or the possibility of infection, which affected two of 19 sampled residents (Resident #31 and #36). The facility census was 76. 1. Review of the facility's Skills Checklists for Peri Care and Catheter care showed - Separate and thoroughly clean all perineal folds on both male and female; - Clean the rectal area by wiping from there to the coccyx area and clean the buttocks. - Use non-dominant hand to open perineal fold and grasp the catheter tubing at the insertion site; - Clean all areas of the inner perineal fold, then clean the catheter tubing from the insertion site. down the tubing; - Do not clean back and forth between the perineal area and the catheter tubing; - Secure tubing using a leg strap to reduce tension. 2. Review of Resident #31's care plan, revised 8/11/19 showed: - Keep skin clean and dry; - Monitor for signs and symptoms of discomfort on urination and frequency;Secure catheter tubing with a stat lock (adhesive devise placed on a resident's leg that has a velcro strap to secure catheter tubing); - Monitor for signs and symptoms of a urinary track infection. Review of the resident's Minimum Data Set (MDS), a federally mandated assessment completed by facility staff dated 8/22/19, showed: - Able to make daily decisions; - Required assist of staff for toilet use and personal hygiene; - Indwelling catheter; - Always incontinent of fecal matter. Review of the resident's medical record showed a laboratory urinalysis (UA) report, dated 10/5/19, showed bacteria consistent with a urinary tract infection. A handwritten note on the UA showed the physician ordered Bactrim DS 800-160 milligram (mg)(antibiotic) one tablet twice a day for ten days. Observation on 10/14/19 at 9:47 A.M., showed Certified Nurse Aides E, F, and G transferred the resident with a mechanical lift from wheelchair to bed and provided peri and catheter care for the resident in the following way: - CNA F used a clean pre moistened wipe for each swipe and wiped under the abdomen, down the right groin once, down the left groin once, then with the forth wipe held the catheter tubing about five inches from the insertion site and wiped the tubing from the insertion site down towards to his/he hand - CNA F then used the next wipe and wiped once down the center of the perineal fold and over the catheter tubing; - The resident wore no device on his/her leg to aide in assisting to anchor the catheter tubing to prevent pulling on the tubing. Observation on 10/17/19 at 8:31 A.M., showed the resident sat in the dining room with at least 15 inches of tubing that lay inside a black hose lay on the floor. After breakfast CNA H pushed the resident in his/her wheelchair back to the resident's room, the tubing dragged the floor. Observation and interview on 10/17/19 at 2:44 P.M., showed the resident lay in bed with no device anchoring the catheter leg strap. Registered Nurse (RN) B observed staff provide catheter care. CNA E and CNA G provided peri and catheter care in the following way: - CNA E used a different pre moistened wipe for each swipe; - He/she cleaned under the abdomen, and down each groin: - He/she manipulated the perineal fold and wiped down once each inner fold; - With another clean wipe, he/she cleaned the catheter tubing from the insertion site downward. The resident complained of burning with the catheter site. - Then CNA E wiped twice down the center of the perineal fold over the catheter tubing he/she had just cleaned. On 1017/19 at 3:06 P.M., CNA E said: - He/she cleaned under the resident's abdomen, down each groin area, down each side of the labia, down the catheter tubing and then wiped twice more down the center of the perineal fold. During an interview on 10/17/19 at 3:12 P.M., RN B said: - Staff should complete all peri care before they cleaned the catheter tubing so as to not re-introduce bacteria onto the tubing. 3. Review of Resident #36's care plan, revised 7/3/19, showed: - No brief on when in bed, utilize paper chux; - Apply moisture barrier as ordered. The care plan does not address peri care for the resident. Review of the resident's MDS, dated [DATE], showed - Some difficulty with daily decision making; - Required assist of staff with toilet use and personal hygiene; - Incontinent of urine and fecal matter. Observation on 10/16/19 at 9:15 A.M., showed the resident lay in bed incontinent of urine and fecal matter. CNA E and CNA F provided peri care to the resident. CNA F completed peri care in the following way: - CNA F used clean pre-moistened wipes for each swipe; - He/she wiped under the resident's abdominal fold, once down each groin, and without pushing back and manipulating the resident's perineal fold wiped in a circular motion over the perineal fold. Observation on 10/16/19 at 9:45 A.M., Licensed Practical Nurse (LPN) C finished treatments on the resident's heels and assisted the resident to his/her side. The incontinent paper chux under the resident was wet. LPN C provided peri care in the following way: - LPN C used cleaned pre-moistened wipes for each swipe; - Wiped once from the rectal area to the coccyx; - Wiped both directions on each buttock in a back and forth motion; - Assisted the resident to lay on his/her back and cleaned under the resident's abdominal fold; - LPN C wiped down each groin and without manipulating the perineal fold, he/she wiped across the top of the resident's perineal fold. 4. During an interview on 10/17/19 at 11:59 A.M., CNA E said: - He/she should use his/her non-dominant hand to manipulate and open the perineal area and clean the entire perineal fold; - Make sure the entire area is clean, then clean the resident's bottom front to back and make sure the entire area is clean. - He/she should wipe under the abdominal fold, down each groin, down the catheter tubing then down the center of the perineal fold. During an interview on 10/17/19 at 12:13 P.M., CNA F said: - He/she should wipe across under the abdomen and wipe down each groin; - He/she should have pulled back the perineal fold and cleaned the entire area, but that was difficult with this resident; - Use one wipe for each swipe and clean all areas. During an Interview on 10/17/19 at 11:11 P.M., the Director of Nurses said: - Staff should use one wipe for each swipe. If they knew there was a clean area on the wipe they could fold it over and use the clean area;; - Staff should wipe in one direction only which is front to back; - Staff should thoroughly clean all areas of the perineal fold on both males and females; - Staff should clean all areas urine or feces touched; - Staff should complete front peri care before they cleaned the catheter tubing; - Staff should anchor the tubing at the insertion site before they clean it and residents should wear a leg device to aid in anchoring the catheter tubing. If the resident refused the leg device it would be care planned.