**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 a facility-initiated transfer when one resident (Resident #49) out of one sampled resident transferred to the hospital. The facility census was 55. Review of the facility's policy titled, Making an Emergency Transfer or Discharge, dated December 2016, showed: - Notify the receiving facility; - Prepare the resident; - Prepare a transfer form to send with the resident; - Notify the resident representative; - The policy did not address notification in writing to the resident or the resident representative. 1. Review of Resident #49's medical record showed: - Resident transferred to the hospital for medical evaluation on 10/16/24, and readmitted to the facility on [DATE]; - No documentation of the written notification to the resident and/or the resident's representative of the resident's transfer to the hospital on [DATE]. During an interview on 10/24/24 at 10:01 A.M., Licensed Practical Nurse (LPN) A said the charge nurse was responsible for completing the transfer/discharge form. If the resident was unable to sign, the family or guardian was called by two nurses and then the form was sent out later by social service. During an interview on 10/24/24 at 10:03 A.M., LPN B said the resident's nurse filled out the transfer/discharge notification and the resident signed if able. If not, the family was notified and social service sent the notification to them to sign and return. During an interview on 10/24/24 at 10:05 A.M., the Assistant Director of Nursing said the transfer/discharge was explained to the resident if they were alert and they sign it. If they weren't alert, the representative was notified and explained. Two nurses should witness, and the form should be left with the shift communication logs. The form was then sent to the resident representative. During an interview on 10/24/24 at 10:15 A.M., the Administrator said nursing was responsible for completion of the transfer/discharge notification. If the resident was unable to sign it, two nurses should contact the resident representative and explain it to them, both nurses should sign, and it was then sent to the representative. It should all be documented. During an interview on 10/24/24 at 11:00 A.M., the Social Services Designee said the transfer/discharge notifications were sent out as soon as possible after he/she got them.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to inform the resident, family, and/or legal representative of their bed hold policy in writing at the time of transfer to the hospital for one resident (Resident #49) out of one sampled resident. The facility's census was 55. The facility did not provide a policy related to bed hold notification. 1. Review of Resident #49's medical record showed: - Transferred and admitted to the hospital on [DATE], and readmitted to the facility on [DATE]; - No documentation the resident or the resident's representative was informed in writing of the facility bed hold policy at the time of transfer. During an interview on 10/24/24 at 10:01 A.M., Licensed Practical Nurse (LPN) A said the charge nurse was responsible for completing the bed hold form if the resident was unable to sign the family or guardian was called by two nurses and then the form was sent out later by social service. During an interview on 10/24/24 at 10:03 A.M., LPN B said the resident's nurse filled out the bed hold notification and the resident signed if able. If not, the family was notified, and social service sent the notification to them to sign and return. During an interview on 10/24/24 at 10:05 A.M., the Assistant Director of Nursing (ADON) said the bed hold was explained to the resident if they were alert, and if able they were able sign it. If not, the representative was notified and it was explained. Two nurses should witness and the form should be left with the shift communication logs. It was then sent to the resident representative. During an interview on 10/24/24 at 10:15 A.M., the Administrator said nursing was responsible for completion of the bed hold notification. If the resident was unable to sign it, two nurses should contact the resident representative and explain it to them, both nurses should sign, and it was sent to the representative. It should all be documented. During an interview on 10/24/24 at 11:00 A.M., the Social Services Designee said the bed hold notifications were sent out as soon as possible after he/she got them.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to complete a comprehensive discharge summary for one resident (Resident #54) out of one discharged resident. The facility's census was 55. The facility did not provide a policy regarding a discharge summary or recapitulation. 1. Review of Resident #54's closed medical record showed: - Resident discharged home on [DATE]; - No documentation of a discharge summary or recapitulation. During an interview on 10/24/24 at 10:11 A.M., the Administrator said there was no discharge or recapitulation done for the resident. It should have been done. Social services was responsible for this and discharge planning should be started as soon as the residents were admitted . During an interview on 10/24/24 at 11:00 A.M., the Social Services Designee said the resident didn't get the discharge summary or recapitulation did but should have. He/She missed completing the discharge summary and was responsible.

Based on observation, interview and record review, the facility failed to ensure a urinary catheter (a tube inserted into the bladder to drain urine) drainage bag and tubing was kept off the floor for two residents (Residents #9 and #21), failed to cover a urinary catheter drainage bag with a dignity bag for one resident (Resident #21), and failed to ensure proper urinary catheter placement when staff raised the catheter drainage bag and tubing above the level of the bladder for one resident (Resident #9) out of two sampled residents. The facility census was 55. Review of the facility's policy titled, Catheter Care, Urinary, revision date July 2017, showed: - Be sure the catheter tubing and drainage bag are kept off the floor. 1. Review of Resident #9's medical record showed: - Diagnoses of primary lateral sclerosis (the breakdown of nerve cells causes weakness in the muscles that control the legs, arms and tongue), neuromuscular dysfunction of the bladder (a condition that occurs when the nerves and muscles of the bladder don't work together properly), quadriplegia (a symptom of paralysis that results in the complete or severe loss of motor function in all four limbs and the body from the neck down), and cystostomy (a surgical procedure that creates a connection between the bladder and the skin to drain urine) status. Review of the resident's Physician Order Sheet (POS), dated October 2024, showed: - An order for suprapubic catheter (a tube that drains urine from the bladder by creating a surgical connection between the bladder and the skin in the lower abdomen) change every month and as needed (PRN) between the 14th and 17th of the month, dated 12/16/21; - An order for catheter care every shift, dated 06/29/23. Observations of the resident showed: - On 10/23/24 at 8:50 A.M., the resident sat in a wheelchair and the catheter drainage bag hung under the wheelchair on the frame and touched the wheel and the bottom of the bag touched the floor; - On 10/23/24 at 10:30 A.M., the resident sat in a wheelchair and the catheter drainage bag hung under the wheelchair on the frame and rested against the wheel. Observation on 10/23/24 at 11:00 A.M., showed: - Certified Nursing Assistant (CNA) D emptied the catheter drainage bag; - CNA D lifted the catheter drainage bag above the level of the resident's bladder; - The urine in the tubing drained back toward's the resident's bladder. 2. Review of Resident #21's medical record showed: - Diagnoses of chronic kidney disease (CKD - a condition in which the kidneys are damaged and cannot filter blood as well as they should), benign prostatic hyperplasia (BPH - enlargement of the prostate causing difficulty in urination), retention of urine (a condition in which the bladder doesn't empty completely even if full), urinary tract infection (an infection in your urinary system), neuromuscular dysfunction of the bladder, and neurogenic bladder (condition that results in lack of bladder control due to a brain, spinal cord or nerve problem). Review of the resident's POS, dated October 2024, showed: - An order for catheter care every shift, dated 03/17/23; - An order to change the catheter bag PRN, dated 03/17/23; - An order to change the 16 French (size of the catheter) Coude (type of catheter that have a bend at the distal tip) suprapubic catheter monthly between the 1st and 5th and PRN for occlusion, dated 02/17/24. Observations of the resident showed: - On 10/21/24 at 9:04 A.M., 10:05 A.M., and 11:29 A.M., the resident sat in in his/her room in a wheelchair, the catheter drainage bag hung under the wheelchair on the frame, the bottom of the bag touched the fall mat, six inches of the catheter tubing lay on the floor, and no privacy cover in place with the catheter drainage bag visible from the hall; - On 10/21/24 at 11:38 A.M., staff propelled the resident in a wheelchair to the dining room and the bottom of the catheter drainage bag and the tubing drug the floor under the wheelchair, no privacy cover in place with the catheter drainage bag visible to other residents, family members, and staff. After the resident was placed at a table, the bottom of the drainage bag and the tubing touched the floor; - On 10/21/24 at 12:20 P.M., the resident sat in the dining room in a wheelchair, the catheter drainage bag hung under the wheelchair on the frame, four inches of the catheter tubing lay on the floor, and no privacy bag in place with the catheter drainage bag visible to other residents, family members, and staff; - On 10/21/24 at 2:30 P.M., the resident lay in a low bed low, the catheter drainage bag hung on the bed frame with a privacy cover in place, the bottom of the drainage bag lay on the floor, and the coiled tubing lay on the floor; - On 10/22/24 at 11:48 A.M., the resident propelled the wheelchair from his/her room, through the hall, through the common area, and to the dining room. The catheter tubing drug on the ground under the wheelchair where it hung from under the wheelchair on the frame and with a privacy cover in place. Staff assisted the resident to the dining room table with the bottom of the catheter drainage bag exposed from under the privacy cover and the tubing lay on the floor; - On 10/22/24 at 12:22 P.M., the resident sat in the dining room in the wheelchair, the catheter drainage bag hung under the wheelchair on the frame, and the bottom of the catheter drainage bag, exposed from under the privacy cover and the tubing touched the floor; - On 10/23/24 at 10:00 A.M., 10:56 A.M., and 2:58 P.M., the resident lay in a low bed, the catheter drainage bag hung on the bed frame with a privacy cover in place, and the bottom of catheter drainage bag along with four inches of the catheter tubing lay on the floor. During an interview on 10/24/24 at 10:30 A.M., CNA D said the catheter drainage bag shouldn't touch the wheels or the floor. The tubing shouldn't either. The catheter, the catheter drainage bag, or the tubing shouldn't be raised above the resident's bladder. During an interview on 10/24/24 at 11:00 A.M., Licensed Practical Nurse (LPN) B said the catheter drainage bag and tubing shouldn't touch the floor or anything. The catheter, the catheter drainage bag, or the tubing shouldn't be raised above the resident's bladder level. During an interview on 10/24/24 at 11:15 A.M., the Director of Nursing (DON) said catheter drainage bags or tubing should not touch the floor or any objects. The catheter, the catheter drainage bag, or the tubing should never be raised above the level of the resident's bladder. All staff were responsible to check placement of the catheter drainage bags and tubing when walking by or doing care. During an interview on 10/24/24 at 12:15 P.M., the Administrator said a catheter drainage bag or tubing shouldn't touch anything. The catheter, the catheter drainage bag, or the tubing should never go above the level of the resident's bladder. All staff should check placement of catheter drainage bags and tubing .

