Based on interview and record review, the facility failed to follow the resident's care plan, dated 8/30/24, to ensure staff utilized safe transfer techniques for one resident (Resident #1) when staff failed to transfer the resident via a mechanical lift out of one sampled resident. The resident sustained a hematoma (a collection of blood that pools outside of a blood vessel in an organ, tissue, or body space) to the chest area. The facility census was 72. The Administration was notified on 12/11/24 of the Past Non-Compliance citation. On , 12/06/24 and 12/09/24, the facility staff took appropriate corrective actions as confirmed by survey staff during the onsite visit. The facility started an investigation, and assessed Resident #1. The facility started an in-service that covered the use of care plans, policy and procedure for transfers, and proper use of a gait belt and Hoyer lift. The deficiency was corrected on 12/09/24. Review of the facility's policy titled, Using the Care Plan, revised October 2018, showed: - The care plan shall be used in developing the resident's daily care routines and will be available to staff personnel who have responsibility for providing care or services to the resident; - Care plans are used to develop daily care practices for staff. Review of the facility's policy titled, Safe Lifting and Movement of Residents, revised July 2017, showed: - In order to protect the safety and well-being of staff and residents, and to promote quality care, this facility uses appropriate techniques and devices to lift and move residents; - Resident safety, dignity, comfort, and medical condition will be incorporated into goals and decisions regarding the safe lifting and moving of residents; - Staff will document resident transferring and lifting needs in the care plan; - Mechanical lifting devices shall be used for heavy lifting, including lifting and moving residents when necessary; - Mechanical lifts shall be made readily available and accessible to staff 24 hours a day. 1. Review of Resident #1's medical record showed: - An admission date of 08/30/24; - Diagnoses of fracture of sixth cervical (neck) vertebra (bones in the spine), hemiplegia (paralysis of one side of the body), chronic obstructive pulmonary disease (COPD - a chronic inflammatory lung disease that causes obstructed airflow from the lungs), dysphagia (difficulty swallowing), and muscle weakness. Review of the resident's significant change Minimum Data Set (MDS), a federally mandated assessment instrument required to be completed by the facility staff, dated 11/27/24, showed: - Moderately cognitively impaired; - Total dependence of one staff for bed mobility, dressing, personal hygiene, and bathing; - Total dependence of two staff for transfers and toilet use; - Always incontinent of bowel and bladder. Review of the resident's Care Plan, dated 08/30/24, showed: - Resident required assist per staff with Activities of Daily Living (ADL) and mobility; - Resident used a wheelchair for locomotion; - Resident required mechanical lift transfers with assistance of two staff for the transfers. Review of the resident's Progress Notes, dated 12/06/24 at 10:41 A.M., showed: - Resident had a soft, swollen pocket to the right upper chest/breast area and the area below the breasts and upper rib cage appeared to be bruised; - Resident complained of pain to the area; - Resident sent to the emergency room via ambulance for evaluation. Review of the resident's Computed Tomography (CT - a medical imaging procedure that uses rays and a computer to create detailed pictures of the inside of the body) scan of the chest, dated 12/06/24, showed: - A probable hematoma within the anterior (the front) right chest wall measured 8.7 centimeters (cm) wide by 5.2 cm deep by 10.2 cm in height. Review of the facility's investigation, dated 12/11/24, showed: - Certified Nurse Assistant (CNA) B and CNA C did not transfer Resident #1 according to his/her care plan; - During an interview CNA B said he/she and CNA C transferred Resident #1 without using a mechanical lift on 12/05/24. The resident said it was okay to transfer him/her without a mechanical lift; - During an interview, Resident #1 said he/she did not tell CNA B and CNA C that it was okay to transfer him/her without a mechanical lift; - During an interview, CNA C said he/she helped CNA B transfer Resident #1 without a mechanical lift on 12/05/24; - CNA B and CNA C were suspended pending the investigation; - Nursing staff were in-serviced regarding the use of care plans, policy and procedure for transfers, and proper use of a gait belt and Hoyer lift on 12/06/24 at 1:00 P.M., and on 12/09/24 at 1:30 P.M. Observation of Resident #1 on 12/11/24 at 11:30 A.M., showed the resident had a large raised purple area to his/her right mid-chest. During an interview on 12/11/24 at 11:22 A.M., Resident #1 said two Certified Nurse Aides (CNA's) moved him/her from a shower chair to his/her wheelchair in the shower room last week. The CNA's bear-hugged him/her, lifted him/her up, and put him/her in the wheelchair. He/She was bruised all over from it. The bruising was painful at times, but that he/she had pain medication that controlled the pain. During an interview on 12/11/24 at 2:29 P.M., Licensed Practical Nurse (LPN) A said he/she was on duty when Resident #1 was found with a hematoma. LPN A was called to the the resident's room by a CNA on duty and found the resident had a small raised bruised area to his/her right chest. Within 30 minutes, the area had doubled in size and he/she notified the Administrator and sent the resident to the emergency room. During an interview on 12/11/24 at 2:45 P.M., the Administrator said on 12/06/24, she was notified Resident #1 had an injury and began investigating immediately. It was found that two CNA's had transferred the resident without using the mechanical lift per the resident's care plan. She expected staff to transfer a resident according to his/her care plan. During an interview on 12/17/24 at 1:51 P.M., CNA C said around lunch time on 12/05/24, Resident #1 asked him/her and another CNA to stand him/her up and transfer him/her to his/her chair. After the resident had been transferred, he/she did not complain of pain, injury, or show any signs of pain. CNA C left to go on break and when he/she returned, the resident was already back in bed. He/She did not know how the resident was injured. During an interview on 12/17/24 at 1:57 P.M., CNA B said on 12/05/24, Resident #1 requested he/she and another CNA transfer him/her without a mechanical lift. He/She and another CNA lifted the resident under the arms and did a two person transfer to the shower chair. The resident did not say anything about having pain or an injury. He/She did not know how the resident was injured. Complaint #MO00246204

Based on interview and record review, the facility failed to allow one resident (Resident #1) to return to the facility after being sent out to the hospital for an evaluation. The facility census was 76 residents. Review of the facility's policy titled, Bed Holds, dated March 2022, showed: - When emergency transfers are necessary, the facility will provide the resident or representative with information concerning our bed-hold policy within 24 hours of such transfer; - If the facility determines that a resident who was transferred cannot return to the facility, the facility will comply with the facility's Discharge Policy. Review of the facility's policy titled, Transfers and Discharges (Including Against Medical Advice (AMA), dated September 2022, showed: - If a Notice of Discharge is given the facility will send a copy of transfer or discharge notice to the Ombudsman. The facility will also provide to the resident and/or resident representative additional information in the notice regarding the process for appealing transfer or discharge; - If the facility has made the decision that a resident cannot return to the facility following a hospital discharge the facility must discharge the resident according to the policy. The medical record should show documentation of the reason the resident cannot return to the facility. A discharge notice must be presented to the resident or resident's representative in the case that a resident is not returning to the facility as decided by the facility; - Provide the resident with a statement of the right to appeal the action to the state agency designated for such appeals, along with the name, address and phone number of the State long term care ombudsman; - For developmentally disabled individuals the appeal rights notice must include the name, address and phone number of the agency responsible for advocating for the developmentally disabled; - The physician should document medical reasons for transfer or discharge in the medical record. A copy of the physician's order for discharge should be attached to the discharge notice. 