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure staff documented enteral nutrition (nutrition through a tube inserted into the stomach or the small intestine) and water residents actually received in order to ensure they met their nutritional and hydration needs. The facility also failed to ensure staff followed facility guidelines related to appropriate enteral medication administration and verification of feeding tube placement. This affected two residents who received enteral feedings and medications (Residents #54 and #213). The facility census was 76. Review of the facility's undated skills check list, which staff provided in place of a policy, showed, in part: -Crush each medication separately and place each in a separate medication cup and mix with water to dissolve. -Pause the feeding and verify tube placement. -Check for residual and clamp the tube. -Remove the plunger from the syringe and unclamp the tube. -Flush the tube with at least 30 milliliters (ml) of water and allow it to flow in via gravity. -Pour in the first medication. -Flush with at least 15 ml of water between each medication and flush with at least 30 ml of water after all medications are administered. -Restart the feeding as ordered. -Complete documentation on the electronic administration record (e-MAR). -It did not address documentation of the amount of tube feeding or water residents actually received in a specified time frame (such as per shift or per day). 1. Review of Resident #213's medical record showed staff admitted the resident on 9/27/19. therefore the resident had not been in the facility long enough to have a completed Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff. Review of the resident's October 2019 electronic medication administration record (e-MAR) showed: -Check tube placement every day and night shift prior to administration of medications and tube feedings, which staff initialed each day and night shift, but did not indicate how staff should check placement of the j-tube (jejunostomy tube-a tube surgically inserted into the small intestine that can be used for nutritional feedings); -Flush the feeding tube with at least 30 milliliters (ml) of water before and after medication administration and flush the tube with 5 ml of water between medications, which staff initialed each shift; -60 ml water flush every three hours during tube feeding infusion, initialed by staff at 11:00 P.M., 2:00 A.M., 5:00 A.M. and 8:00 A.M., but did not document how much water the resident actually received each shift or each day; -Infuse Fibersource HN (a nutritional supplement high in fiber and protein) at 70 ml and hour via the j-tube, to run between 8:00 P.M. until noon the following day, each day, which staff initialed daily, but did not document how much of the supplement the resident actually received each shift or each day; -Coreg (a heart medication) 12.5 milligrams (mg) twice a day per tube; -Seroquel 25 mg three times a day per tube for anxiety; -Isosorbide (a heart medication) 10 mg three times a day per tube; -Loratadine (asthma medication) 10 mg daily per tube; -Montelukast (asthma medication) 10 mg daily per tube; -Omeprazole (a stomach medication) suspension 2 mg/ml, give 10 ml per tube daily; -Ramipril (heart medication) capsule 2.5 mg daily per tube; -Ferrous sulfate (iron supplement used to treat anemia) 325 mg daily; -Citalopram (antidepressant) 10 mg daily per tube. Review of the resident's care plan, last revised on 10/15/19, showed; -Had a J-tube used for enteral feeding; -Resident was dependent on enteral feeding and water flushes for intake; -Do not aspirate j-tube; -Received nothing by mouth; -Will remain free of side effects or complications related to enteral feedings and will maintain adequate nutrition and hydration; -Registered dietitian to evaluate and made diet change recommendations as needed; -Did not address documentation of actual nutrition and fluid intake each shift or each day. During an observation and interview on 10/16/19 at 9:01 A.M., observation showed and the resident said: -The resident's Fibersource HN infused per an infusion pump at 70 ml an hour with the date on the infusion bag documented as 10/15/19 at 10:00 P.M. -The resident said his/her tube feeding should run from 8:00 P.M. to noon the next day, but the nurse who attached the tubing to his/her feeding tube last night did not attach it correctly and it ran onto the floor, so staff had to start it all over when they discovered this. During an observation on 10/16/19 at 9:13 A.M., the resident repeated the information about his/her tube feeding issue last night to Licensed Practical Nurse (LPN) A, who said he/she was not informed that part of the resident's tube feeding ran out on the floor and that he/she needed to inform the resident's physician to get further directions related to the tube feeding. Observation and interview on 10/16/19 at 9:18 A.M., showed Licensed Practical Nurse (LPN) A did and said the following as he/she administered medications through the resident's j-tube: -Checked the e-MAR for each medication and checked the e-MAR against each medication card or container; -Crushed a Coreg 12.5 mg tablet in a plastic sleeve and put it in a medication cup; -Crushed a citalopram tablet in a plastic sleeve and put it in a separate medication cup; -Measured 7.5 ml of ferrous sulfate (220 mg/5 ml), to equal 325 mg, in a separate medication cup; -Crushed a Seroquel 25 mg tablet in a plastic sleeve and placed in a separate medication cup; -Measured 10 ml of omeprazole (2 mg/ml), to equal 20 mg, with a syringe and put it in a separate medication cup; -Crushed an Isosorbide 