Based on observation and interview, the facility staff failed to post the required daily nurse staffing information which included the total number of staff and the actual hours worked by both licensed and unlicensed nursing staff directly responsible for resident care, in a prominent location readily accessible to residents and visitors. The facility census was 55. Review of the facility policy titled, Daily Staffing Information, dated July 2014, showed: -It is the policy of the facility, as required by Centers for Medicare and Medicaid Services (CMS), to post daily staffing information in the facility. This must be posted in a prominent place, readily accessible to residents and visitors at the start of each shift; - Staffing is to be posted daily utilizing a standardized form that includes the facility name, current date, total number of staff and actual hours worked; - Each facility should complete the Daily Staffing Information form indicating the actual hours worked by staff; - The staffing information form should be posted in the facility in a clearly visible place or places that are accessible to facility staff, patients, and visitors. Observation on 10/21/24 at 9:16 A.M., the facility's Nurse Staffing information located on a white board behind the nurse's station, showed: -Did not include total number of staff and actual hours worked by both licensed and unlicensed nursing staff; -Did not show unlicensed nursing staff directly responsible for resident care. Observations on 10/22/24 at 9:00 A.M. - 3:30 P.M., 10/23/24 at 8:15 A.M. - 4:30 P.M., and 10/24/24 at 7:54 A.M., showed: - The white board was blank; - The facility did not post the required daily nurse staffing information. During an interview on 10/24/24 at 8:01 A.M., the Director of Nursing (DON) said the white board behind the nurse's station was used for the required daily nurse staffing information. The posted information didn't include unlicensed nursing staff. During an interview on 10/24/24 at 12:16 P.M., the Administrator said there was a white board at the nurse's station outlined to show the date, census, and the nursing staff. It should be filled out daily and should be changed when the morning shift came in daily. Unlicensed nursing staff should be included on the white board.

Based on observation, interview, and record review, the facility failed to store medications in a safe and effective manner. This had the potential to affect all residents. The facility census was 55. Review of the facility's policy titled, Insulin Pen Injection Administration, dated June 2020, showed: - Follow manufacturer instructions for expiration dating. Review of Lantus (a type of insulin) manufacturer's insert, dated 08/2022, showed to discard the Lantus pen after 28 days of opening, even if it has insulin in it. 1. Observation on 10/23/24 at 10:02 A.M., of the nurse medication cart showed two Lantus pens labeled with an opened date of 09/21/24, 32 days after opening. During an interview on 10/24/24 at 9:45 A.M., the Corporate Registered Nurse (RN) said the facility's policy was to follow the manufacturer insert since different insulins were good for different amounts of days after opened. During an interview on 10/24/24 at 10:50 A.M., Licensed Practical Nurse (LPN) B said insulin pens should be dated and discarded within the designated time frame. During an interview on 10/24/24 at 11:00 A.M. the Assistant Director of Nursing (ADON) said Lantus was good for 30 days once opened and should be discarded in the sharps container once that time frame was reached. During an interview on 10/24/24 at 11:10 A.M., the Administrator said it was expected that nurses would follow the policy in regards to how long an insulin pen was opened for.

Based on observation, interview, and record review, the facility failed to ensure a dumpster was closed at all times and maintained to keep pests out and/or to keep the garbage contained in the dumpster. The facility census was 55. The facility did not provide a policy in regards to the dumpster. Observations of the outside trash dumpster showed: - On 10/21/24 at 11:33 A.M., the dumpster lid opened with three bags above the top of the dumpster opening; - On 10/21/24 at 3:00 P.M., the dumpster lid opened; - On 10/22/24 at 9:30 A.M., the dumpster lid opened. Staff walked with a cart of trash, placed the trash in the dumpster, and did not close the dumpster lid; - On 10/22/24 at 10:10 A.M., the dumpster lid opened; - On 10/22/24 at 12:49 P.M., the dumpster lid opened; - On 10/23/24 at 11:00 A.M., the dumpster lid opened; - On 10/24/24 at 8:30 A.M., the dumpster lid opened; - On 10/24/24 at 8:30 A.M., around the dumpster showed a twenty foot radius of debris including gloves, masks, plastic, paper, and plastic silverware lay on the ground; - On 10/24/24 at 8:30 A.M., a black trash bag containing kitchen trash lay on the ground between the two recycling dumpsters with cardboard in them. During an interview on 10/24/24 at 11:00 A.M., the Dietary Manager (DM) said the dumpster lid should be closed after discarding trash. During an interview on 10/24/24 at 11:10 A.M., the Maintenance Director said the dumpster lid should be closed after staff put trash in it. If trash was dropped out when putting trash in the dumpster, staff should pick it up. All staff were responsible for keeping the trash area clean. There shouldn't be trash on the ground. During an interview on 10/24/24 at 12:00 P.M., the Administrator said trash should not be on the ground around the dumpster and the dumpster lid should always be closed.

Based on observation, interview, and record review, the facility failed to use proper infection control techniques during incontinent care for four residents (Residents #9, #21, #48 and #205) out of four sampled residents and one resident (Resident #3) outside the sample. The facility failed to properly store trash and regulated medical waste boxes filled with biohazard material. The facility also failed to use proper infection control techniques during trash disposal. The facility census was 55. Review of the facility policy titled, Handwashing, dated April 2015, showed: - It is the policy that all staff thoroughly cleanse hands with friction, soap, and water to control infection and reduce transmission of organisms; - Hands should be thoroughly washed before and after providing resident care. Review of the facility policy titled, Perineal Care, dated July 2017, showed: - The purposes of this procedure are to provide cleanliness and comfort to the resident, to prevent infections and skin irritation, and to observe the resident's skin condition; - Place the equipment on the beside stand; wash and dry hands thoroughly; - Put on gloves, wet washcloth and apply soap or skin cleansing agent; - Wash the perineal area, including thighs, do not reuse the same washcloth; - Wash the rectal area, dry area; - Discard disposable items, remove gloves, wash and dry hands; - Reposition the bed covers, clean the bedside stand, wash and dry hands. Review of the facility policy titled, Catheter Care, Urinary, revised 07/2017, showed: - The purpose is to prevent catheter-associated urinary tract infections; - Be sure the catheter tubing and drainage bag are kept off the floor. Review of the facility policy titled, Isolation, dated April 2015, showed: - It is the policy that residents whose medical condition warrants it will be placed in isolation following the Center for Disease Control and Prevention (CDC) guidelines and physician orders to further prevent the possible spread of infection; - If there is a reason to believe that a resident has an infectious or communicable disease, the charge nurse shall immediately notify the resident's attending physician for appropriate isolation instruction; - The order shall be entered on the Physician Order Sheet (POS); - Isolation procedures shall remain in effect until discontinued by the attending physician; - Refer to the current CDC guidelines regarding isolation requirements; - Appropriate isolation equipment and supplies will be gathered and placed outside the resident's room, isolation barrels will be placed inside the resident's room; - An isolation room is identified by an appropriate sign posted on the room entrance door informing visitors to see the nurse before entering; - The charge nurse is responsible for completing the isolation checklist; - The charge nurse shall notify the director of housekeeping/laundry of the isolation. Review of the facility policy titled, Isolation Precautions/Enhanced Barrier Precaution (EBP), dated 03/20/24, showed: - EBP refers to an infection control intervention designed to reduce transmission of multi drug-resistant organisms (MDRO) that employ targeted gown and glove use during high contact resident care activities; - EBP is used in conjunction with standard precautions and expand the use of PPE to putting on a gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs to staff hands and clothing; - EBP are indicated for residents with any of the following: infection or colonization with a CDC-targeted MDRO when contact precautions do not otherwise apply; or wounds and/or indwelling medical devices even if the resident is not known to be infected or colonized with a MDRO; - EBP should be used when staff do the following care for the resident: dressing; bathing/showering; transferring; providing hygiene; changing linens; changing briefs or assisting with toileting; device care or use such as a central line, urinary catheter (a tube inserted into the bladder to drain urine), feeding tube (a tube inserted into the stomach for feeding and medication administration), tracheostomy/ventilator; wound care with any skin opening requiring a dressing. The facility did not provide a policy regarding infection control practices for trash and medical waste storage and disposal. 1. Observation on 10/22/24 at 10:10 A.M., of Resident's #3's incontinent care showed: - Certified Nursing Assistant (CNA) G and CNA H entered the resident's room, did not perform hand hygiene, and put on gloves; - CNA G wet two washcloths and lay the wet washcloths on the bedside table without a barrier; - CNA G and CNA H unfastened the brief, lowered resident's pants, and CNA G removed the gloves, did not perform hand hygiene, and put on gloves; - CNA G retrieved a washcloth from the bedside table, cleaned the peri area, lay the soiled washcloth on top of the clean washcloth on the bedside table, picked up the same soiled wash cloth from the bedside table and wiped the resident's buttocks, changed gloves, and did not perform hand hygiene; - CNA G placed a clean brief under the resident; - CNA G moved the bed back against the wall, placed a pillow under the resident's feet, covered the resident with linens, gave the resident the call light, and adjusted the head of the bed with the crank handle at the foot of the bed. 2. Observation on 10/23/24 at 9:55 A.M., of Resident #9's incontinent care showed: - CNA D and CNA E entered the resident's room, did not perform hand hygiene, and put on gloves; - CNA D wet washcloths; - CNA D removed the resident's brief soiled with urine and cleansed the buttocks; - CNA D dropped the wet washcloth on the floor and on top of his/her shoe; - CNA D didn't change gloves, didn't perform hand hygiene, used another washcloth and cleansed the groin folds; - CNA D dropped the wet washcloth on the floor and on top of his/her shoe; - CNA D used another wet washcloth and cleansed the groin; - CNA D dropped the wet washcloth on the floor and on top of his/her shoe with the others; - CNA D didn't change gloves, didn't perform hand hygiene, helped CNA E apply a new brief, pulled up the resident's pants, and assisted the resident in a chair. During an interview on 10/23/24 at 2:45 P.M., CNA D said hands should be washed at the start and at the end of care. Gloves should be changed when going from dirty to clean care. During an interview on 10/23/24 at 10:10 A.M., Licensed Practical Nurse (LPN) B said hands should be washed at the start and end of incontinent care and when going from dirty to clean care. 3. Observation on 10/22/24 at 9:57 A.M., of Resident #21's incontinent and suprapubic (a type of indwelling catheter) catheter care showed: - CNA G entered the room, did not perform hand hygiene, did not put on a gown and gloves; - CNA G unhooked the catheter drainage bag from the wheelchair frame, lay it on the floor, picked up the catheter drainage bag. hooked it on the bed frame. and the bottom of the catheter drainage bag and tubing touched the floor; - CNA G did not perform hand hygiene, put on gloves, lowered the resident's pants, unfastened and lowered the brief soiled with fecal material between the resident's legs; - CNA G did not change gloves, did not perform hand hygiene, removed the wipes from the wipe