1. Review of Resident #1's medical record showed: - admission date of 12/15/23; - Diagnoses of spina bifida occulta (a gap formed in the spine at birth), pressure ulcer of the sacral region (a wound caused from limited mobility to the spine that connects to the pelvis), colostomy (when the colon is diverted through the abdomen), dysphagia (difficulty swallowing), schizophrenia (a chronic mental illness that affects a person's thoughts, feelings and behaviors), bipolar disorder (extreme mood swings, along with changes in thinking and behavior), type 2 diabetes mellitus (a chronic disease when the body doesn't produce enough insulin or use it properly), attention-deficit hyperactivity disorder (a chronic mental disorder that affects a person's behavior and ability to focus and control impulses), anxiety (excessive fear, dread, or uneasiness), and depression (persistent low mood and loss of interest); - Resident is his/her own responsible party; - An entry on the resident's Electric Medical Record (EMR) assessments page, dated 09/26/24, for the completion of a transfer form for discharge to the hospital; - No official discharge notice to the resident or resident's representative. Review of the resident's Preadmission Screening and Resident Review (PASARR - an evaluation guided by federal regulations that require all individuals being considered for admission to a Medicaid-certified nursing facility (NF) be screened prior to admission, to determine if the person has, or is suspected of having, a mental illness, intellectual disability, or related condition) Level I screening, dated 11/15/23, showed: - The resident with a diagnosis of spina bifida and schizophrenia that would qualify as a related condition; - A PASRR Level II screening was indicated for intellectual disability or related condition. Review of resident's Level II PASARR dated, 11-21-23, showed resident had auditory hallucinations, schizophrenia, psychotic disorder, anxiety disorder, MDD, personality disorder, adjustment disorder, bi-polar disorder, obsessive-compulsive disorder, spina bifida, hydrocephalus, paraplegia, suicidal ideations; - The PASRR Level II Evaluation, dated 11/30/23, showed the residents' needs could be met in a nursing facility. Review of the resident's discharge Minimum Data Set (MDS - a federally mandated comprehensive assessment instrument completed by facility staff), dated 09/26/24, showed: -Resident was discharged with return anticipated; - Able to make consistent and reliable decisions independently. Review of the resident's nurse's note, dated 09/26/24, at 4:07 A.M., showed: - The resident was returned from the hospital at approximately 9:00 P.M., on 09/25/24, via ambulance; - The resident complained of chest pain. Vital signs obtained; - The resident was able to answer questions appropriately but then began to switch the conversation to family deaths and his/her role in them; - The resident said he/she was going to do something stupid and requested to go to the hospital; - The on-call provider was contacted and order obtained to send the resident to the hospital for a thorough psychiatric evaluation and treatment; - Emergency Medical Services (EMS) arrived and departed facility with resident en route to the emergency room (ER). Review of the resident's hospital records, dated 09/26/24, showed: - On 09/26/24, the resident was seen by a telepsychiatry physician; - On 09/26/24, the psychiatrist recommendations were for medication adjustments and supportive psychotherapy (a variety of treatments that aim to help a person identify and change troubling emotions, thoughts, and behaviors); - On 09/26/24, the resident was cleared by psychiatry to return to the facility. The resident wanted to return to the facility; - On 09/26/24, the facility reported to the hospital staff they would not take the resident back until he/she has had an inpatient psychiatric stay with medication adjustments; - On 09/26/24, the hospital continued to search for placement. The resident was never admitted to the hospital, but remained in the ER; - On 10/08/224, the resident continued to be stable for discharge from the ER back to the facility; - On 10/09/24, the resident was accepted for admission to another skilled nursing facility from the ER; - The resident remained in the ER from 09/26/24 - 10/09/24, without admission to the hospital. During an interview on 10/08/24, at 10:20 A.M., the Director of Nursing (DON) said: - On the morning of 09/26/24, the resident complained of chest pain. The resident said he/she was going to do something stupid. The on-call provider was notified and the staff received an order to send the resident out for a psychiatric evaluation; - The facility did not discharge the resident, they were waiting for the resident to receive in-patient psychiatric services; - The medical director said the resident was not safe at the facility and the staff were not able to provide care to the resident. Therefore, they could not accept the resident back to the facility. Review of a letter from the facility's Medial Director, dated, 10/08/24, showed: - Based on the psychiatric evaluation, the staff at the facility would need to do 1:1 suicidal watch care for Resident #1, which the facility is not equipped or staffed to provide. After speaking with the DON and the Psychiatric Nurse Practitioner, the decision to not readmit the resident at this time was made for the resident's safety. It was advised that the resident be admitted to a behavioral psychiatric unit for acute care. During an interview on 10/08/24 at 11:35 A.M., the Registered Nurse Case Manager (RN CM) at the ER said: - The resident was brought into the ER on the morning on 09/26/24; - The resident underwent a psychiatric evaluation on 09/26/24. The resident was deemed able to return to the facility with medication modifications; - The facility medical director refused to accept the resident back to the facility until the resident had an inpatient psychiatric stay with medication adjustments; - He/She sent over 50 referrals to other long-term care facilities and received 25 denials. Due to the medical complexities of the resident, in-patient psychiatric facilities were not equipped to manage the resident's medical needs; - The facility did not issue the resident a discharge notice and did not assist with finding placement; - The resident was not admitted to the hospital due to being medically stable. The resident had been in the ER for two weeks. During an interview on 10/15/24 at 2:21 P.M., the DON said she went to the ER and interviewed the resident. The resident said he/she didn't want to live in a facility anymore. The resident wanted to live on his/her own in an apartment. She said the resident still had a 1:1 sitter at the ER. She went to the ER to do an assessment, not to discharge the resident, but the resident was not better. The resident was still hearing voices. The DON said the facility did not issue a discharge notice at that time. During an interview on 10/15/24 at 2:30 P.M., the Administrator said the DON went to the ER and saw the resident on 10/09/24. The hospital found placement for the resident at another long-term care facility. The Administrator said the facility did not begin the discharge process at any time for Resident #1. No discharge process had been started, but the resident would not be allowed back to the facility without an in-patient psychiatric stay. MO00242905

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to notify the resident and the resident's representative in writing of a transfer or discharge to a hospital, including the reasons for transfer, for seven residents (Resident #8, #21, #31, #33, #35, #36, and #55) out of 10 sampled residents. The facility's census was 82. The facility did not provide a policy for transfer/discharge notification. 1. Review of Resident #8's medical record showed: - The resident transferred to the hospital on [DATE], and readmitted to the facility on [DATE]; - The resident transferred to the hospital on [DATE], and readmitted to the facility on [DATE]; - The resident transferred to the hospital on [DATE], and readmitted to the facility on [DATE]; - The resident transferred to the hospital on [DATE], and readmitted to the facility on [DATE]; - No documentation of written notification provided to the resident and/or the resident's representative for the transfers to the hospital on [DATE], 03/16/24, 03/27/24, and 07/18/24. 2. Review of Resident #21's medical record showed: - The resident transferred to the hospital on [DATE], and readmitted to the facility on [DATE]; - The resident transferred to the hospital on [DATE], and readmitted to the facility on [DATE]; - The resident transferred to the hospital on [DATE], and readmitted to the facility on [DATE]; - The resident transferred to the hospital on [DATE], and readmitted to the facility on [DATE]; - No documentation of written notification provided to the resident and/or the resident's representative for the transfers to the hospital on [DATE], 04/08/24, 04/22/24, and 05/27/24. 