10 mg tablet in a plastic sleeve and put it in a separate medication cup; -Crushed a loratadine 10 mg tablet in a plastic sleeve and put it in a separate medication cup; -Opened a ramipril 2.5 mg capsule and put he contents in a separate medication cup; -Crushed a montelukast 10 mg tablet in a plastic sleeve and put it in a separate medication cup; -Created a clean field on an over-the-bed table and set 3 plastic cups of water, a syringe and each of the medications on it; -Turned the infusion pump on hold; -Put on gloves; -Placed a towel over the resident's abdomen and disconnected the infusion tubing from the j-tube; -Said the resident had a j-tube, so he/she could not aspirate to check for placement; -Attached a piston syringe to the j-tube and flushed the j-tube with 30 ml of water; -Did not do any other form of feeding tube placement check; -Put 5 ml of water into each medication cup and stirred to dissolve each medication, then individually aspirated one medication at a time into the piston syringe and flushed the medication into the j-tube, followed by a flush of 15 ml of water between each one; -Flushed the tube with 60 ml of water with the piston syringe, after he/she administered all of the medications; -Removed his/her gloves and sanitized his/her hands; -Re-attached the infusion tubing to the j-tube and resumed the tube feeding at 70 ml an hour; -LPN A said he/she flushed the medications and water with the piston syringe, rather than by administering them by gravity, because staff had so much trouble getting medications to go through the tube. This way, he/she knew the medications went through the tube. The resident's j-tube had been clogged many times. -He/she said the resident received an automatic 60 ml water flush through the infusion pump every three hours and verified this setting. During an interview on 10/16/19 at 12:01 P.M., LPN A said he/she contacted the resident's physician and received an order to extend the resident's tube feeding time two hours to make up for the tube feeding lost the previous night. 2. Review of Resident #54's admission MDS, dated [DATE], showed: -Long- and short-term memory problems with severely impaired decision-making skills; -Totally dependent for all care; -Had a feeding tube; -Received greater than 51% of his/her calorie intake through a feeding tube; -Received greater than 501 milliliters (ml) of fluids a day through a feeding tube. Review of the resident's care plan, last revised on 9/23/19, showed: -Received nothing by mouth; -Dependent on tube feedings and water flushes for nutrition and fluid intake, see physician orders for current feeding orders; -Will maintain adequate nutrition provided via tube feeding with no signs and symptoms of malnutrition; -Registered dietitian to evaluate and made diet change recommendations as needed; -Did not address documentation of actual nutrition and fluid intake for a specified period of time. Review of the resident's September 2019 e-MAR showed: -Enteral Feed Order-Glucerna 1.2 (a specific nutritional supplement used to control blood sugar levels) at 55 ml an hour per g-tube (gastrostomy tube, a feeding tube surgically inserted into the stomach) continuously, which staff initialed daily, but no documentation of the actual intake administered each shift or each day; -Enteral Feed Order-Infuse Glucerna 1.2, which staff initialed each shift, but no documentation of the actual amount administered each shift or each day. Review of the resident's October 2019 e-MAR showed: -Enteral Feed Order-Glucerna 1.2 at 55 ml an hour via g-tube continuously, which staff initialed each morning, but no documentation of the actual daily intake; -Enteral Feed Order-Infuse Glucerna 1.2 every shift, which staff initialed each shift, but no documentation of the actual intake each shift. Review of the resident's current electronic physician order sheet (e-POS) showed: -Infuse Glucerna 1.2 at 55 ml and hour continuously via g-tube; -Flush feeding tube with 200 ml of water every six hours; -Nothing by mouth. Observation on 10/16/19 at 8:30 A.M., showed: -The resident sat in a wheelchair in his/her room and an enteral feeding infused via a mechanical pump at 55 ml an hour. -Staff documented Glucerna 1.2 on the tube feeding bag and dated it 10/15/19 at 5:00 P.M. During an interview on 10/17/19 at 5:28 P.M., the director of nurses (DON) said: -Staff should check feeding tube placement, unless contraindicated by the physician. -If the POS directed to check placement, the staff should check placement. -Staff should check placement according to facility policy, which he/she thought was by injecting air into the tube and auscultation (listening with a stethoscope). -Staff could give an initial slight push with the piston syringe if the medication or flush did not flow by gravity. -Staff should ultimately administer medications and flushes by gravity, not by pushing all of the medications and flushes through the feeding tube with the use of a piston syringe. -Staff should document tube feeding supplement and water intake on the electronic record, but was not sure of the specific place. During an interview on 10/17/19 at 6:00 P.M., Registered Nurse (RN) A said he/she did not know of any place to document specific tube feeding and water intake. Staff initialed tube feeding and water flushes on the MAR, but there was no place to document specific amounts residents received each shift or each day.