package, and lay the wipes on top of the opened package on the bed; - CNA G did not change gloves, did not perform hand hygiene, picked up a wipe up off the opened package on the bed, and wiped the skin around the suprapubic catheter; - CNA G did not change gloves, did not perform hand hygiene, picked up a wipe up off the opened package on the bed, wiped from the catheter insertion point down, wiped the catheter three times with the same area of the wipe, and did not change gloves and did not perform hand hygiene between each wipe; - CNA G did not change gloves, did not perform hand hygiene, assisted the resident to roll to the side, picked up a wipe up off the opened package on the bed, cleaned the fecal material from the buttocks; - CNA G did not change gloves, did not perform hand hygiene, placed a clean brief under the resident, fastened the brief, pulled the resident's pants up, lay the opened wipe package on the nightstand, and touched the bed sheet, the blanket and the call light. During an interview on 10/22/24 at 10:28 A.M., CNA G said hands should be washed or sanitized prior to resident care and putting on gloves. When performing catheter care, should wear PPE of gloves and a gown. For suprapubic catheter care, should clean the skin around the tubing, tubing, and clean the catheter tubing away from the opening. Should change gloves and sanitize hands between the catheter care and a new area, and when moving from dirty to clean care. The catheter drainage bag and tubing should not touch the floor. No items should be placed on the floor and dirty items should be placed in a bag. 4. Observation on 10/22/24 at 11:00 A.M., of Resident #21's incontinent and catheter care showed: - CNA E did not perform hand hygiene, put on gloves and a gown, wet the washcloths with peri cleanser, lay the wet washcloths on the nightstand without a barrier; - CNA E lowered the resident's pants, unfastened the brief, provided catheter care, dropped the soiled wet wash cloth on the floor, changed gloves, and sanitized hands; - CNA E cleaned fecal material from the buttocks, placed the brief soiled with fecal material on the floor, placed the soiled washcloth on top of the brief on the floor, did not change gloves, did not perform hand hygiene, retrieved a washcloth from the nightstand, removed gloves and placed them on the floor, wiped his/her bare hands with a paper towel, did not perform hand hygiene, and put on gloves; - CNA E placed a clean brief under the resident, removed the soiled incontinent pad from the bed and placed it on the floor; - CNA did not change gloves, did not perform hand hygiene, fastened the brief, pulled the resident's pants up, and put shoes on the resident; - CNA E picked up the soiled brief and gloves from the floor and placed in a trash container; - CNA E placed the soiled washcloths inside the soiled incontinent pad left on the floor, removed the gown and gloves, and sanitized hands; - CNA E exited the room, retrieved trash bags, entered the room, did not perform hand hygiene, did not put on gloves, used an opened trash bag to pick up the soiled linens from the floor, removed the trash bag from the trash container, placed the trash bag on the floor, and placed a new bag in the trash container; - CNA E did not perform hand hygiene, did not put on gloves, assisted the resident to sit on the side of the bed, transferred the resident to the wheelchair, removed the catheter drainage bag from the bed frame to the wheelchair frame, straightened the bed linens on the bed, retrieved the trash bags with the trash and the soiled items from the floor, did not perform hand hygiene, exited the resident's room, took the trash bags to the barrels at the end of the hall, did not perform hand hygiene, entered another resident's room, turned off the call light, exited the resident's room with that resident's water cup, did not perform hand hygiene, pushed Resident #21 in the wheelchair to the common area, did not perform hand hygiene, touched the pitcher of tea in the dining room, filled the other resident's cup with his/her bare hands with tea, walked back down the hall, did not perform hand hygiene, entered the other resident's room and provided the cup of tea to the other resident, did not perform hand hygiene, and pushed the other resident in the wheelchair to the dining room. During an interview on 10/24/24 at 11:00 A.M., CNA E said the catheter drainage bag should hang on the side of the bed frame and should not drag the floor or be tugged on. If a resident was in a wheelchair, the catheter drainage bag should be placed under the wheelchair on the frame so it doesn't get caught on the resident's feet or drag the floor, and there should be a privacy cover on it at all times. The tubing should not touch floor at any time. During incontinent care, he/she should change gloves and sanitize hands if gloves were visibly dirty and when moving from dirty to clean care, should wash hands before care and when done with care, carry out trash and dirty linens in bags, and sanitize or wash hands again. Soiled items should go in a bag and not lay on the floor, nothing should go on the floor. Should sanitize or wash hands between residents and between rooms. Should sanitize hands after any interactions with residents or resident items. Gloves and gown should be worn during care of residents with catheters, there should be a sign on the door showing contact precautions or EBP, and PPE should be in containers outside the resident's door. 5. Observation on 10/24/24 at 2:05 P.M., of Resident #48's incontinent care showed: - CNA D and CNA F did not perform hand hygiene and put on gloves; - CNA D and CNA F transferred the resident from the geri-chair (a reclining chair on wheels) to the bed on top of two incontinent pads; - CNA D and CNA F staff assisted the resident to remove his/her urine soaked clothes; - CNA D unfastened and removed the resident's urine soaked brief; - CNA D cleaned the resident's front peri area; - CNA D did not perform hand hygiene, did not change gloves, and cleaned the resident's left buttock and hip; - CNA D did not clean the resident's right buttock and hip; - CNA D changed gloves, did not perform hand hygiene, and applied cream to the resident's buttocks. During an interview on 10/24/24 at 2:15 P.M., CNA D said all parts of the resident should be cleaned and hands should be cleaned prior to putting on gloves. 6. Review of Resident #205's Progress Notes showed: On 10/18/24 the resident had extended-spectrum beta-lactamase (ESBL - enzymes produced by some bacteria that may make them resistant to some antibiotics) the in sputum and urine and was on contact precautions; - On 10/19/24, the resident remained in his/her room on isolation for ESBL and methicillin-resistant Staphylococcus aureus (MRSA - a type of infection that can be resistant to several antibiotics) in the sputum. Observation on 10/23/24 at 9:04 A.M., of Resident #205's incontinent care showed: - CNA D and CNA E did not perform hand hygiene, put on a gown, gloves, and a mask with an eye shield, entered the resident's open door of the room with signage on the door showed EBP precautions, and closed the door; - CNA D and CNA E assisted the resident to the toilet in the shared bathroom and lowered the resident's pants and brief; - CNA D used a wet washcloth to wipe fecal material from the resident's buttocks, draped the washcloth with the fecal material folded inside of it over the side of the trash can in the shared bathroom, did not perform hand hygiene, did not change gloves, touched the toilet handle, assisted the resident to transfer from the toilet, removed the gloves and gown, did not perform hand hygiene, touched the bedside table, touched the door handle of the room, and performed hand hygiene; - CNA E removed the gloves, gown, and the mask with the eye shield, performed hand hygiene, put on gloves, tied the red biohazard trash bag in the regulated medical waste box, left the box open without the lid, did not remove gloves, did not perform hand hygiene, left the room with the opened box, walked to the emergency eye wash station room, touched the outside door knob with gloved hands, removed the biohazard trash bag from the opened box, sat the opened box near the eye washing station, removed the gloves, and touched the inside door knob of the emergency eye wash station room; - CNA D put on gloves and a gown; tied the red biohazard bag inside the regulated medical waste box; closed the box; removed the washcloths soiled with fecal material from the shared bathroom; placed them in a red biohazard bag; did not change gloves, did not perform hand hygiene, adjusted a wedge under the resident's feet and the wheelchair headrest; removed the gown, gloves and the mask with eye shield; did not perform hand hygiene; removed the closed box from the resident's room; walked to the emergency eye station room; touched the outside door handle to open the door; touched the inside door handle; removed and discarded the gloves in the trash can under the nurses station desk; and performed hand hygiene. During an interview on 10/23/24 at 10:02 A.M., CNA E said there was another resident that shared the bathroom with Resident #205. During an interview on 10/24/24 at 8:30 A.M., the Assistant Director of Nursing (ADON) said contact precautions for ESBL and MRSA, if in the sputum, would be droplet precautions and should include gown, gloves, mask, and a face shield. Resident #205 couldn't use the same bathroom as another resident. If the room had a shared bathroom, staff should provide a urinal/bed pan and a bedside commode for the resident on isolation precautions. During an interview on 10/24/24 at 8:38 A.M., the Director of Nursing (DON) said MRSA and ESBL precautions were contact precautions for urine and droplet precautions if in the sputum. Staff were to wear PPE of a gown, gloves, and a mask with a face shield when providing care for Resident #205. Resident #205 should not share a bathroom with another resident. The resident should have a bed side commode so not to spread the infections to another room or resident. 7. Observation on 10/23/24 at 9:04 A.M., of the emergency eye wash station room showed: - A large trash barrel with the lid open due to the overflow of trash bags, two full trash bags on top of the lid, and seven trash bags on the floor in front of the overflowing trash barrel; - Three red biohazard trash bags and one regulated medical waste box filled with biohazard material in the corner behind the door sat on the floor; - One empty used regulated medical waste box to left of the sink with the top of the box touching the eye wash station and no identifiers on the box; - One full sharps container turned upside down in the right sink basin and one full sharps container sat on the right side of the sink. During an interview on 10/23/24 at 9:31 A.M., CNA E said he/she saw the red bags out of the boxes and sat on the floor of the emergency eye wash station room so he/she removed the red bag from the box and sat the box aside so staff could use the box again. 8. Observation on 10/23/24 at 9:38 A.M., of the soiled utility room showed: - One full and closed regulated medical waste box under the sink; - One large trash barrel with the lid open due to the overflow of trash bags, one full trash bag on top of the lid, and three full trash bags sat on the floor to the right of the large trash barrel. 9. Observation on 10/23/24 at 10:10 A.M., showed: - Housekeeper I had gloves on and took a trash barrel full of regular full trash bags to the dumpster with fluids leaking out of them; - Housekeeper I did not remove the gloves, did not perform hand hygiene, returned to the facility, and touched multiple door handles, including the eye washing station door; - Housekeeper I did not remove the gloves, did not perform hand hygiene, took out another trash barrel of full regular trash bags to the dumpster while touching multiple door handles; - Housekeeper I removed the gloves, did not perform hand hygiene, returned to the facility, pushed the trash barrel, and touched multiple door handles, including the washing station closet door. During an interview on 10/23/24 at 9:42 A.M., Housekeeper I said he/she emptied the trash barrels in the soiled utility room into the dumpster. He/She threw the red bags out in a different area than the regular trash. He/She believed it was a safety area. During an interview on 10/24/24 at 2:30 P.M., the Administrator said the red biohazard bags for the medical waste trash boxes stay inside the boxes, staff were to take them out of the residents' rooms to be discarded, and placed in the storage unit that the contracted company picked up the waste from. The red biohazard bags and the medical waste boxes should not be kept in the eye wash station and the soiled utility rooms.