3. Review of Resident #31's medical record showed: - The resident transferred to the hospital on [DATE], and readmitted to the facility on [DATE]; - No documentation of written notification provided to the resident and/or the resident's representative for the transfer to the hospital on [DATE]. 4. Review of Resident #33's medical record showed: - The resident transferred to the hospital on [DATE], and readmitted to the facility on [DATE]; - The resident transferred to the hospital on [DATE], and readmitted to the facility on [DATE]; - The resident transferred to the hospital on [DATE], and readmitted to the facility on [DATE]; - No documentation of written notification provided to the resident and/or the resident's representative for the transfers to the hospital on [DATE], 10/26/23, and 11/14/23. 5. Review of Resident #35's medical record showed: - The resident transferred to the hospital on [DATE], and readmitted to the facility on [DATE]; - The resident transferred to the hospital on [DATE], and readmitted to the facility on [DATE]; - The resident transferred to the hospital on [DATE], and readmitted to the facility on [DATE]; - The resident transferred to the hospital on [DATE], and readmitted to the facility on [DATE]; - The resident transferred to the hospital on [DATE], and readmitted to the facility on [DATE]; - The resident transferred to the hospital on [DATE], and readmitted to the facility on [DATE]; - No documentation of written notification provided to the resident and/or the resident's representative for the transfers to the hospital on [DATE], 05/09/24, 05/12/24, 05/23/24, 07/09/24, and 08/18/24. 6. Review of Resident #36's medical record showed: - The resident transferred to the hospital on [DATE], and readmitted to the facility on [DATE]; - The resident transferred to the hospital on [DATE], and readmitted to the facility on [DATE]; - No documentation of written notification provided to the resident and/or the resident's representative for the transfers to the hospital on [DATE] or 08/22/24. 7. Review of Resident #55's medical record showed: - The resident transferred to the hospital on [DATE], and readmitted to the facility on [DATE]; - The resident transferred to the hospital on [DATE], and readmitted to the facility on [DATE]; - No documentation of written notification provided to the resident and/or the resident's representative for the transfers to the hospital on [DATE] or 07/19/24. During an interview on 09/12/24 at 4:00 P.M., the Administrator said she would expect notice of a resident's transfer or discharge to the hospital to be given to the resident and/or the resident's representative in writing. She would also expect it to be documented in the resident's medical record that the notice was given to the resident or their representative.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to notify the resident and/or the resident's representative in writing of their bed hold policy at the time of transfer to the hospital for five residents (Resident #21, #31, #33, #36, and #55) out of 10 sampled residents. Facility census was 82. Review of the facility's policy titled, Bed Holds, dated March 2022, showed: - Upon admission and when a resident is transferred to hospitalization or for therapeutic leave, the facility will provide information regarding the bed-hold policy to the resident or representative in a written format that is understood by the resident or representative; - When emergency transfers are necessary, the facility will provide the resident or representative with information concerning the bed-hold policy within 24 hours of such transfer. 1. Review of Resident #21's medical record showed: - The resident transferred to the hospital on [DATE], and readmitted to the facility on [DATE]; - The resident transferred to the hospital on [DATE], and readmitted to the facility on [DATE]; - The resident transferred to the hospital on [DATE], and readmitted to the facility on [DATE]; - The resident transferred to the hospital on [DATE], and readmitted to the facility on [DATE]; - No documentation the resident and/or the resident's representative was informed in writing of the facility's bed hold policy at the time of the transfers. 2. Review of Resident #31's medical record showed: - The resident transferred to the hospital on [DATE], and readmitted to the facility on [DATE]; - No documentation the resident and/or the resident's representative was informed in writing of the facility's bed hold policy at the time of the transfer. 3. Review of Resident #33's medical record showed: - The resident transferred to the hospital on [DATE], and readmitted to the facility on [DATE]; - No documentation the resident and/or the resident's representative was informed in writing of the facility's bed hold policy at the time of the transfer. 4. Review of Resident #36's medical record showed: - The resident transferred to the hospital on [DATE], and readmitted to the facility on [DATE]; - The resident transferred to the hospital on [DATE], and readmitted to the facility on [DATE]; - No documentation the resident and/or the resident's representative was informed in writing of the facility's bed hold policy at the time of the transfers. 5. Review of Resident #55's medical record showed: - The resident transferred to the hospital on [DATE], and readmitted to the facility on [DATE]; - The resident transferred to the hospital on [DATE], and readmitted to the facility on [DATE]; - No documentation the resident and/or the resident's representative was informed in writing of the facility's bed hold policy at the time of the transfers. During an interview on 09/12/24 at 4:00 P.M., the Administrator said she filled out the Bed Hold Notice form, mailed it to the resident's representative, and then made a note in the resident's chart.

Based on interview and record review, the facility failed to develop and implement comprehensive care plans for two residents (Resident #33 and #35) out of 18 sampled residents. The facility's census was 82. Review of the facility policy titled, Care Plans, Comprehensive Person-Centered, dated October 2017, showed: - The Interdisciplinary Team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident; - The care planning process will facilitate resident and/or representative involvement, include an assessment of the resident's strengths and needs, and incorporate the resident's personal and cultural preferences in developing the goals of care; - Identifying problem areas and their causes, and developing interventions that are targeted and meaningful to the resident, are the endpoint of an interdisciplinary process; - Care plan interventions are chosen only after careful data gathering, proper sequencing of events, careful consideration of the relationship between the resident's problem areas and their causes, and relevant clinical decision making; - Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change; - The IDT must review and update the care plan when there has been a significant change in the resident's condition, when the desired outcome is not met, when the resident has been readmitted to the facility from a hospital stay, and at least quarterly, in conjunction with the required quarterly Minimum Data Set (MDS - a federally mandated assessment to be completed by facility staff). 1. Review of Resident #33's medical record showed: - A diagnosis of Parkinsonism (a disease of the central nervous system that affects movement, often including tremors); - admitted to hospice for Parkinson's Disease on 11/08/23. Review of the resident's care plan, dated 09/09/24, showed Parkinsonism, including risks, goals, and interventions were not addressed. 2. Review of Resident #35's medical record showed: - A computed tomography (CT - a medical imaging scan used to obtain detailed internal images of the body) scan report, dated 06/02/22, showed a right-sided mediport (medical device put just below skin for access if blood needs drawn or intravenous medications need given) catheter; - No documentation for assessments of the mediport, an order to access the mediport, or and order/protocol to maintain the mediport. Review of resident's care plan, dated 08/04/24, showed the mediport, including risks, goals, and interventions were not addressed. Observation on 09/13/24 at 1:45 P.M. showed a right side upper chest mediport on Resident #35. The mediport had three small bumps for identification to access the mediport in the proper place. During an interview on 09/13/24 at 1:45 P.M., Resident #35 said he/she had a mediport because of poor veins and was a very hard person to stick for blood or intravenous (IV) access. He/She had the mediport for years. During an interview on 09/13/24 at 3:00 P.M., the DON and MDS Coordinator said the interdisciplinary team was in charge of developing the care plans. The DON and MDS Coordinator said that if a resident's condition changed, then the care plan would be revised. During an interview on 09/13/24 at 3:00 P.M., the Administrator said the interdisciplinary team was in charge of developing the care plans. The care plan should accurately reflect the resident's current condition.