Based on observation and interview, the facility failed to post the complete nurse staffing data in a prominent place readily accessible to all residents and visitors on a daily basis at the beginning of each shift. The facility census was 76. 1. Observation on each day, 10/14/19 through 10/17/19 , showed: - An eight by ten white picture frame held the daily staff posting, which sat on a ledge by the receptionist desk at the entrance of the facility, approximately four feet from the floor; - Each morning, staff hand wrote each days posting in its entirety by the number of staff scheduled to work verses the number of hours actually worked by staff. During an interview on 10/17/19 at 11:11 A.M., the Director of Nursing said: - The staff coordinator filled out the staff posting form and placed it in the picture frame placed on the ledge by the receptionist desk; - The report was filled out in advance not after each shift began; Staff posting was not posted anywhere else in the building besides at the receptionist desk.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews the facility failed to ensure staff provided written notice of transfer or discharge to residents or their responsible parties and the reasons for the transfer in writing, in a language they understood. This affected three of 19 sampled residents (Residents #32, #43, #171). The facility census was 76. 1. Review of Resident #32's nursing progress notes, dated 7/3/19- 7/5/19, showed: -7/3/19 at 4:49 A.M.-The resident voiced shortness of breath and chest pain, acetaminophen 650 milligrams (mg) given with no relief, started on oxygen at 2 liters (L.) via a nasal cannula for a low oxygen saturation level, emergency services (EMS) contacted, and staff sent the resident to the hospital via an ambulance at 4:35 A.M. -7/3/19 at 9:38 A.M.-Staff provided EMS with a medication list, a history and physical (H & P), transfer paperwork, and gave the resident a copy of the bed hold policy. -7/5/19 at 8:54 A.M.-Staff called the hospital and verified his/her room number and hospital staff said the resident had fluid overload, probably from missing dialysis (treatment to remove excess fluid and toxins from the blood when the kidneys no longer function correctly). Review of the resident's Minimum Data Set (MDS) for a significant change, dated 8/21/19, showed: -Was re-admitted from an acute care hospital on 7/9/19; -Had diagnoses that included end stage kidney disease. Review of the resident's medical record showed no documentation that staff provided the resident and the resident's responsible person with a written notification that showed where to and why the resident was discharged . 2. Review of Resident #171's admission MDS, dated [DATE], showed: -Diagnoses included a complex medical condition, cancer and end stage kidney disease; -Had a surgical wound; -Received intravenous (IV) medications and dialysis within the last 14 days. Review of the resident's medical records showed: -10/6/19 at 3:33 P.M.-Received an order to send the resident to the hospital, non emergent, due to purulent (contains pus) drainage from the resident's wound that is covering the floor and soaking through the sheets. -10/6/19 at 3:40 P.M. late entry-Bed hold and transfer discharge notice sent with the resident. -10/10/19 at 2:00 P.M.-Staff re-admitted the resident -The medical record did not document that the facility provided the resident and the resident's responsible person with a written discharge notice that contained where staff discharged the resident to and why. 3. Review of Resident #43's comprehensive Minimum Data Set (MDS), a federally mandated assessment tool completed by facility staff, dated 9/5/19 showed: - Date of admission [DATE]; - Severe cognitive impairment; - Diagnoses included Dementia. The medical record showed the resident was taken to the emergency room and admitted to the hospital on [DATE]. There were no records in the resident's chart that showed a written notice of transfer or discharge was provided to the resident or the responsible party. During an interview 10/17/19 at 4:38 P.M. the Social Services Director (SSD) said: - It did not look like a notice was given to the or his/her responsible party or the resident; -Typically she or the nurses would type up the notices and deliver them to the resident and/or the responsible party; 4. During an interview on 10/17/19 at 3:02 P.M., the administrator said that nursing staff attached the notice of discharge and the bed hold notification to the discharge/transfer form when they sent a resident to the hospital. She was not aware that the facility should send a written notice of discharge to the responsible person as well. During an interview on 10/17/19 at 3:03 P.M., the corporate nurse said: -Staff gave a discharge notice to residents when staff discharged them. -Staff either gave or mailed a copy of the discharge notice to the durable power of attorney, if the resident had one. -He/she was not aware that the facility had to provide a written discharge notice to both the resident and the responsible party that indicated where the resident was discharged to and why. -The facility had no policy related to this. -The facility only had a policy related to an involuntary discharge.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of Resident #43's comprehensive Minimum Data Set (MD), a federally mandated assessment tool completed by facility staff, dated 9/5/19 showed: - Date of admission [DATE]; - Severe cognitive impairment; - Diagnoses included Dementia; - Received hospice services; - At risk for pressure ulcers. Observation on 10/16/19 at 8:27 A.M. showed the resident's Low Air Loss (LAL) mattress was set on 200, with a range of 50 to 350, with normal pressure; - The resident had just been transferred to his/her wheelchair. Observation on 10/17/19 at 8:12 A.M. showed the LAL mattress was at the same setting (200); - The resident was not in his/her bed at this time. Review of the resident's medical record showed: - October 2019 Physician Orders Sheet (POS) showed the following orders: -Treatment orders for two wounds; -Hospice to order/provide Low Air Loss Mattress with perimeter overlay; -The order did not show any setting to be maintained. Review of the resident's Care Plan dated 10/15/19 included the intervention to use pressure reduction mattress on the bed but did not specify the setting to be maintained; - The resident weighed 122.4 pounds in September; - There was no documentation found with any recommended settings of the LAL mattress in the resident's medical record. During an interview on 10/17/19 at 9:00 A.M. Certified Nurse Aide (CNA) B CNA's did not do anything with the LAL mattresses setting. During an interview on 10/17/19 at 3:45 P.M. the Director of Nursing (DON) said: - The LAL mattress was set according to the resident's weight and manufacture guidelines; - The medical equipment company told the facility to set it according to the resident's weight; - The firmness is increased when staff provide care; - When she and the ADON have checked the mattress, it had been lower than 200; - CNA's monitor the LAL settings when they provide care; - Desirable settings were communicated verbally to the CNA's or through the care plans. 