Based on observation, interview, and record review, the facility failed to store and distribute food under sanitary conditions, increasing the risk of cross-contamination and food-borne illness. This had the potential to affect all residents. The facility census was 55. Review of the facility's policy titled, Food Labeling, revised January 2012, showed: - Foods must be properly labeled; - Write time and date of preparation on a label and place on the container. The facility did not provide policies regarding kitchen cleaning, meal carts, or covering of foods. 1. Observation on 10/21/24 at 9:28 A.M., and 10/22/24 at 8:59 A.M., of the kitchen showed: - No cleaning logs; - Scattered debris below the food preparation table on the shelf under the table; - Cooking sheet attached to the stove separating the fryer and the cooking stove to be dirty and covered in grease; - 20 fluorescent lights in the kitchen area without covers. 2. Observation on 10/21/24 at 9:28 A.M., and 10/22/24 at 8:59 A.M., of the preparation and cooking area showed: - The cooked/prepped food refrigerator with bags of greens, grapes, tomatoes, and onions all in quart bags, and an opened bag of turkey lunch meat, undated; - The freezer with three individually wrapped pizza sticks and an open bag of hot dogs, undated; - The bread shelf with two opened loaves of bread and one package of opened hotdog buns, undated. 3. Observation on 10/21/24 at 9:28 A.M., and 10/22/24 at 8:59 A.M., of the dry food pantry showed: - One half used package of chocolate chips, undated; - One half used bottle of cooking wine, undated; - One opened bag of sprinkles, butterscotch chips, and backing cocoa, undated; - One half used 128 ounce (oz) bottle of barbecue sauce, undated; - One quarter used one gallon bottle of Worcestershire sauce, undated; - One opened five pound bag of buttermilk biscuit mix, undated; - One gallon storage bag of breadcrumbs, not labeled and undated; - The freezer labeled potatoes had a half bag of french fries, undated; - The freezer labeled waffles had a big bag of uncooked waffles, undated; - One gallon bag of waffles in the refrigerator, undated; - The freezer with five sausages in a bag, undated; - A gallon bag of lasagna noodles frozen, not labeled and undated. 4. Observation on 10/21/24 at 12:13 P.M., of the 100 Hall meal cart pushed down the 100 Hall showed 10 cups and two bowls of cake not covered. 5. Observation of the 300/400 Hall meal cart pushed down the halls showed: - On 10/21/24 at 12:14 P.M., seven uncovered plates of cake and 15 uncovered drinks; - On 10/24/24 at 12:38 P.M., two bowls of uncovered cookies and 11 uncovered drinks. During an interview on 10/24/24 at 11:00 A.M., the Dietary Manager (DM) said he/she asked about the uncovered lights and was told new bulbs were put in at some point and the covers were just not put back on. There shouldn't be crumbs on any shelving and the pan beside the fryer and the fryer area did need to be cleaned. All food items should be dated and labeled once opened. During an interview on 10/24/24 at 12:00 P.M., the Administrator said she would expect the kitchen staff to follow policies, everything to be dated and labeled, and areas kept clean. During an interview on 10/24/24 at 12:40 P.M., the Assistant director of Nursing (ADON) said all food and drinks on the hall carts should be covered. During an interview on 10/24/24 at 12:50 P.M., the DM said food and drinks on the hall carts should be covered. During an interview on 10/24/24 at 1:01 P.M., Certified Nursing Assistant (CNA) C said the food and drinks on the hall cart should be covered. Whoever prepared the food or drink should cover them.

Based on interview and record review, the facility failed to issue a Centers for Medicare and Medicaid Services (CMS) Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN: Medicare requires SNFs to issue a SNF ABN to beneficiaries prior to providing care that Medicare usually covers, but may not pay for because the care is not medically reasonable and necessary or considered custodial) Form 10055 for one resident (Resident #164 ) out of three sampled residents who remained in the facility when benefits were not exhausted, and failed to issue a CMS Notice of Medicare Non-Coverage (NOMNC: Medicare requires SNFs to issue a NOMNC to beneficiaries no later than two days before covered services end) Form 10123 for two residents (Resident #163 and #164) out of three sampled residents. The facility's census was 59. 1. Review of Resident #163's NOMNC form showed: - The resident's skilled Medicare Part A services started on 06/07/23, ended on 07/01/23, and the resident discharged to home; - The facility failed to get verbal consent or provide the resident's representative with the NOMNC form. 2. Review of Resident #164's NOMNC and SNF ABN forms showed: - The resident's skilled Medicare Part A services started on 04/21/23, ended on 05/03/23, and the resident remained in the facility; - The facility failed to get verbal consent or provide the resident's representative with the SNF ABN and NOMNC forms at least two days prior to services ending. During an interview on 8/11/23 at 10:10 A.M., the Director of Nursing (DON) said he/she would expect the SNF ABN and NOMNC forms to be completed and signed appropriately. The DON said the business office manager is responsible for having these signed. During an interview on 8/11/23 at 12:12 P.M. , the Administrator said he/she would expect the SNF ABN and NOMNC forms to be completed and signed prior to a resident's discharge from skilled Medicare services. The facility did not provide a policy.