Based on observation, interview, and record review, the facility failed to have an order for and a process in place for accessing, maintaining, and assessing a mediport (medical device put just below skin for access if blood needs drawn or intravenous medications need given) for one resident (Resident #35) out of one sampled resident. The facility did not provide a policy on mediport care/maintenance. 1. Review of Resident #35's medical record showed: - A computed tomography (CT - a medical imaging scan used to obtain detailed internal images of the body) scan report, dated 06/02/22, showed a right-sided mediport catheter; - No order for the mediport; - No orders and/or protocols to access and maintain the mediport; - No documentation for assessments of the mediport. Review of resident's care plan, dated 08/04/24, showed the mediport, including risks, goals, and interventions, not addressed. Observation on 09/13/24 at 1:45 P.M. showed a right side upper chest mediport on Resident #35. The mediport had three small bumps for identification to access the mediport in the proper place. During an interview on 09/13/24 at 1:45 P.M., Resident #35 said staff accessed his/her mediport on 09/11/24, to draw lab work. He/She had the mediport for years because of poor veins and was a very hard person to stick for blood or intravenous (IV) access. Only one staff person knew how to access the mediport at the facility. During an interview on 09/13/24 at 2:00 P.M., the Director of Nursing (DON) said she was the only person in the facility who knew how to access and draw blood from Resident #35's mediport. She would expect there to be orders for the mediport and care/maintenance for the mediport. She would also expect assessments to be completed for the mediport.

Based on observation, interview, and record review, the facility failed to maintain a medication error rate of five percent (%) or less. There were six errors out of 43 opportunities for errors, resulting in an error rate of 13.95%. This affected six residents (Resident #17, #20, #24, #33, #44 and #46), out of 10 sampled residents. The facility census was 82. The facility did not provide a policy for insulin pens. Review of Novolog (a rapid acting insulin injected just below the skin that helps lower mealtime blood sugar spikes) Flex Pen (insulin in a pen-type device) manufacturer instructions, revised February 2023, showed: - Before each injection small amounts of air may collect in the cartridge during normal use, to avoid injecting air and to ensure proper dosing: remove the cap; attach the needle; prime the pen by turning the dose selector to select two units; press and hold the button and make sure a drop of insulin appears; select the dose; and give the injection. Review of Humalog (a fast acting insulin injected just below the skin) Kwik Pen (insulin in a pen-type device) manufacturer instructions, revised August 2023, showed: - Remove the cap; - Attach the needle; - Prime the pen before each injection. Priming the pen means removing the air from the needle and cartridge that may collect during normal use and ensures that the pen is working correctly. If you do not prime before each injection, you may get too much or too little insulin; - To prime the pen: turn the dose knob to select 2 units; push and hold the button and make sure a drop of insulin appears; - Select the dose; - Give the injection. Review of Fiasp (a rapid acting insulin injected just below the skin) Flextouch (insulin in a pen-type device) manufacturer instructions, dated July 2023, showed: - Remove the cap; - Check the liquid in the pen; - Attach the needle; - Prime the pen. Prime the pen by turning the dose selector to select two units; press and hold the button and make sure a drop of insulin appears; - Select the dose; - Give the injection. 1. Review of Resident #17's Physician's Order Sheet (POS), dated September 2024, showed: - An order for Humalog Kwikpen inject six units subcutaneously ((an injection just beneath the skin) before meals, dated 09/04/24; - An order for Humalog Kwikpen inject per sliding scale (progressive increase in the pre-meal or nighttime insulin dose based on pre-defined blood glucose ranges) for a blood sugar of 351-400, give six units, dated 09/04/24. Observation of the resident on 09/12/24 at 10:45 A.M., showed: - The resident's blood sugar was 384; - Certified Medication Technician (CMT) A administered Humalog Kwikpen 12 units to the resident; - CMT A failed to prime the Humalog Kwikpen prior to the administration of the insulin to the resident per the manufacturer's instructions for use. 2. Review of Resident #46's POS, dated September 2024, showed an order for Novolog Flexpen inject per sliding scale for a blood sugar of 151-200, give two units, dated 05/01/24. Observation of the resident on 09/12/24 at 11:08 A.M., showed: - The resident's blood sugar was 162; - CMT A administered Novolog Flexpen two units to the resident; - CMT A failed to prime the Novolog Flexpen prior to the administration of the insulin to the resident per the manufacturer's instructions for use. 3. Review of Resident #20's Physician Order Sheet (POS), dated September 2024, showed: - An order for Novolog Flexpen inject 12 units subcutaneously before meals, dated 08/19/24; - An order for Novolog Flexpen inject per sliding scale for a blood sugar of 151-200, give two units, dated 08/19/24. Observation of the resident on 09/12/24 at 11:19 A.M., showed: - The resident's blood sugar was 185; - CMT A administered Novolog Flexpen 14 units to the resident; - CMT A failed to prime the Novolog Flexpen prior to the administration of the insulin to the resident per the manufacturer's instructions for use. 4. Review of Resident #24's POS, dated September 2024, showed an order for Fiasp Flextouch Pen inject per sliding scale for a blood sugar of 181-220, give four units, dated 06/17/24. Observation of the resident on 09/12/24 at 11:27 A.M., showed: - The resident's blood sugar was 214; - CMT A administered Fiasp Flextouch Pen four units to the resident; - CMT A failed to prime the Fiasp Flextouch Pen prior to the administration of the insulin to the resident per the manufacturer's instructions for use. 5. Review of Resident #44's POS, dated September 2024, showed an order for Novolog Flexpen inject per sliding scale for a blood sugar of 150-199, give three units, dated 03/01/23. Observation of the resident on 09/12/24 at 11:41 A.M., showed: - The resident's blood sugar was 184; - CMT A administered Novolog Flexpen three units to the resident; - CMT A failed to prime the Novolog Flexpen prior to the administration of the insulin to the resident per the manufacturer's instructions for use. 6. Review of Resident #33's POS dated, September 2024, showed an order for Novolog Flexpen inject per sliding scale for a blood sugar of 151-200, give two units, dated 10/31/23. Observation of the resident on 09/12/24 at 11:41 A.M., showed: - The resident's blood sugar was 155; - CMT A administered Novolog Flexpen two units to the resident; - CMT A failed to prime the Novolog Flexpen prior to the administration of the insulin to the resident per the manufacturer's instructions for use. During an interview on 09/12/24 at 11:50 A.M., CMT A said that he/she was not aware that insulin pens needed to be primed. During an interview on 09/12/24 at 4:30 P.M., the Administrator said she would expect the manufacturer's guidelines to be followed when administering insulin with an insulin pen.