3. Review of Resident #213's admission Minimum Data Set (MDS), a federally mandated assessment tool completed by facility staff dated 8/9/19 showed: - Date of admission 8/2/19; - Cognitively intact; - Diagnoses included Diabetes Mellitus, Osteoporosis, Stroke; - Required extensive assistance with transferring between surfaces, including to or from bed, chair, wheelchair and required one person assist; - Required extensive assistance with toilet use and required one person assist; - Used a wheelchair; - Always continent of bowel and bladder. During an observation on 10/16/19 at 9:59 A.M., the resident requested to go to the bathroom while Licensed Practical Nurse (LPN) A cleansed tube feeding equipment in the resident's bathroom. The resident got out of bed and started to the bathroom, holding onto furniture and the wall to steady him/herself. The LPN came out and assisted the resident to the bathroom, waited outside door until the resident finished, then assisted him/her back to bed. During an interview on 10/15/19 at 9:37 A.M. the resident said: - He/she tried to go to the bathroom on his/her own because staff take too long to answer the call light; - By the time he/she gets to the bathroom he/she is so weak he/she has to lay his/her head on the grab bar because he/she feels like he/she is going to pass out. Review of the resident's care plan did not show any information about toileting or transfers. During an interview on 10/17/19 9:00 at A.M. Certified Nurse Aide (CNA) B said: - The resident tells CNA's if he/she needed anything; - He/she went to the resident's room in every morning and walked him/her to the bathroom. The resident did not typically need help going to the bathroom. During an interview on 10/17/19 at 3:10 P.M. CNA A said: -The resident was generally independent with everything, he/she did not typically need help getting to the bathroom. During an interview on 10/17/19 at 10:46 A.M. the Rehabilitation ADON said: - The resident was wheelchair bound. He/she required a one person assist for toileting. During an interview on 10/17/19 at 3:49 P.M. the DON said the level of care the resident required should have been included in the care plan. 4. During an interview on 10/17/19 at 3:49 P.M. the DON said care plans should reflect the care needed to be provided. 1. Review of Resident #52's admission MDS, dated [DATE], showed: -Brief interview for mental status (BIMS) score of 11 (8-12 indicates moderate cognitive impairment); -Required extensive assistance of two for bed mobility, transfers and toilet use; -Did not ambulate; -Used a wheelchair for mobility; -Frequently incontinent of bowel and bladder; -Did not have a pressure ulcer; -Skin and ulcer treatments included pressure reduction devices for the bed and chair; -Turning and re-positioning were not selected as skin and ulcer treatments. Review of the resident's care plan, last updated on 10/7/19, showed: -Required two staff to re-position and turn in bed, toilet and transfer; -Used a wheelchair for mobility; -Incontinent of bladder; -Had a Stage II (partial thickness tissue loss presenting as a shallow open ulcer with a red or pink wound bed) wound to the coccyx; -Had a skin impairment on the right inner buttock; -Float heels while in bed as tolerated; -Pressure reducing cushion when in wheelchair; -Pressure reduction mattress on bed; -Treatment to right inner buttock skin impairment per wound protocol; -Did not address that the resident preferred to spend most of his/her time in the wheelchair, or directions related to re-positioning or off-loading while in the wheelchair to prevent pressure to the buttocks and coccyx areas; -Did not address resident education related to the need for re-positioning or off-loading to prevent pressure and aid in healing of his/her buttock or coccyx areas. Review of the resident's current electronic physician order sheet (e-POS) showed and order for wound care for the right buttock wound. Observation on 10/17/19 at 9:36 A.M., showed the following as Registered Nurse (RN) A provided wound care for the resident: -The resident sat in a wheelchair in his/her room. -Certified Nurse Aide (CNA) C assisted the resident to stand, provided a walker for the resident to support him/herself, pulled down the resident's pants and removed his/her brief. -The resident had an approximately pea-sized open area to the right inner buttock with a red, moist wound bed and evidence of healing along the outer edges of the wound. -A coccyx wound was not observed. -RN A provided wound care to the right inner buttock wound. -CNA C cleansed a small amount of fecal material from the rectal area, then put on a new brief, pulled the resident's pants up and assisted him/her to sit in the wheelchair. During an interview on 10/17/19 at 10:07 A.M., CNA D said: -Staff encouraged the resident to re-position fairly often throughout the day. -The offered to assist him/her to the recliner or to bed and helped him/her stand. -The resident preferred to stay in his/her wheelchair because he/she did not like to lie down during the day. -Staff communicated the need to re-position him/her during shift changes and the CNA's were aware he/she had a pressure ulcer. -The resident had a cushion in his/her wheelchair and to use when he/she was in the recliner. -Staff reminded the resident of the need to be off of his/her bottom because of the sore, but the resident chose to stay up in the wheelchair. During an interview on 10/17/19 at 11:26 A.M., as the resident sat in his/her wheelchair, the resident and his/her spouse said: -The resident said he/she did not like to lay down during the day because it hurt to lay in bed very long. Staff talked to him/her about staying off of his/her bottoms to help prevent sores and to heal the one he/she had, but he/she did not like to lay down in bed. -The resident said he/she did stand up to go to the bathroom and at other times throughout the day, with the assist of staff. -The resident's spouse, who was his/her roommate, said he/she was concerned that the resident sat so much in the wheelchair, but knew