Based on interview and record review, the facility failed to complete a significant change Minimum Data Set (MDS, a federally mandated assessment to be filled out by the facility staff) assessment within 14 days of a resident admitted to hospice. This affected one resident (Resident #34) out of three sampled residents. The facility census was 59. Review of the facility's policy titled, Resident Assessment Instrument (RAI), revised November 2017, showed: - A comprehensive assessment of a resident's needs, strengths, goals, life history, and preferences, using the RAI specified by CMS (Centers for Medicare and Medicaid Services) and shall be made within fourteen (14) days of the resident's admission; - The assessment coordinator is responsible for ensuring that the interdisciplinary team (IDT, a group of health care professionals from diverse fields who work in a coordinated effort toward a common goal for a resident) conduct timely resident assessments and reviews when there has been a significant change in the resident's condition. 1. Review of Resident #34's medical record showed: - admitted to hospice on 06/15/23. Review of the resident's MDS showed: - A significant change MDS assessment submitted on 07/07/23; - The facility failed to submit a significant change MDS assessment within 14 days after the resident admitted to hospice. During an interview on 08/11/23 at 12:11 P.M., the MDS Coordinator said a MDS significant change assessment should be submitted within 14 days after a resident goes on hospice services. During an interview on 08/11/23 at 12:13 P.M., the Director of Nursing (DON) said a MDS significant change assessment should be submitted within 14 days after a resident goes on hospice services. During an interview on 08/11/23 at 12:15 P.M., the Administrator said a MDS significant change assessment should be submitted within 14 days after a resident goes on hospice services.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to implement a care plan with specific interventions tailored to meet individual needs for three residents (Residents #8, #41, and #59) out of 15 sampled residents. The facility census was 59. The facility failed to provide a policy regarding comprehensive care plans. 1. Review of Resident #8's face sheet showed: - admitted on [DATE]; - Diagnoses included anxiety disorder (mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities), schizoaffective disorder (a mental health problem including psychosis as well as mood symptoms), violent behavior, and unspecified mood disorder. Review of the resident's quarterly oral cavity observation on 07/31/23 showed mouth pain and broken/loose teeth and/or caries (cavities). Review of the resident's progress notes showed: - On 06/17/22, resident continues to pull at teeth, educated by staff that manipulating her bad teeth will not reduce pain. Resident continues to pull/wiggle teeth. Resident frequently asks for pain medication during night for mouth pain with moderate effect for short durations; - On 07/12/22, resident seen by doctor during virtual nursing home rounds. Received new order for Orajel for dental pain. Orders noted and processed. Review of the resident's patient chart note report from Dr. [NAME], Doctor of Dental Surgery (DDS), showed: - Resident presented for extraction of teeth #26 and 27 on 10/03/22; - Resident was not cooperative and could not finish anesthetic delivery to complete extractions. Review of the resident's care plan did not address dental issues. 2. Review of the facility's policy titled, Smoking Policy and Procedure,, dated 10/21/22, showed: - Any resident that expresses an interest to smoke will be passed at the time of admission and at least quarterly or with any significant change to determine the level of assistance and supervision needed for resident safety. This includes e-cigarettes (battery powered device that provides vaporized nicotine solution); - Based on the assessment findings, the resident's plan of care will be revised to reflect the level of assistance or supervision needed to ensure resident safety; - Residents determined by the care plan team to not require supervision can smoke at will in the designated smoking area. Review of Resident #41's medical record showed: - admitted on [DATE]; - Diagnoses included chronic obstructive pulmonary disease (COPD, lungs cannot get enough oxygen into the blood or eliminate enough carbon dioxide from the body), hypertension (high blood pressure) and peripheral vascular disease (condition in which narrowed blood vessels reduce blood flow to the limbs); - Care plan last revised 06/09/23 did not address smoking. During an interview on 08/09/23 at 3:32 P.M., the resident said he/she uses a vape pen (type of e-cigarette) and is able to go out and smoke anytime he/she wants to. Resident said he/she has never been assessed for safe smoking. Resident said he/she has used the vape pen since admission to the facility. 3. Review of Resident #59's medical record showed: - admitted on [DATE]; - Diagnoses of senile degeneration of the brain (a decrease in the ability to think, concentrate, or remember), unspecified mood (affective) disorder (general emotional state or mood is distorted or inconsistent with circumstances), and Alzheimer's with early onset (progressive disease that destroys memory and other important mental functions occurring before the age of 65 years); - An order for haloperidol lactate solution (an antipsychotic medication - medications to treat a mental disorder characterized by a disconnection from reality); five milligrams per milliliter; inject two milligrams every two hours as needed for behaviors, dated 06/05/2023; - Antipsychotic medication not addressed on care plan. During an interview on 08/11/23 at 12:12 P.M., the Administrator, the Director of Nursing, and the MDS (Minimum Data Set - a federally mandated assessment performed by the facility) Coordinator said they would expect smoking/vaping, dental issues, and antipsychotic medications to be addressed on the care plan.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to update and revise care plans with specific interventions tailored to meet individual needs for one resident (Resident #14) out of 15 sampled residents. The facility census was 59. Review of the facility's policy titled, Resident Assessment Instrument (RAI), revised November 2017, showed: - A comprehensive assessment of a resident's needs, strengths, goals, life history, and preferences, using the RAI specified by CMS (Centers for Medicare and Medicaid Services) and shall be made within fourteen (14) days of the resident's admission; - The interdisciplinary team (IDT, a group of health care professionals from diverse fields who work in a coordinated effort toward a common goal for a resident) must develop, review and update the care plan when the resident has been readmitted to the facility from a hospital stay. 1. Review of Resident #14's medical record showed: - admitted on [DATE]; - Diagnoses included pneumonia (an infection that inflames the air sacs in one or both lungs), chronic obstructive pulmonary disease (COPD, a chronic inflammatory lung disease that causes obstructed airflow from the lungs) and tobacco dependence; - discharged to hospital on [DATE]; - readmitted on [DATE]. Review of resident's care plan, revised 07/31/23, showed: - Resident has not smoked a cigarette since admission on [DATE]; - No documentation with specific interventions tailored to meet individual needs related to smoking. During an interview on 08/08/23 at 3:31 P.M. and 08/09/23 at 1:25 P.M., the resident said he/she was a smoker, can request to smoke anytime and smokes supervised by staff. He/she was not sure why supervision was needed while smoking. During an interview on 08/09/23 at 1:10 P.M., Registered Nurse (RN) B said resident is a smoker and requires supervision while smoking. Residents that require supervision can smoke upon request and an employee will take them to the designated smoke area. There are no designated smoke times and residents that have been assessed to smoke independently can do so at his/her leisure. During an interview on 08/11/23 at 9:08 A.M., Certified Nursing Assistant (CNA) C said resident was a smoker. If a resident makes a request to smoke, a staff member takes him/her to the designated smoke area and supervises if that resident requires supervision. Residents who smoke independently don't have to ask a staff member to smoke or be supervised. During an interview 08/11/23 at 10:16 A.M., CNA D said resident was a smoker. Residents are assessed by someone in nursing to determine if he/she is able to smoke independently or if supervision is required. Independent residents can smoke at any time and there is a designated smoke area outside. During an interview on 08/11/23 at 12:11 P.M., the Minimum Data Set (MDS, a federally mandated assessment instrument completed by the facility staff) Coordinator said the care plan should reflect if a resident is a smoker and be revised/updated as needed. During an interview on 08/11/23 at 12:13 P.M., the Director of Nursing (DON) said the care plan should reflect if a resident is a smoker and be revised/updated as needed. During an interview on 08/11/23 at 12:15 P.M., the Administrator said the care plan should reflect if a resident is a smoker and be revised/updated as needed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to follow physician's orders for one resident (Resident #57) out of 15 sampled residents. The facility's census was 59. Review of Resident #57's medical record showed: - A diagnosis of venous thrombosis (a condition that occurs when a blood clot forms in a vein) and embolism (sudden blocking of an artery); - An order for Eliquis (medication used to treat and prevent blood clots and stroke) 5 milligrams (mg), give one tablet twice daily for venous thrombosis and embolism, dated 03/27/23; - A Note to Attending Physician/Prescriber from the Consulting Pharmacist to reduce medication to 2.5 mg twice daily for prophylaxis or discontinue, signed in agreement by the attending physician and dated 06/17/23; - No clarification from the attending physician on whether to reduce the dose or discontinue the medication. Review of the resident's June 2023 Medication Administration Record (MAR) showed: - The MAR dated 06/01/23 to 06/30/23 with Eliquis 5 mg as given twice daily; - A total of 28 missed opportunities to reduce/discontinue Eliquis after 06/17/23. Review of the resident's July 2023 MAR showed: - The MAR dated 07/01/23 to 07/31/23 with Eliquis 5 mg as given twice daily except when the resident was hospitalized from [DATE] to 07/26/23; - A total of 52 missed opportunities to reduce/discontinue Eliquis. Review of the resident's August 2023 MAR showed: - The MAR dated 08/01/23 to 08/11/23 with Eliquis 5 mg as given twice daily; - A total of 22 missed opportunities to reduce/discontinue Eliquis. During an interview on 08/11/23 at 3:50 P.M., the Director of Nursing (DON) said she would expect pharmacy recommendations addressed by the physician to have the new orders taken off and processed by the nurse generally within 24 hours. The facility did not provide a policy.