Based on interview and record review, the facility failed to maintain an Infection Prevention and Control Program (IPCP) that included an antibiotic stewardship program. This deficient practice had the potential to affect all residents in the facility. The facility census was 82. Review of the facility's policy titled, Infection Prevention and Control Program, dated 2018, showed: - The facility's Infection Prevention and Control Program (IPCP) follows national standards and guidelines to prevent, recognize and control the onset and spread of infection whenever possible; - The Infection Prevention and Control Program includes an antibiotic stewardship program. Review of the facility's policy titled, Infection Prevention and Control Manual Antibiotic Stewardship and Multidrug Resistant Organisms (MDROs), dated 2017, showed the Director of Nursing (DON) or designee will track antibiotic use and monitor adherence to evidence-based criteria. The facility did not provide documentation for the antibiotic stewardship program. During an interview on 09/10/24 at 9:30 A.M., the Administrator said the former DON/Infection Preventionist quit suddenly in August 2024, and he/she had been responsible for the antibiotic stewardship program. During an interview on 09/13/24 at 2:45 P.M., the DON said she was unable to find the antibiotic stewardship program documentation. The former DON quit suddenly and took all of the antibiotic stewardship program information.

Based on interview and record review, the facility failed to provide documentation of ongoing assessments, monitoring, and communication between the facility and the dialysis (a process for removing waste and excess water from the blood) center for one resident (Resident #7) out of 18 sampled residents and two residents (Resident #31 and #32) outside of the sample. The facility's census was 73. Record review of the facility's policy, End-Stage Renal Disease, Care of a Resident With revised September 2010, showed: - Agreements between this facility and the contracted end stage renal disease facility (ESRD) include all aspects of how the resident's care will be managed including: a) How the care plan will be developed and implemented; b) How information will be exchanged between the facilities. 1. Review of Resident #7's medical record showed: - Diagnoses of chronic kidney disease (longstanding disease of the kidneys leading to renal failure), and dependence on renal dialysis; - Started dialysis 1/23/23; - Goes to dialysis three times a week; - No documentation to assess and monitor the resident's condition before and after dialysis treatments; - No documentation of on-going communication between the facility and dialysis staff. 2. Review of Resident #31's medical record showed: - Diagnoses of chronic kidney disease, and dependence on renal dialysis; - Started dialysis 11/29/19; - Goes to dialysis three times a week; - No documentation to assess and monitor the resident's condition before and after dialysis treatments; - No documentation of on-going communication between the facility and dialysis staff. 3. Review of Resident #32's medical record showed: - Diagnoses of chronic kidney disease, and dependence on renal dialysis; - Started dialysis 1/11/21; - Goes to dialysis three times a week; - No documentation to assess and monitor the resident's condition before and after dialysis treatments; - No documentation of on-going communication between the facility and dialysis staff. During an interview on 02/9/23 at 10:35 A.M., the Administrator said they use two centers for the three residents that receive dialysis. The Administrator said they talk with the centers as needed, but do not talk routinely with them for every appointment and no documentation is shared routinely with the centers. She said the nurses do not do assessments when their dialysis residents come back and do not have coordinated plans of care. She said they coordinate transportation when residents come back from their appointments. She said staff will lay eyes on the dialysis residents and take them to dinner when they arrive back at the facility. During an interview on 02/9/23 at 12:31 P.M., the Infection Preventionist said they just look at the ports and the area surrounding the port, as well as labs and vital signs. The labs are usually drawn and the nurse who gets the labs off the fax sends it to the doctor, but that is really it as far as checking the dialysis residents. He/she denied having a coordinated plan of care. He/she said sometimes the dialysis center will give a heads up if something is concerning for them to look for, but otherwise the residents will often go straight to the dining room to eat or to their room when returning from dialysis. He/she said they do not always document information about the dialysis or resident's condition in the chart.

Based on interview and record review, the facility failed to ensure the physician responded to the pharmacist's recommendations in regard to the resident's antidepressant medications for two residents (Resident #14 and #22) out of 18 sampled residents. The facility's census was 73. Record review of the facility's policy titled, Gradual Dose Reduction of Psychotropic Drugs, updated September 2022, showed: - Reducing the need for and maximizing the effectiveness of medications shall be considered for all residents who use psychotropic drugs; - GDR's will be documented on the psychotropic Dose Reduction History form; - The GDR may be clinically contraindicated for reasons that include, but not limited to, returned or worsened after most recent attempt at a GDR within the facility and the physician has documented rationale for why any additional attempted dose reduction at that time would likely impair the resident's function or increase distressed behavior. 1. Record review of Resident #14's Physician's Order Sheet (POS), dated February 2023, showed: - Orders for Citalopram (antidepressant medication) 40 milligrams (mg) daily for depression; - Orders for Mirtazapine (antidepressant medication) 30 mg at bedtime for major depressive disorder. Record review of the monthly Pharmacist's Review, dated 5/19/22, showed: - Recommendation to decrease Citalopram 40 mg daily to 30 mg daily; - Recommendation to decrease Mirtazapine 30 mg to 22.5 mg at bedtime; - Not addressed by physician. 2. Record review of Resident #22's POS, dated February 2023, showed: - Orders for Citalopram 10 mg daily for major depressive disorder. Record review of the monthly Pharmacist's Review, dated 8/10/22, showed: - Recommendation to decrease Citalopram 10 mg daily if appropriate; - Not addressed by physician due to Resident being out to hospital on the date received. During an interview on 2/8/23 at 4:25 P.M., the Psychiatric Nurse Practitioner (NP) said rounds are made every other week. The facility is able to fax or call reports in if they have a gradual dose reduction (GDR) that needs addressed. Once reviewed, the new order will be added to point click care (PCC), sign and return the GDR recommendation. During an interview on 2/8/23 at 4:51 P.M., the Administrator said she would expect the physician/NP to respond within 30 days. The facility tries to get the GDR recommendations to the physician/NP within 48-72 hours. The Director of Nursing (DON) is the one who will follow up with responses. During an interview on 2/9/23 at 5:35 P.M., the DON said she would expect all medications on a GDR to be addressed. During an interview on 2/9/23 at 5:35 P.M., the Administrator said she would have expected a GDR from August, 2022 to have already been addressed with some kind of reply.