he/she did not want to lay down during the day. During an interview on 10/17/19 at 4:18 P.M., the MDS coordinator (MDSC) said: -Re-positioning and off-loading directions are included in the CNA tasks. -Staff should include pressure ulcer prevention and care interventions on the comprehensive care plans for residents at risk for, or who have actual pressure ulcers. -He/she expected interventions such as re-positioning and resident education related to the need to re-position and off-load to prevent and heal pressure ulcers to be on the care plan. -Care planning is an interdisciplinary process, so he/she expected all staff who cared for the resident (charge nurses, social services, dietary, the assistant director of nurses, etc.) to add interventions to the care plan. -Ultimately, verification of appropriate care plan interventions fell on the MDSC. During an interview on 10/17/19 at 3:45 P.M. and 5:28 P.M., the director of nurses (DON) said that staff should include pressure ulcer prevention interventions, such as re-positioning, off-loading and resident education, in care plans for residents with a risk or actual presence of a pressure ulcer. The facility used the RAI (Resident Assessment Instrument-federal guidelines for resident assessments and care plan development) manual as their care plan policy. Based on observation, record review and interview the facility failed to develop and implement comprehensive, person centered care plans that included measurable objectives to meet the residents' needs, conditions, and risks for three sampled residents (Residents #43, #213, #52). The facility census was 76.

2. Review of July 2019 and September 2019 Resident Council Minutes showed residents complained of the food service being slow and the orders not being accurate. 3. Review of Resident #51's quarterly Minimum Data Set (MDS), a federally mandated assessment tool completed by facility staff, dated 9/17/19 showed: - Date of admission 6/11/19; - Moderate cognitive impairment; During an interview on 10/14/19 at 10:05 A.M. the resident said they are supposed to start serving breakfast at 7:30 A.M. but he/she usually does not get it until after 8:00 A.M. Observation showed meal times posted in the dining room as follows: - Breakfast- 7:30 A.M. to 9:00 A.M.; - Lunch- 11:30 A.M. to 1:00 P.M.; - Dinner- 4:30 P.M. to 6:00 P.M. Observation on 10/14/19 at 11:43 A.M. showed the following: - 19 residents were in the dining room, including Resident #51, no meals had been served; - Staff served the first tray; - At 12:11 P.M. the resident had gotten up and sat back down three different times asking about the chicken salad he/she had ordered, staff told the resident that it takes longer for the chicken salad to be made; - At 12:17 the resident got up again, the Administrator asked the resident what he/she was waiting for and the resident said chicken salad, the Administrator went in to the kitchen then came back out and walked the resident back to his/her seat; - At 12:23 P.M. staff served the resident chocolate pie; - At 12:33 P.M. staff served the resident chili; - At 12:38 P.M. the resident told staff he/she no longer wanted the chicken salad; - The resident was never served chicken salad. 4. During a group interview with 11 residents on 10/15/19 at 10:04 A.M. residents said: - Food is slow getting out to them, especially at dinner time; - Sometimes they do not get what they ordered; - Their computer system to order the meal makes it slow, the paper sometimes does not print, and sometimes the computer does not work. - Residents had waited two hours to be served because they lost their ticket; -They only have one staff serving the dining room and they need more. Observation on 10/16/19 beginning at 11:02 A.M. showed: - The Lead [NAME] requested to have an order reprinted for a resident because he/she was unable to read the ticket. Some of the order tickets had black splotches on them making it difficult to read; - One unknown resident ordered chicken strips from the menu, [NAME] A said he/she would serve the resident grilled chicken instead because they were out of chicken tenders. 5. During an interview on 10/16/19 at 2:59 P.M. the Administrator said: - Certified Nurse Aides (CNA) take orders from the residents and put them in on a tablet; - Puree diets are prepared and served first, then room trays, then the dining room based on recommendations from their Regional Director of Dining Services;. - Lunch room tray orders are taken at 10:30 A.M. and they start taking orders in the dining room at 11:30 A.M.; -She addressed the residents that they are in transition with dietary staff and requested them to be patient; - She had not received any complaints directly from residents lately; - Every once in a while staff will have to reprint it, than order, the system will not print an order at times, they can see on the system who has put an order and can determine if the ticket had been printed; - It depended on what residents ordered as to how long she would expect for it to be served to the resident after they order, some food had a longer cooking time; - She ordered chicken strips on Sunday, 10/13/19 and did not come on the truck this week; - Did not know the circumstances for Resident #51's order of the chicken salad but said the resident is always getting up and sitting down; - As a general rule, residents should get what they order, its it is on the menu, however, they might have to substitute the meal if a delivery truck was late. Based on observation, record review, and interview, the facility failed to provide residents with a nourishing, well-balanced diet, taking in to consideration the preferences of each resident. The facility census was 76. Review of the facility's menu that is available daily included the following: - Grilled Chicken Caesar Salad; - Chicken Salad Sandwich; - Chicken Strips. 1. Review of Resident #27's annual Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 8/17/19, showed the resident had a Brief Interview for Mental Status (BIMS) score of 15 (13-15 indicates is cognitively intact). During an interview on 10/15/19 at 8:19 A.M., Resident #27 said: -Several staff have come and gone in the kitchen recently. -He/she and other residents do not always get what they ordered. -They sometimes wait two hours to receive their meals. -He/she sometimes just leaves the dining room and does not eat when he/she has to wait so long. -The dining room tended to be very noisy and only one nurse in the dining room.