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to assess and complete smoking assessments upon admission and quarterly for three residents (Resident #6, #14, and #41) out of 15 sampled residents and one resident (Resident #55) outside the sample. The facility census was 59. Review of the facility's policy titled, Smoking Policy and Procedure, dated 10/21/22, showed: - Any resident that expresses an interest to smoke will be assessed at the time of admission and at least quarterly or with any significant change to determine the level of assistance and supervision needed for resident safety. This includes e-cigarettes (battery powered device that provides vaporized nicotine solution); - Based on the assessment findings, the resident's plan of care will be revised to reflect the level of assistance or supervision needed to ensure resident safety; - Residents determined by the care plan team to not require supervision can smoke at will in the designated smoking area. 1. Review of Resident #6's medical record showed: - admitted on [DATE]; - Diagnoses included cerebral infarction (stroke), right side hemiplegia (inability to move one side of the body) and chronic obstructive pulmonary disease (COPD, a group of lung diseases that block air flow and make it difficult to breathe); - No documentation of a completed smoking assessment upon admission; - No documentation of a completed quarterly smoking assessment. Observation on 08/10/23 at 3:04 P.M. showed the resident outside smoking with other residents and a staff member present. During an interview on 08/11/23 at 9:00 A.M., the resident said he/she can smoke whenever he/she wanted and did not need someone with him/her. 2. Review of Resident #14's medical record showed: - admitted on [DATE]; - Diagnoses included pneumonia (an infection that inflames the air sacs in one or both lungs), COPD, and tobacco dependence; - No documentation of a completed smoking assessment upon admission. During an interview on 08/08/23 at 3:31 P.M. and 08/09/23 at 1:25 P.M., the resident said he/she smoked, can request to smoke anytime and smoked supervised by staff. He/she was not sure why supervision was needed while smoking. Observation on 08/10/23 at 9:03 A.M. showed the resident smoking at the designated smoke area outside with employee supervision. 3. Review of Resident #41's medical record showed: - admitted on [DATE]; - Diagnoses included COPD, chronic respiratory failure (lungs cannot get enough oxygen into the blood or eliminate enough carbon dioxide from the body), hypertension (high blood pressure) and peripheral vascular disease (condition in which narrowed blood vessels reduce blood flow to the limbs); -No documentation of a completed smoking assessment upon admission; -No documentation of a completed quarterly smoking assessment. During an interview on 08/09/23 at 3:32 P.M., the resident said he/she uses a vape pen (type of e-cigarette) and is able to smoke anytime. Resident said he/she has never been assessed for safe smoking. Resident said he/she has used the vape pen since admission to the facility. 4. Review of Resident #55's medical record showed: - admitted [DATE]; - Diagnoses included left side hemiplegia, cerebral infarction and tobacco dependence; - No documentation of a completed smoking assessment upon admission; - No documentation of a completed quarterly smoking assessment. During an interview on 08/09/23 at 1:25 P.M. and 08/09/23 at 1:25 P.M., the resident said he/she smoked and smoked anytime without supervision. Resident said he/she has smoked since admission. During an interview on 08/10/23 at 9:21 A.M., Registered Nurse (RN) B said smoking assessments were located under the observation tab in the electronic health record (EHR). During an interview on 08/10/23 at 9:26 A.M., the Infection Preventionist said smoking assessments were located under the observation tab in the resident's EHR. During an interview on 08/11/23 at 9:08 A.M., Certified Nursing Assistant (CNA) C said if a resident makes a request to smoke, a staff member takes him/her to the designated smoke area and supervises if that resident requires supervision. Residents who smoke independently don't have to ask a staff member to smoke or be supervised. During an interview on 08/11/23 at 10:16 A.M., CNA D said residents are assessed by someone in nursing to determine if he/she is able to smoke independently or if supervision is required. Independent residents can smoke at any time and there is a designated smoke area outside. During an interview on 08/11/23 at 12:11 P.M., the Minimum Data Set (MDS, a federally mandated assessment instrument completed by the facility staff) Coordinator said a smoking assessment should be completed upon admission, when required and at least quarterly thereafter. During an interview on 08/11/23 at 12:13 P.M., the Director of Nursing (DON) said a smoking assessment should be completed on all residents upon admission, when required and at least quarterly thereafter. During an interview on 08/11/23 at 12:15 P.M., the Administrator said a smoking assessment should be completed on all residents upon admission, when required and at least quarterly thereafter.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility staff failed to limit the use of an as needed (PRN) antipsychotic medication (a medication to treat a mental disorder characterized by a disconnection from reality) to 14 days or to document the rationale for extending the order for one resident (Resident #59) out of 15 sampled residents. The facility census was 59. 1. Review of Resident #59's Face Sheet showed: - Diagnoses of senile degeneration of the brain (decrease in the ability to think, concentrate, or remember), Alzheimer's with early onset (disease that destroys memory and other important mental functions occurring prior to the age of [AGE] years old) and unspecified mood (affective) disorder (general emotional state or mood is distorted or inconsistent with circumstances). Review of the resident's Physician's Orders showed: - An order for haloperidol (an antipsychotic medication) 2 milligram (mg) tablet, give every two hours as needed (PRN), for Alzheimer's disease with early onset, dated 04/16/23 and discontinued 05/05/23; - An order for haloperidol 5 mg per milliter (mL) solution, inject 2 mg every two hours as needed for behaviors related to Alzheimer's disease with early onset, dated 04/16/23 and discontinued 06/04/23 with a discontinue note on the order reading order discontinued as over 14 days old and psych PRN. - An order for haloperidol 5 mg per milliliter solution, inject 2 mg every two hours as needed for agitation/behaviors related to Alzheimer's disease with early onset, dated 06/05/23. Review of Note to Attending Physician/Prescriber from the Consulting Pharmacist, dated 05/01/23, showed: - This patient has been receiving haloperidol 2 mg every two hours PRN and is due for an evaluation of being discontinued; - Physician agrees with discontinuing haloperidol, signed and dated 05/04/23. Review of the Resident's Medication Administration Record (MAR), dated July 2023, showed the last administered dose of haloperidol was on 07/26/23. No documentation found in the resident's record of the attending physician's rationale to continue the current haloperidol order beyond 14 days or any indication of the duration for the PRN order. Observations of the resident showed: - On 08/08/23 at 12:15 P.M., sitting in the dining room being fed by staff; - On 08/09/23 at 10:55 A.M., lying in a low bed with eyes closed and fall mat in place; - On 08/11/23 at 09:11 A.M., lying in a low bed with eyes closed and fall mat in place. During an interview on 08/11/23 at 12:12 P.M., the Director of Nursing (DON) said she would expect a medication prescribed as needed (PRN) not to be utilized for longer than 14 days unless advised by the physician to continue and an antipsychotic medication should have an appropriate diagnosis for the indication. The facility did not provide a policy.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to label and store medications in a safe and effective manner. This had the potential to affect all residents. The facility census was 59. Review of the facility's policy titled Medication Storage in the Facility, dated [DATE], showed: - Medications and biologicals are stored safely, securely, and properly following the manufacturer or supplier recommendations; - Medication requiring refrigeration or temperatures between 36 degrees Fahrenheit and 46 degrees Fahrenheit are kept in a refrigerator; - Outdated drugs will be immediately withdrawn from stock by the facility. They will be disposed of according to drug disposal procedures, and reordered from pharmacy if a current order exists; - Temperature sensitive drugs will be properly stored at the facility. Review of the package insert of Aplisol PPD solution (a solution used to test for tuberculosis), showed: - Do not freeze. This product should be stored at 36-46 degrees Fahrenheit and protected from light. Vials in use more than 30 days should be discarded due to possible oxidation and degradation which may affect potency. Observation on [DATE] at 02:38 P.M. of the medication room refrigerator showed: - One opened vial of Aplisol PPD solution with no opened date and an expiration date of 11/23; - One opened vial of Aplisol PPD solution with no opened date and an expiration date of 05/24; - One opened vial of Aplisol PPD solution with an opened date of [DATE] and an expiration date of 05/24. Review of the refrigerator temperature log, dated [DATE], showed: - The temperature range is between 36-46 degrees Fahrenheit. - Recorded temperatures that fell out of range were 34 degrees on [DATE], 32 degrees on [DATE], 34 degrees on [DATE], 34 degrees on [DATE], and 31 degrees on [DATE]. During an interview on [DATE] at 3:00 P.M., Certified Medication Technician (CMT) F said he/she would tell the charge nurse if the refrigerator temperature was out of range. During an interview on [DATE] at 3:20 P.M., Registered Nurse (RN) B said refrigerator temperatures should be checked on night shift and, if out of range, then staff will adjust the temperature and check again in an hour. If not in range, they need to call maintenance. During an interview on [DATE] at 3:30 P.M., the Infection Preventionist said PPD solution should be discarded after 30 days. During an interview on [DATE] at 3:45 P.M., the Director of Nursing (DON) said there is a night shift nurse to check expired vials and medications. All vials should be dated when opened. Medication refrigerators are checked by nursing, and they're signed off. If it's out of range, the DON should get a phone call. For anything that's in the medication fridge, we call pharmacy and they advise what he/she needs to do. The DON is not sure where that would be documented. Maintenance is usually involved when something is out of whack. During an interview on [DATE] at 3:50 P.M., the Administrator said medication refrigerator temperatures have never been out of range since he/she has been there. It has never been brought to her attention.

Based on record review and interview, the facility failed to maintain quarterly Quality Assurance & Performance Improvement (QAPI) meetings with the required members. The facility's census was 59. Review of the facility's policy, titled QAPI, revised October 28, 2020, showed: - All department managers, the administrator, the director of nursing, medicare coordinator/designee, infection control and prevention officer, medical director, consulting pharmacist, resident and/or family representatives (if appropriate), and three additional staff members will provide QAPI leadership by being on the quality assessment and assurance (QAA) committee. 1. Review of QAPI Meeting information, dated 02/21/22 and provided by the Administrator, showed the following members attended: - Administrator; - Director of Nurses; - Assistant Director of Nurses; - Infection Preventionist; - No record of Medical Director or other staff attending. 2. Review of QAPI Meeting information, dated 08/17/22 and provided by the Administrator, showed the following members attended: - Administrator; - Director of Nurses; - Assistant Director of Nurses; - Infection Preventionist; - Director of Operations; - No record of Medical Director or other staff attending. 3. Review of QAPI Meeting information, dated 12/05/22 and provided by the Administrator, showed the following members attended: - Administrator; - Director of Operations; - Assistant Director of Nurses; - MDS (Minimum Data Set - a mandatory assessment completed by the facility) Coordinator; - Medical Director; - Infection Preventionist; - No record of Director of Nurses attending. 4. Review of QAPI Meeting information, dated 02/22/23 and provided by the Administrator, showed the following members attended: - Administrator; - Director of Operations; - Director of Nurses; - Assistant Director of Nurses; - MDS Coordinator; - Medical Director; - No record of Infection Preventionist attending. 5. Review of QAPI Meeting information, dated 05/19/22 and provided by the Administrator, showed the following members attended: - Administrator; - Director of Operations; - Director of Nurses; - Infection Preventionist; - No record of Medical Director or one other staff attending. During an interview on 08/11/23 at 09:41 A.M., the administrator said they have QAPI meetings quarterly and she has the required members at each meeting.