Based on observation, record review and interview, the facility failed to label and store drugs in accordance with currently accepted professional principles and had potential to affect all residents. The facility's census was 73. Review of the facility's policy titled, Storage of Medications, last revised April 2007, showed: - Drugs and biologicals shall be stored in the packaging, containers or other dispensing systems in which they are received. Only the issuing pharmacy is authorized to transfer medications between containers; - The nursing staff shall be responsible for maintaining medication storage and preparation areas in a clean, safe and sanitary manner; - Medications requiring refrigeration must be stored in a refrigerator located in the drug room at nurse's station or other secure location. Medications must be stored separately from food and must be labeled accordingly. 1. Observation of the Certified Medication Technician (CMT) medication room on 2/7/23 at 1:28 P.M. showed: - Floor debris including several rubber bands and torn paper; - Refrigerator temperature was 40 degrees and no log found; - Refrigerator had a long, dark hair in bottom of refrigerator shelf along with a puddle of water; - A wet, dripping box containing 50 individually wrapped acetaminophen (pain and fever reducer) suppositories 650 milligrams (mg); - A red plastic container with 83 individually wrapped 650 mg acetaminophen suppositories; - One unopened Lantus (long-acting insulin) pen 3 milliliters (ml); - Seven unopened Levemier (insulin) pens 3 ml each; - One unopened Aspart (short acting insulin) Flexpen 3 ml; - Two unopened Novolog (fast acting insulin) pens 3 ml each; - Five unopened Toujeo pens (Insulin glargine injection); - Three unopened Basaglar (long acting insulin) pens 3 ml each; - Five unopened Novolog vials 10 ml each; - Two unopened Humolog (fast acting insulin) vials 3 ml each; - One unopened Humulin R (short acting insulin that lasts several hours) vial 3 ml; - One unopened Levemier vial 10 ml. 2. An observation on 02/08/23 at 9:03 A.M. of the CMT medication room showed: - The refrigerator temperature was 32 degrees, no log found; - Above medications remained in refrigerator; - Two small containers of pudding; - One small container of applesauce; - Floor debris including several rubber bands, torn paper and two clear plastic squeezable vials with unknown medication. During an interview on 2/8/23 at 9:03 A.M., the Director of Nursing (DON) said the applesauce and pudding were placed in there for the next med pass and she could not find the refrigerator temperature log. 3. An observation on 2/09/23 at 4:43 PM of the CMT Medication room showed: - Refrigerator temperature was 40 degrees, no log found; - Above medications remained in refrigerator; - One small container of pudding; - One small container of applesauce; - Floor debris including several rubber bands and torn paper. During an interview on 2/9/23 at 4:43 P.M., the DON said they still had not found the temperature log. During an interview on 2/9/23 at 5:35 P.M., the Administrator said she would expect the medication storage room to be clean and free of debris, the refrigerator to have a temperature log and food not be stored in the medication refrigerator. According to product labels from insulin manufacturers, the recommended storage temperature for unopened insulin is approximately 36 to 46 degrees Fahrenheit. According to manufacturer's recommendation for acetaminophen suppositories, they may be stored at room temperature or in the refrigerator, but must not be frozen.

Based on interview and record review, the facility failed to ensure the quality assessment and assurance (QAA) committee attendees included an Infection Preventionist (IP). This failure had the potential to affect all 73 residents who reside at the facility. The facility's census was 73. Record review of the QAA Committee Members did not show the Infection Preventionist as a committee member. Record review of the QAA committee attendance records, dated July 2022 through December 2022, provided by the facility, showed the Infection Preventionist did not attend the meetings as required. During an interview on 2/9/23 at 5:35 P.M., the Administrator said their Infection Preventionist is new and recently certified. She said the Infection Preventionist needs to be put on the list. She said the previous IP attended meetings. Record review of the facility's policy titled, Quality Assurance and Performance Improvement, dated November 2016, regarding QAA did not include a list of required committee members.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interviews, the facility failed to ensure all residents were kept free from possible accident hazards when the facility staff failed to monitor one resident (Resident #12) outside the sample for self administration of dietary supplements bought on the Internet and for giving the same supplements to another resident (Resident #49) out of a sample of 18. The facility census was 73. Record review of the facility policy titled Medications Brought to the Facility by the Resident/Family, revised April 2007, showed: -The facility shall ordinarily not permit residents and families to bring medications into the facility; -Residents and families must report to the nursing staff any medications that they want to bring, or have brought into the facility; -The facility discourages the use of medications brought in from outside, and will inform residents and families of that policy, as well as applicable laws and regulations; -If a medication is not otherwise available and/or it is determined to be essential to the resident's life, health, safety, or well-being to be able to take a medication brought in from outside, the Director of Nursing Services and nursing staff, with support of the Attending Physician and Consultant Pharmacist, shall check to ensure that: A) State law and regulations allow such use; B) The medications have been ordered by the resident's Attending Physician, and documented on the physician's order sheet; C) The contents of each container are labeled in accordance with established policies; D) The contents of each container have been verified by a licensed pharmacist. The facility did not provide a policy regarding residents having dietary supplements. The facility did not provide a policy regarding resident safety regarding purchasing medication/supplements online and sharing with other residents. 1. During an interview on 2/6/23 at 3:00 P.M., Significant Other (SO) A said Resident #12 gave Resident #49 a bottle of Cannabidiol (CBD, a compound found in cannibas) gummies. Review of Resident #49's medical record showed: -An admission date of 1/17/22; -Diagnoses included Alzheimer's dementia (progressive mental deterioration), Type 2 diabetes, anxiety, major depressive disorder, delusional disorders (a mental disorder marked by false beliefs) and chronic pain; -The Minimum Data Set (MDS-a federally mandated assessment, required to be completed by the facility) for significant change, dated 1/19/23, identified Resident #49 as severely cognitively impaired with a Cognition Score of 5; -The Physician order sheet, current as of 2/9/23, no order for self administration of CBD gummies; -The Medication Administration Record (MAR) from 12/1/22 through 2/9/23, showed no documentation of CBD gummies administration; -The nursing notes from 12/1/22 through 2/7/23 showed no documentation regarding resident receiving CBD gummies from Resident #12, nor the physician being notified Resident #49 took two CBD gummies. Record review on 2/7/ 2022 at 10:00 A.M., showed Resident #49's care plan did not address: - The use of CBD gummies for self-administration; - The resident taking a bottle of supplements from another resident; - Any interventions for monitoring. Review of Resident #12's medical record showed: -admission date of 5/05/22; -Diagnoses included Chronic obstructive pulmonary disease (COPD- a chronic inflammatory lung disease that causes obstructed airflow from the lungs), type 2 diabetes mellitus (an impairment in the way the body regulates and uses sugar), anxiety (a feeling of worry, nervousness, or unease), and depression (a serious medical illness that negatively affects how you feel, the way you think and how you act); -The significant change MDS, dated [DATE], identified Resident #12 as cognitively intact, with a cognition score of 15 (highest); -The current Physician order sheet, as of 2/9/23, showed no order for self administration of CBD gummies; -The Medication Administration Record (MAR) from 12/1/22 through 2/9/23, showed no documentation of CBD gummies administration; -No documentation of notification to the doctor regarding CBD gummy use; -No documentation of an investigation as to how the resident acquired the CBD Record review on 2/7/ 2022 at 10:00 A.M., showed Resident #12's care plan did not address: - The use of CBD gummies for self-administration; - The resident purchasing dietary supplements off of the Internet; - The resident giving other residents bottles of dietary supplements for self administration; - Any interventions for monitoring. During an interview on 2/7/23 at 10:00 A.M., Resident #12 said he/she ordered CBD gummies from the Internet and had them delivered to the facility. Resident #12 said the CBD gummies are the only supplement he/she has ordered. He/she ordered five bottles of the CBD gummies and gave one bottle to Resident #49 because he/she thought it might help with Resident #49's pain. Resident #12 said he/she takes two of the CBD gummies every day and had consumed at least one entire bottle. Resident #12 said he/she did not consult a doctor prior to taking and did not know of any possible side effects or interactions with other medications. Resident #12 did not know what other medications Resident #49 took. Resident #12 said he/she still had a bottle at her bedside. Resident #12 found the packing slip for the CBD gummies. The order for five bottles was placed on 12/5/2022 and delivered to the resident at the facility on 12/15/2022. Resident #12 said he/she gave Resident #49 a bottle, and he/she had one bottle left so he/she guessed she had gone through three bottles. Observation showed a bottle of Proper CBD Gummies 300 MG Pure Organic Hemp