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure staff followed hand washing/sanitizing protocols to prevent the spread of infection, which affected four of 19 sampled residents (Residents #52, #170, #12 and #36). The facility census was 76. Review of the facility's un-dated skills checklist for handwashing, provided in place of a facility policy, showed how staff should wash their hands, but did not address the use of alcohol-based hand sanitizers or when staff should wash their hands or use hand sanitizers. Review of the facility's un-dated skills checklist for dressing changes and wound treatment, provided in place of a facility policy, showed: -Gather and set up equipment; -Wash hands and apply gloves; -Position the resident where only the area for the dressing change is exposed; -Remove the old dressing and dispose of it in an approved container; -Remove gloves and wash hands; -Cleanse wound as ordered-did not address removal of gloves or handwashing/sanitizing at this time; -Apply treatment as ordered and dress wound; -Remove gloves and wash hands; -Put supplies away and clean table surface; -Remove trash with soiled dressings from the room; -Wash hands; -Document wound care. Review of the CDC (Centers for Disease Control) guidelines, dated 10/25/02, showed hands should be washed/sanitized: -Before having direct contact with residents; -After contact with a resident's skin; -After contact with body fluids or excretions, mucous membranes, non-intact skin and wound dressings; -If moving from a contaminated body site to a clean body site during care; -After contact with objects in the immediate vicinity of the resident; -After glove removal. 1. Review of Resident #52's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 9/13/19, showed: -Required extensive assistance for transfers; -Had diagnoses that included pneumonia and septicemia (infection in the blood). Review of the resident's care plan, related to skin impairment, last revised on 10/7/19, showed: -Had wounds on the coccyx and the right inner buttock; -Treatment to the right inner buttock wound per protocol. Observation on 10/17/19 at 9:36 A.M., showed Registered Nurse (RN) A and Certified Nurse Aide (CNA) C provided care for the resident in the following manner: -Both staff sanitized their hands and put on gloves. -RN A sanitized a table with wipes from a container of sanitizing wipes, created a clean field with a towel, and placed wound care supplies on the clean field. -CNA C placed a walker in front of the resident and assisted him/her to a standing position, then pulled down his/her pants and removed his/her brief. -RN A cleansed the right inner buttock wound, removed his/her gloves, applied a wound cream to the open area on the right inner buttock, removed his/her gloves and put on new gloves, without washing or sanitizing his/her hands. -CNA C cleansed a small amount of fecal material from the resident, removed his/her gloves and put on new gloves, then both staff assisted the resident to sit in his/her wheelchair. -CNA C bagged trash, removed his/her gloves, washed his/her hands and left the room. -RN A removed his/her gloves, but did not wash or sanitize his/her hands, picked up the wound care cream, container of sanitizing wipes and the moist wipes container, placed the moist wipes container in the resident's bathroom, then left the room and placed the remaining items on the medication cart, then returned to the resident's room and sanitized his/her hands. During an interview on 10/17/19 at 9:56 A.M., RN A said that staff should wash or sanitize their hands as soon as they remove their gloves and before they touched other items. 2. Review of Resident #170's electronic physician order sheet (e-POS), with active orders as of 10/17/19, showed: -Diltiazem (a heart medication) 30 milligrams three times a day; -Gabapentin (a medication used for seizures and nerve pain) 100 mg three times a day; -Received intravenous (IV) antibiotic therapy for an unidentified infection; -Diagnoses included acute and chronic respiratory failure, chronic obstructive pulmonary disease (COPD-disease that obstructs air flow in the lungs, interferes with breathing, and causes increased risk for lung infections) and an open wound to the left elbow. Observation on 10/17/19 at 12:44 P.M., showed Certified Medication Technician (CMT) A administered medications to the resident in the following manner: -Checked each medication against the electronic medication administration record (e-MAR) and put them in a medication cup; -Entered the resident's room, washed his/her hands and put on gloves; -Removed the resident's oxygen face mask, administered the medications, replaced the face mask, removed his/her gloves and left the room without washing or sanitizing his/her hands, and returned to the medication cart. During an interview on 10/17/19 at 12:51 P.M., CMT A said staff should wash or sanitize their hands after they remove their gloves and before they leave a resident's room. 3. Review of Resident #12's care plan, last revised, 6/26/19, showed: - Follow facility protocols for treatment of injury; Review of the resident's Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 7/26/19, showed: - Able to make daily decisions; - Required assistance of staff with transfers, toilet use and personal hygiene; - Indwelling catheter (sterile tube placed in the bladder to drain urine);- Occasionally incontinent of fecal matter; - Stage IV ( full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often involves undermining or tunneling) pressure ulcer. Review of the resident's physician order sheet for 10/19, showed the physician ordered Cleanse with normal saline or wound cleanser. Apply hydrogel and cover with a border gauze every day shift for left ischium. Observation on 10/16/19 at 10:39 A.M., showed: - Licensed Practical Nurse (LPN) C entered the resident's bathroom and shut the door; - He/she created a clean field with a paper chux which he/she lay on top of the sink in