Based on record review and interviews, the facility failed in prevention of communicable disease in regard to Tuberculosis (TB) (a communicable disease that affects the lungs characterized by fever, cough and difficulty breathing) screening for two residents (Resident #22 and #50) out of five sampled residents. Also, the facility failed to implement a risk management process specific to Legionnaires' disease (a serious type of pneumonia caused by legionella bacteria) which had the potential to affect all residents, staff and the public. The facility's census was 59. The policy, Tuberculosis Testing, last revised April 2015, showed: - Within seven days of admission, each resident will receive a two-step Mantoux (a test that uses a liquid called tuberculin, that is injected just below the skin, causing a small, pale bump to appear and is read within 48-72 hours) test; - One intradermal (just below the skin) injection with in seven days of admission and one intradermal injection one to three weeks after first injection. 1. Review of Resident #22's medical record showed: - An admission date of 04/21/23; - On 04/21/23, a first-step administered and read on 04/24/23; - On 05/02/23, a second-step administered and read on 5/08/23; - The facility failed to read the second step within 48-72 hours. 2. Review of Resident #50's medical record showed: - An admission date of 06/15/23; - On 06/15/23, a first-step administered and read on 06/18/23; - The facility failed to administer a second-step. During an interview on 08/10/23 at 2:00 P.M., the Infection Preventionist (IP) said he/she missed the second step for Resident #50 and the second step for Resident #22 was read late. During an interview on 08/11/23 at 12:12 P.M., the Administrator and Director of Nursing (DON) collectively said they would expect the TB screens to be done according to policy and to be read within the 48-72 hour window. Review of the facility's policy titled, Legionella Water Management Program, last revised July 2019, showed: - As part of the infection prevention and control program, the facility will have a water management program; - The water management team will consist of at least the personnel including: The Infection Preventionist (IP), Administrator, Medical Director, Director of Maintenance, and the Director of Environmental Services; - The purpose of the water management program is to identify areas in the water system where Legionella bacteria can grow and spread, and to reduce the risk of Legionnaires' Disease; - The water management program used by facility is based on the Center for Disease Control, Prevention and American Society of Heating, Refrigerating and Air-Conditioning Engineers (ASHRAE) recommendations for developing a Legionella water management program; - The Water Management Program will be reviewed at least once a year, or sooner if any of the following occur: control limits not met consistently, major maintenance or water system change, disease cases associated with the water system or changes in law, regulations, standards or guidelines. During an interview on 08/11/23 at 9:51 A.M., the Administrator said the facility had a change in the maintenance staff and would look into finding the information from last year. During an interview on 08/11/23 at 10:05 A.M., the Administrator said she was unable to provide documentation that showed Legionella prevention process had been in place for the past year. During an interview on 08/11/23 at 11:11 A.M., the Maintenance Supervisor said he/she had just taken over his/her position and has not yet put the Legionella checks in place but was working on it. During an interview on 08/11/23 at 12:12 P.M., the Administrator and DON said they would expect the facility to perform monitoring for Legionella per the facility policy.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure one resident (Resident #1) out of five sampled residents, was free of misappropriation when a staff member stole the resident's medications. The census was 61. Record review of the facility's Controlled Substances policy dated July 2014 showed: - The facility shall comply with all laws, regulations, and other requirements related to handling, storage, disposal and documentation of Schedule II and other controlled substances;. - The Director of Nurses will identify staff members who are authorized to handle controlled drugs; - The Director of Nurses shall investigate any descrepancies in the narcotics reconsiliation to determine the cause and identify any responsible parties and shall give the Administrator a written report of such findings. Record review of the facility's Misappropriation Policy dated 6/5/2023, showed: - All employees will receive written education in the form of this policy upon hire date and reviewed annually; - The definition of misappropriation will include but is not limited to; personal property, identification, money, and use of the resident's personal property with or without permission. 1. Record review of Resident #1's medical record showed: - The resident admitted on [DATE] and passed away on 05/26/23; - The resident had an order for Xanax (a drug used to treat anxiety) .25 milligram (mg) Record review of the facility's investigation dated 05/19/23 showed: - The Administrator (ADM) had been notified by the Director of Nurses (DON) that multiple B-12 (a mineral replacement to treat anemia) injections were missing; - While searching for missing B12 injections, the DON observed Licensed Practical Nurse (LPN) A's personal lunch bag with blank envelopes placed carefully on the top; - The DON searched the bag and discovered a bottle of pills belonging to Resident #1, multiple baggies filled with pills that had been labeled with the drug names and prices written on the outside of the baggie; - The DON contacted the ADM and they contacted the [NAME] Bluff Police Department; - LPN A was arrested and employment terminated. Record review of the DON's written statement showed: - On 5/19/2023 it was reported to the her by LPN B, several B-12 injections were missing and the DON began looking for them; - While looking for the medications, she noticed LPN A's personal lunch bag with envelopes hiding the top of the bag; - The DON thought the bag looked suspicious and investigated the contents; - The DON found a bottle of Xanax (a drug used to treat anxiety) belonging to Resident #1; - There were multiple other medications in bottles and baggies; - These were labeled for sale; - When the police arrived they accompanied the DON, searched LPN A ' s personal belongings and found $1000 in cash, 123 Hydrocodone 5-325, 2 Hydrocodone 7.5/325, and multiple unidentified medications; - The DON found the B-12 injections in the medication room, not with any of LPN A's belongings. Record review of the reconciliation of the medications to be destroyed, completed by the DON, showed the following missing medications: - A total of 242 Hydrocodone 5-325; - A total of 206 Hydrocodone 7.5-325; - A total of 101 Hydrocodone 10-325; - A total of 31 Morphine Sulfate Contin 15 mg; - A total of 30 Morphine Sulfate Contin 30 mg; - A total of 85 Hydromorphone (a medication used to treat severe pain) 2mg; - A total of 49 Tramadol (a medication used to treat moderate pain) 50 mg; - A total of 47 Xanax .5 mg; During an interview on 06/1/2023 at 9:35 A.M., the DON said LPN A had been an employee for over 20 years and there had never been any indication she was a drug dealer or supplier. The DON said from her investigation, there is no evidence LPN A took any current medications, but only took those medications that had been discontinued or the resident had been discharged . The DON said the entire event started when LPN B could not find some B12 injections. She said she went to help look for the B12 and saw LPN A's lunch bag with blank envelopes stacked on top. She said that looked out of place to her so she invstigated. When she saw Resident #1's pill bottle, she knew she better inform the Adm and the police. The DON said they (facility and police) found a massive amount of pain medications all neatly separated by strength, in baggies labeled with names identifying each pill and a monetary amount identified. She said LPN A was agitated and said she had a prescription for hydrocodone from the pain clinic in the next town. LPN A was arrested and taken to jail. The DON said from that point she started to reconcile the medications in the to be destroyed drawer. The DON said in January 2023 she implemented a new narcotic medication destruction policy and procedure to better monitor and track discontinued narcotics. The DON said staff are to bring the discontinued medications (narcotics) to her. She enters the medications in a log and keeps the medications behind a locked door. The DON said she had not destroyed medications in a while. She said she compared what she had to her log and physician's orders and found over 700 medications total were unaccounted for. The DON said she did not have the capability to confirm if some of the pills LPN A had in baggies were some of the facility's unaccounted for medications. She said she thought LPN A had discovered a way to steal the medications by simply taking discontinued prescriptions with her instead of turning them in to the DON. The DON said Resident #1 had brought in some medications from home upon admission. The facility's pharmacy had packaged the medications and discontinued the home medications. LPN A had simply put the bottle the resident brought from home in her bag instead of turning it in. The DON said the B12 injections were found and all accounted for, just misplaced. During an interview on 06/01/2023 at 5:45 P.M., Law Enforcement Officer A said they interviewed and searched LPN A and found multiple medications believed to have been taken from the facility. LPN A has been arrested and charges are pending. During an interview on 06/04/2023 at 7:00 P.M., LPN A refused to speak with SLCR. During an interview on 06/05/2023, LPN B said there had never been any evidence that LPN A was taking medications out of the building. Complaint #MO218704

Based on interview and record review, the facility failed to ensure that a current copy of a resident's advance directive (a legal document which allows a person to make their end-of-life wishes known in the event they are unable to communicate) was in the resident's medical record for one resident (Resident #38) out of 15 sampled residents. The facility's census was 59. Record review of the facility's policy titled, Advance Directives, dated February 2012, showed the Interdisciplinary Team will review annually with the resident his or her advance directives to ensure that such directives are still the wishes of the resident. Such reviews will be made during the annual assessment process. Record review of Resident #38's medical record showed a handwritten order, dated 10/27/15, Do Not Resuscitate (DNR) per family Power of Attorney (POA) on a Physician's Order Sheet (POS), dated 10/1/15 through 10/31/15. The record did not contain any other updated information related to the advance directives. During an interview on 3/24/21 at 4:05 P.M., the Administrator said she would expect a resident's advance directive to be reviewed annually to assure the orders match on the POS, care plan, and reflect the resident's current wishes.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to notify the responsible party of a change in condition or significant change in condition for one resident (Resident #14) out of 15 sampled residents and one resident (Resident #259), a closed record, outside of the sample. The facility's census was 59. 1. Record review of the facility's policy titled, Change in Condition, dated February 2012, showed: - Change in condition is defined as an improvement or decline in the resident's physical, mental or psychosocial status that affects less than two areas of activities of daily living; - Significant change is defined as an improvement or decline in the resident's physical, mental or psychosocial status that affects two or more areas of activities of daily living; - The resident's primary physician or designated alternate will be notified immediately of any change in resident's physical or medical conditions, this includes: accident involving the resident, deterioration in health, mental, or psychosocial status, need to alter treatment (i.e. need to discontinue an existing form of treatment due to adverse consequences or to commence new form of treatment); - The resident's designated medical contact or guardian will also be notified; - Notification of physician and/or responsible parties shall be documented in the clinical record as well as on the 24 hour report form. Status changes, which are not significant enough to be reported, must also be documented in the medical record; - All changes of condition must be completely and objectively documented in the clinical chart; - It is the responsibility of the nursing staff to inform the resident's medical contact of any change of condition. Appropriate follow through from shift to shift is imperative for all residents with any change in condition. The nursing staff must utilize the tools provided for formal communication from shift to shift. 