Extract, THC Free Formula, labeled as a dietary supplement, which had directions to take 1 to 2 gummies once a day, stored in a plastic storage cart next to the resident's bed. Review of the manufacturer's website for the Proper CBD gummies showed the following advisory: While CBD is generally considered safe, it can cause side effects like dry mouth, diarrhea, and reduced appetite. Additionally, CBD can interact with other medications you're taking, so it's important to talk to your doctor before using it. During an interview on 2/7/23 at 1:05 P.M., the DON said he/she was aware that Resident #12 had CBD gummies and had given some to Resident #49. The DON said the gummies were removed from Resident #49's refrigerator. The DON said the facility does not allow residents to keep medications or supplements in their room. The DON said he/she did not address the issue with Resident #12 or contact Resident #49's doctor with the information. He/She did not know if Resident #12 had any supplements in his/her room currently. He/She said the administrator said he/she would address the situation with Resident #12. The DON did not know if there was any documentation regarding the incident in either resident's medical record, or if any interventions had been put in place. During an interview on 2/7/23 at 1:20 P.M., the Administrator said he/she had been made aware that Resident #12 gave Resident #49 CBD gummies on 12/29/2022. The Administrator said she confirmed the bottle had been removed. Staff counted the gummies in the bottle and found two missing. The administrator thought staff had contacted Resident #49's Nurse Practitioner, but did not know if anyone had contacted Resident #12's doctor. The Administrator said she had talked with Resident #12 about giving the gummies to Resident #49, but could not find any documentation of that conversation or any other interventions taken. The Administrator thought the conversation with Resident #12 took place around the first week of January 2023. The Administrator was not aware Resident #12 currently had more CBD gummies in his/her room. The Administrator did not know if either residents' care plan had been updated. During a phone interview on 2/7/23 at 1:38 P.M., the Medical Nurse Practitioner (MNP) said residents are not supposed to have medications or supplements in their rooms. The MNP would have expected the CBD gummies to have been removed and both residents to be monitored. He/she said the primary physician should have been contacted to see if an order needed obtained for the resident to take CBD gummies. He/she was not aware that Resident #12 still had CBD gummies in his/her room. During interview on 2/8/23 at 8:45 A.M., the Administrator said she and the DON, the Social Services Director and the MDS coordinator held a care plan meeting last evening with Resident #12 regarding buying medications or supplements off the Internet, without letting the facility know and giving supplements to other residents. The Administrator said Resident #12 informed them that he/she kept the gummies where no one could get to them in her purse. Resident #12 was to have surrendered all the gummies to staff, but she would make sure Resident #12 wasn't hiding more gummies in a drawer as was seen the day before.

Based on observation, interview and record review, the facility failed to utilize proper technique during incontinent care for one resident (Resident #3) when staff touched the trash can during care and dropped the box of wipes on the floor three times. Staff did not change gloves, perform hand hygiene after touching the trash can and the box of wipes that he/she picked up from the floor. During wound care staff failed to use a barrier for supplies, disinfect the bandage scissors, used for multiple residents, before and after use, and perform appropriate hand hygiene and glove changes for one resident (Resident #14), outside of 18 sampled residents. The facility failed to maintain infection control practices to prevent the development and transmission of infection when staff did not wash or sanitize hands and wear gloves during medication administration for one resident (Resident #69) out of 18 sampled residents and nine residents (Resident #1, #3, #11, #15, #27, #36, #39, #48, and #58) outside of the sample. The facility's census was 73. Record review of the facility's policy titled, Handwashing/Hand Hygiene, revised August 2015, showed: - The facility considers hand hygiene the primary means to prevent the spread of infections; - Wash hands with soap and water for the following situations: * Hands are visibly soiled; * After contact with a resident with infectious diseases; - Use an alcohol-based hand rub containing at least 62% alcohol; or alternatively, soap and water for the following situations: * Before and after coming on duty; * Before and after direct contact with residents; * Before preparing or handling medications; * Before moving from a contaminated body site to a clean body site during resident care; * Before handling clean or soiled dressings, gauze pads, etc; * After contact with resident's intact skin; * After removing gloves. - Hand hygiene is the final step after removing and disposing of personal protective equipment. 1. Observation on 2/5/23 at 1:39 P.M. showed: - Resident #3 lay in bed on a mechanical lift sling wearing pants which were visibly wet. Certified Medication Technician (CMT) G and Certified Nurses Aide (CNA) H removed the resident's pants, brief, and sling, then placed the soiled sling in the resident's wheelchair. CMT G and CNA H then provided peri care for the resident; - CMT G picked up the trash can with bare hands and handed it to CNA H who held the trash can with his/her forearms and set it onto the floor; - CMT G applied gloves without sanitizing hands; - CNA H, with forearms that were used to hold the trash can, repositioned the resident while CMT G provided peri care; - An open wipe container fell from the bed three times during care, and CMT G picked it up and placed it back onto the bed without changing gloves; - CMT G did not to change gloves after providing peri care. During an interview on 2/5/23 at 1:50 P.M., both CMT G and CNA H said hands should be sanitized when going into a room, with every glove change and when going from dirty to clean. Hands should be washed before exiting the room and in between glove changes if gloves are soiled. Both said the Hoyer sling should have been taken to be cleaned and a new sling obtained. CNA H said he/she knew the minute he/she had picked the trash can up with his/her arms, that they should have been sanitized before repositioning the resident with his/her arms. Both said they did not sanitize with every glove change. 2. Observation on 2/7/23 at 9:33 A.M. showed: - Licensed Practical Nurse (LPN) I and Registered Nurse (RN) J performed wound care for Resident #14; - LPN I did not provide a barrier for supplies that had been placed on the resident's nightstand; -LPN I cut off the old bandage with scissors and did not clean scissors prior to removing the bandage; -LPN I sat the scissors on the nightstand with no barrier after cutting the bandage; -LPN I removed gloves and applied new gloves without washing or sanitizing hands; -LPN I sprayed gauze with wound cleanser, then removed Xeroform from the resident's wound; -LPN I removed gloves and washed hands, then applied gloves and cleansed wound with wound cleanser; -LPN I removed gloves and washed hands and opened rolled gauze and Xeroform and applied to the resident's wound; -LPN I removed gloves and washed hands, then applied gloves and applied tape to gauze and wrote the date; -LPN I removed gloves and washed scissors with soap and water and put scissors in pocket of scrub pants. During an interview on 2/7/23 at 11:36 A.M., LPN I said he/she should have placed a barrier between supplies and a dirty surface. Hands should be washed or sanitized before wound care wash, sanitize from dirty to clean, and wash hands after care. Scissors should be cleaned with a Sanicloth wipe or soap and water before and after use. 3. Observation of medication pass by CMT K on 2/7/23 at 11:48 A.M. through 12:49 P.M. showed: - CMT K did not wash or sanitize hands prior to or after providing medication to Resident #36; - CMT K did not wash or sanitize hands prior to or after providing medications to Resident #11; - CMT K did not wash or sanitize hands prior to or after providing medications to Resident #3; - CMT K did not wash or sanitize hands prior to or after providing medications to Resident #39; - CMT K did not wash or sanitize hands prior to or after providing medications to Resident #69; - CMT K did not wash or sanitize hands prior to providing medications to Resident #27; - CMT K did not wash or sanitize hands after providing medication to Resident #15; - CMT K did not wash or sanitize hands prior to inserting eye drops into both eyes of Resident #48 with ungloved hands; - CMT K did not wash or sanitize hands prior to providing medication for Resident #1; - CMT K removed a straw from a package for Resident #58 and touched the end of the straw that would go into the resident's mouth with his/her bare hand. During an interview on 2/7/23 at 12:49 P.M., CMT K said he/she can't wash hands in between each person, but tried to sanitize. Hands should be washed when going into rooms and sanitized when leaving. Hands should be washed before and after eye drops and gloves worn when touching someone's eye, and should not touch anything that goes into a resident's mouth without gloves. 4. Observation on 2/9/23 at 1:05 P.M. showed: - RN F removed a bandage from the elbow of Resident #54; - RN F pulled scissors from his/her pocket and cut new dressing to fit; - RN F placed scissors on sink without placing a barrier; - RN F removed gloves and placed the scissors back into his/her pocket before washing hands. During an interview on 2/9/23 at 1:50 P.M., RN F said a barrier should have been laid down prior to providing wound care, and scissors should have been sanitized before and after use. During an interview on 2/9/23 at 5:35 P.M., the Director of Nursing said she would expect scissors to be sanitized before and after each use. She would expect hand hygiene to be performed between clean and dirty while providing care.