the resident's bathroom; - Placed his/her supplies on the clean field; - Without sanitizing or washing his/her hands, LPN C donned a pair of gloved and hooked the resident's catheter leg bag strap for the resident; - LPN C changed his/her gloves but did not wash or sanitize his/her hands and wiped around the left ischium wound with a normal saline soaked gauze 4X4, he/she then wiped across the top of the wound cavity with the same 4X4; - Changed his/her gloves but did not sanitize or wash hands; Placed hydrogel on a gauze 4X4 and with his/her hand placed the gauze in the cavity of the wound - He/she removed gloves, did not wash hands and covered with a border gauze; - Without washing or sanitizing his/her hands, he/she removed a pad in the resident's wheelchair due to drainage being of the incontinent pad in the wheelchair; - Placed the soiled chux in the waste basket and without washing hands or changing gloves, he/she assisted the resident to pull up a clean brief and assisted the resident to pull up his/her pants; - LPN C then removed his/her gloves and washed his/her hands. 4. Review of Resident $36's MDS, dated [DATE], showed: - Moderately impaired decision making skills; - Dependent on staff for toilet use and required assist for personal hygiene; - Frequently incontinent of urine and always incontinent of fecal matter; - Stage III (full thickness tissue loss, subcutaneous fat may be visible but bones, tendons or muscle is not exposed. Slough may be present and may include undermining or tunneling). Review of the current POS for 10/19, showed the physician ordered: - Left and right malleoulus, cleanse with normal saline solution or wound cleanser. - Apply moisture barrier cream to area, apply optifoam heel and wrap loosely with Kerlix to secure. Change every other day and as needed. - Right gluteal wound: Cleanse with normal saline solution or wound cleanser. - Pat dry. Apply Exuderm Thin (hydrocolloid) dressing. - Change change every three days and as needed. - Triamcinolone Acetonide Cream (TAC). Apply to abdomen and groin topically two times a day for rash. Observation on 10/16/19 09:32 A.M., Licensed Practical Nurse (LPN) C entered he resident's room without washing or sanitizing his/her hands, he/she donned gloves and applied TAC cream to the resident's abdomen. Changed his/her gloves and assisted the resident to roll on his/her side and removed the hydrocolloid dressing to the open area to the right buttock, removed his/her gloves and sanitized his/her hands. At 09:45 A.M., LPN C gathered supplies and sat them on top of his/her treatment cart. He/she sprayed 4x4s in a plastic cup with wound cleanser, brought the supplies into the resident's room, put on gloves and set up a paper chux clean field, set supplies on clean field, grabbed several pair of gloves and placed them on the clean field. LPN C washed his/her hands, retrieved moisturizing lotion from bathroom and donned a pair of gloves. LPN C removed the resident's gripper footies, retrieved scissors from his/her pocket and cut off and removed the dressings to the right foot and left foot. Both outer ankle bones had areas the size, of at least a penny, that were red with yellow centers. He/she changed gloves but did not wash his/her hands and cleaned both of the resident's ankles with the wet gauze 4X4s. He/she changed his/her gloves but did not wash or sanitize his/her hands and applied moisturizing lotion to the right foot, then changed gloves, rubbed lotion to the left and right foot and changed gloves then applied a foam heel protector. Without washing his/her hands, he/she changed gloves, wrapped the right foot with Kerlix and removed gloves and secured the Kerlix with tape and placed sock on resident's foot. LPN C answered the resident's phone for him/her and took a message then without washing his/her hands, put on gloves and wrapped left foot with Kerlix. He/she removed his/her gloves and secured the Kerlix with tape, sanitized his/her hands, gloved and put the sock on the foot. LPN C removed his/her gloves, washed his/her hands, gloved and assisted the resident to roll to his/her side, the resident was incontinent of urine. LPN C provided perineal incontinent care and changed his/her gloves. Without washing his/her hands, LPN C placed a gown on the resident, removed his/her gloves and closed blinds then removed gloves, sanitized and regloved. At 10:14 A.M., LPN D entered the resident's room and without washing his/her hands, gloved, did not wash hands and assisted the resident up in bed. LPN C changed his/her gloves and sanitized his/her hands. LPN C cleaned the right gluteal open area with a 4x4 wet with wound cleanser, then wiped the buttocks, coccyx and across the open area with no sting sure prep pads. Without washing his/her hands LPN C changed gloves, reached in his/her pocket for a pen to date the hydrocolloid and placed it over the open area. He/she and LPN D positioned the resident with a wedge slightly under the resident's right side and covered resident with clean sheet and blanket. LPN C picked up the supplies and placed in a trash bag with his/her gloves, then he/she washed his/her hands. During an interview on 10/16/19 at 12:25 P.M., LPN C said: - When he/she wiped across Resident #12's wound he/she reached the wet 4X4s into the the wound, that is how he/she cleaned the wound bed; - He/she should have washed his/her hands every time he/she changed his/her gloves; - He/she should have washed his/her hands when he/she moved from a dirty to a clean task. During an interview on 10/17/19 at 11:11 A.M., the Director of Nurses said: - Staff should wash their hands after they enter the resident's room and get the clean field and supplies set up; - If you touch anything before the beginning of the treatment, staff should remove gloves and wash their hands before they begin the treatment; - Staff should wash their hands after they remove soiled bandages, after cleaning each wound and after a new treatment on each wound; - Staff should wash hands prior to leaving a resident's room. - It is not acceptable practice to clean around a wound and with the same 4X4 wipe across the wound bed; - If there is depth, staff should spray the wound cleanser into the wound, not wipe with a wet 4X4.