Based on interview and record review, the facility failed to ensure five of five randomly selected Certified Nurse Aides (CNAs) received the required annual 12 hour resident care training including dementia training, based on performance reviews. This deficient practice had the potential to affect all residents. The facility's census was 73. Record review of the facility's policy titled, Continuing Education of Certified Nurse Aides, dated November 2016, showed: - The purpose of this policy is to ensure the monitoring of nurse aide performance and ongoing education for the maintenance of continue competence of nurse aides; - In-service education programs are planned an conducted asked on performance reviews to assure the continue competence of the nurse aide staff to consistently apply interventions that meet the needs of residents; - Competency will be evaluated initially and at least annually for all nurse aides; - The facility will conduct a performance review of each nurse aide at least once every 12 months; - In-service education will be provided based on performance reviews; - At least 12 hours of education will be provided per year; - In-service programs will include weaknesses identified in performance reviews, special needs of residents determined by facility staff, specific nursing aide training topics include infection control, abuse prevention, dementia management, resident rights, accident prevention, fire and disaster, resident privacy /Heath Insurance Portability and Accountability Act (HIPAA; a law designed to provide privacy standards to protect patients' medical records and other health information provided to health plans, doctors, hospitals, and other health care providers); - The effectiveness of in-service education is measured by the demonstrated competencies of the nurse aide; - Ongoing education will be measured by the date of employment of each nurse aide. Record review of the CNA individual in-service records, showed the following: - CNA A, hired 12/7/18, no documentation of the number of hours for training, no documentation of a training needs assessment based on performance reviews, no documentation of dementia training; - CNA B, hired 12/15/17, no documentation of the number of hours for training, no documentation of a training needs assessment based on performance reviews, no documentation of dementia training; - CNA C, hired 11/6/17, with no documentation of the number of hours for training, no documentation of a training needs assessment based on performance reviews; - CNA D, hired 7/9/14, no documentation of the number of hours for training, no documentation of a training needs assessment based on performance reviews, no documentation of dementia training; - CNA E, hired 8/1/11, no documentation of the number of hours for training, no documentation of a training needs assessment based on performance reviews, no documentation of dementia training. During an interview on 1/23/20 at 4:15 P.M., the Administrator said she would expect CNAs to receive the required annual education including education for care of the resident with dementia. She would expect the number of hours to be documented.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide information and education to each resident or the resident's representative of the pneumococcal vaccines and offer the pneumococcal vaccines upon admission for three residents (Resident #6, #43 and #48) out of six sampled residents. This deficient practice had the potential to affect all residents. The facility's census was 73. 1. Record review of the United States Department of Health and Human Services Centers for Disease Control (CDC) Pneumococcal Vaccine Timing for Adults, dated 11/30/15, showed the following: - Pneumococcal disease in older adults are at greatest risk of serious illness and death; - CDC recommends two pneumococcal vaccines for adults: 13-valent pneumococcal conjugate vaccine (PCV 13, Prevnar 13) and 23-valent pneumococcal vaccine (PPSV 23, Pneumovax 23); - CDC recommends vaccination with PCV 13 for all adults 65 years or older and adults 19 through [AGE] years old with certain medical conditions: - CDC recommends vaccination with PPSV 23 for all adults 65 years or older and adults 19 through [AGE] years old with certain medical conditions. 2. Record review of Resident #6's medical record showed: - The resident admitted on [DATE]; - The resident [AGE] years old; - Diagnosis of Alzheimer's disease (a progressive disorder that causes brain cells to waste away, the most common cause of dementia, a continuous decline in thinking, behavioral and social skills that disrupts a person's ability to function independently); - The staff did not document the resident's pneumococcal vaccine history; - The staff did not document education provided to the resident or representative regarding the benefits and potential side effects of the pneumococcal vaccines; - The staff did not obtain a signed consent/refusal form for PCV 13 or PPSV 23. 3. Record review of Resident #43's medical record showed: - The resident admitted on [DATE]; - The resident [AGE] years old; - Diagnoses of dementia and bipolar disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs) ; - The staff did not document the resident's pneumococcal vaccine history; - The staff did not document education provided to the resident or representative regarding the benefits and potential side effects of the pneumococcal vaccines; - The staff did not obtain a signed consent/refusal form for PCV 13 or PPSV 23. 4. Record review of Resident #48's medical record showed: - The resident admitted on [DATE]; - The resident [AGE] years old; - Diagnosis of Alzheimer's disease; - The staff did not document the resident's pneumococcal vaccine history; - The staff did not document education provided to the resident or representative regarding the benefits and potential side effects of the pneumococcal vaccines; - The staff did not obtain a signed consent/refusal form for PCV 13 or PPSV 23. 5. Observation of the medication refrigerator on 1/23/20 at 10:36 A.M. showed Prevnar 23 vaccine available for use. No Prevnar 13 vaccine available in facility. 6. During an interview on 1/22/20 at 3:29 P.M., the Director of Nurses (DON) said she usually just talks to them about the pneumonia vaccine and most have gotten it in the past. She doesn't document that she talks to them about it but she should. During an interview on 1/23/20 at 4:15 P.M., the Administrator said she would expect residents to be educated and offered the pneumonia vaccine upon admission and for the information to be documented. 7. Record review of the facility's policy titled, Infection Prevention and Control Manual, Resident Immunizations and Vaccinations, dated 2017, showed: - It is the policy of this facility that residents will be offered immunization against pneumococcal disease; - Adults > 65 years who have already received a dose of PPSV23, should also receive a dose of PCV13 a year or more later; - If patients do not know their vaccination history for pneumococcal vaccine they should be given both vaccines according to CDC recommendations; - Primary care physicians will be asked that all new admissions be screened and given both pneumococcal vaccines according the Advisory Committee on Immunization Practices (ACIP) recommended schedule, unless specifically ordered otherwise by the Primary physician on the admission orders; - Every admission is screened using the criteria contained within the standing protocol and given the vaccine if indicated, after receiving education regarding the vaccine; - A record of the vaccination will be placed in the resident's medical record and in their vaccination record.