2. Record review of Resident #14's Physician's Order Sheet (POS), dated 3/1/21 through 3/31/21, showed: - admitted on [DATE]; - The resident has a responsible party assigned; - Diagnoses of metabolic encephalopathy (a chemical imbalance that affects the brain), diabetes mellitus (disease in which your blood glucose, or blood sugar, levels are too high), cellulitis of left lower limb (a serious bacterial skin infection), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), and polyosteoarthritis (five or more joints are affected with joint pain); - An order, dated 2/22/21, for wound care to evaluate and treat; - An order, dated 3/15/21, for wound care to left buttock, cleanse with wound cleanser pat dry, apply collagen (structural protein for healing) cut to fit, use skin prep around peri wound bordered dressing daily and as needed; - An order, dated 3/15/21, for wound care to right buttock, cleanse with wound cleanser pat dry, apply collagen cut to fit, use skin prep around peri wound bordered dressing daily and as needed. Record review of the resident's MDS (Minimum Data Set, a federally mandated assessment instrument completed by the facility), showed on the quarterly MDS, dated [DATE], the resident required assistance of one person for transfer. On the significant change MDS, 12/23/20, the resident required an increase to two staff for assistance transferring. Record review of the comprehensive care plan, revised 12/30/20, showed resident requires a mechanical lift (a device used to lift a person out of bed or chair) for transfer. Record review of Resident #14's medical record showed no documentation of notification to the family of the resident's change in condition with his/her skin or the increased need for transfer assistance. During an interview on 3/23/21 at 3:45 P.M., the resident's responsible party said he/she was not notified that there had been a change of condition regarding the need to use a mechanical lift or that wounds had developed. 3. Closed record review of Resident #259's admission MDS, dated [DATE], showed: - admission diagnoses of fractures and other multiple trauma (hip fracture and other fracture), diabetes mellitus (high blood sugar), Alzheimer's disease (a progressive disorder that causes brain cells to waste away); - The resident had two unstageable deep tissue injuries (deep bruising which could develop into a pressure ulcer). Record review of the resident's closed medical record showed: - The resident had a responsible party; - On 4/21/20, stage I ulcer (superficial reddening of the skin) to coccyx (small triangular bone at the base of the spinal column). Hydrogel (have a marked cooling and soothing effect on the skin) with dressing applied; - On 5/4/20, the wound company's assessment of the resident showed pressure ulcer of right buttock, stage III (a deep crater with or without undermining of adjacent tissue) and local infection of the skin and subcutaneous (situated under the skin) tissue; - No documentation of notification to the family of the resident's change in condition with his/her skin or of an infection. During an interview on 4/1/21 at 11:30 A.M., the resident representative said they were not aware Resident #259 had any skin wounds. When they called the facility to see how Resident #259 was doing, the facility said the resident was in good spirits. The facility did not communicate that the resident had an infection. The resident was admitted to the hospital on [DATE] for fever and weakness. The hospital said the resident had sepsis (a life-threatening complication of an infection) and he/she passed away a few days later. 4. During an interview on 3/17/21 at 12:23 P.M., Licensed Practical Nurse (LPN) O said if a resident has a change in condition he/she would do an assessment of the resident, notify the physician and the family. If he/she can not reach the family then a message would be left for the family. He/she would pass it on to the next shift to try to contact the family. During an interview on 3/24/21 at 4:05 P.M., the Administrator said she would certainly expect the responsible party to be notified when there is a change of condition in the resident. Compliant #MO00169902

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure three residents (Residents #12, #14, and #39) out of 15 sampled residents were free from physical restraints. The facility's census was 59. 1. Record review of the facility's undated policy titled, Restraint Alternative Interventions, showed for behavior of sliding out of or leaning out of chair: - Physical Therapy/Occupational Therapy seating or wheelchair evaluation; - Specialized seat cushion; - Adjust wheelchair back and seat to create a tiltback and wedge; - Create a nonslip seat surface; - Wedge cushion; - High back chair; - Recliner; - Solid seat insert; - Formed foam pads; - Lap board; - Over bed table; - Seat belt resident is able to remove; - Position-change alarm. Record review of the facility's policy titled, Obtaining and Following Physician Orders, dated July 2014, showed physician orders will be obtained by licensed personnel and followed. 2. Observations of Resident #12 showed: - On 3/19/21 at 10:46 A.M., the resident sat in a recliner in his/her room and a pommel (a cushion with a padded horn in the center to prevent a person from sliding out of a chair or wheelchair) cushion sat in place in his/her wheelchair; - On 3/19/21 at 11:36 A.M. the resident sat in the dining room in his/her wheelchair with a pommel cushion in place; - On 3/23/21 at 11:18 A.M., the resident sat in the hallway in his/her wheelchair with a pommel cushion in place; - On 3/24/21 at 9:19 A.M., the resident sat in his/her wheelchair with a pommel cushion in place while being wheeled down the hall by staff. Record review of Resident #12's Physician's Order Sheet (POS), dated 3/1/21 through 3/31/21, showed no order for pommel cushion. Record review of Resident #12's Occupational Therapy Discharge summary, dated [DATE], showed: - Functional abilities progressed as a result of skilled interventions; - The resident is able to sit up in wheelchair approximately two hours without episodes of falling out of chair; - The resident is able to maintain upright sitting posture while in wheelchair; - The patient uses wheelchair as primary mode of functional mobility within facility; - No documentation of a pommel cushion. Record Review of the resident's Physical Therapy Discharge summary, dated [DATE], showed: - Due to decreased cognition and consultation with nursing staff, Resident #12 can no longer use a merrywalker (an enclosed wheeled walker) as it would be considered a restraint at this time; - The resident is able to self propel in a wheelchair throughout facility; - No documentation regarding the use of a pommel cushion. Record review of the resident's care plan, last reviewed 3/17/21, showed: - On 2/24/21, resident propelling self in wheelchair with supervision; - On 3/17/21, resident moved from merrywalker to wheelchair after being evaluated by therapy, as it is least restrictive device. - No documentation of a pommel cushion. During an interview on 3/19/21 at 10:30 A.M., Restorative Nursing Assistant (RNA) E said: - Resident #12 previously used a merrywalker, but it had been discontinued; - The resident has been using the wheelchair with a pommel cushion for about a month; - The resident can't get up from the wheelchair with the pommel cushion in place; - The resident does not like the pommel cushion and tries to pull it out, but can't remove the cushion; - One of the nurses instructed RNA E to start using the pommel cushion with Resident #12; - RNA E could not remember the nurse's name. During an interview on 3/19/21 at 11:05 A.M., Physical Therapist (PT) C said: - Resident #12 could walk safely with the merrywalker, but could no longer release the handle and get out of it by himself/herself anymore; - Therapy recommended discontinuing the merrywalker and using a wheelchair; - The therapy department did not recommend the pommel cushion and didn't know it was in use. 3. Observations of Resident #14 showed: - On 3/18/21 at 9:46 A.M., the wheelchair at the resident's bedside with a pommel cushion; - On 3/24/21 at 8:35 A.M., resident sat in a tilted wheelchair with a pommel cushion. Record review of Resident #14's POS, dated 3/1/21 through 3/31/21, showed no order for pommel cushion. Record review showed: - The comprehensive care plan, last updated 1/14/21, did not address the use for a pommel cushion; - The Occupational Therapy (OT) discharge note, dated 10/7/20, showed recommendation for sit to stand transfers, standard wheelchair preferably with drop seat; regular cushion with dycem (anti-slip fabric); - The Physical Therapy Aide (PTA) note, dated 1/8/21 at 11:41 A.M., showed: Resident assessed for wheelchair positioning. Extending leg rests placed on wheelchair for improved lower extremity (LE) support. Dycem placed in wheelchair seat to prevent sliding and maintenance request to drop rear axle of wheelchair to decrease risk of sliding forward and improve seated posture to improve with activities of daily living (ADL's) and increase participation in facility activities; - No notes related to restorative care provided on the treatment administration record (TAR) and no notes in the electronic record for the use of a pommel cushion. During interviews on 3/24/21: - At 8:40 A.M., Certified Nurse Assistant (CNA) Y and CNA Z said the cushion has been in use for a long time, it is always there; - At 9:14 A.M., PT C said the resident is not on their caseload and he/she does not recommend a pommel cushion; - At 10:20 A.M., RNA D said the resident has had the pommel cushion about three months and they don't involve therapy, the charge nurse told him/her to do it but he/she doesn't remember what charge nurse told him/her. It is there because the resident slides in his/her chair. RNA D range of motion (ROM) to lower extremities and bed mobility three times a week. The RNA does not make notes, but puts it in matrix if he/she can get in the computer. 4. Observations of Resident #39 showed: - On 3/16/21 at 3:00 P.M., the resident sat in a wheelchair with a pommel cushion; - On 3/19/21 at 9:19 A.M., the resident sat on his/her bed next to his/her wheelchair with a pommel cushion in the wheelchair. Record review of Resident #39's POS, dated 3/1/21 through 3/31/21, showed no order for pommel cushion. Record review of the resident's Therapy Screening Form, dated 3/2/21, showed: - Wheelchair positioning issues; - Recommend different wheelchair with chair to floor height of 17 inches so feet will touch floor. Brakes not locking efficiently in current wheelchair. Recommend cushion with back strap to prevent forward sliding in chair. Spoke with RNA D for such recommendations and/or facility with need to purchase appropriate wheelchair for resident. Record review of the resident's care plan, last reviewed 3/17/21, showed: - On 3/10/21, have therapy evaluate for more appropriate wheelchair for resident as some falls related to resident reaching for items from floor, and wheelchair may be too tall; - On 3/12/21, provide resident with 18 inch tall wheelchair per therapy suggestion. Pommel cushion in wheelchair for resident safety to aide in preventing him/her from sliding out of wheelchair. (Causes wheelchair to be too tall and resident's feet don't touch floor); - On 3/15/21, wheelchair changed to be less than 18 inches tall to accommodate pommel cushion. During an interview on 3/18/21 at 11:04 A.M., Physical Therapy Assistant (PTA) B said the therapy department did a screening for the resident and recommended a wheelchair that would allow the resident's feet to reach the floor and a cushion with a back strap to prevent him/her from sliding out of it. The therapist did not recommend the pommel cushion. PTA B thought maybe that was a nursing judgment. During an interview on 3/19/21 at 9:19 A.M., Certified Nursing Assistant (CNA) A said the resident always uses the cushion in his/her wheelchair to keep from sliding out. 5. During an interview on 3/24/21 at 4:05 P.M., the Administrator she didn't know what a pommel cushion was and the Director of Nursing (DON) said she feels that a pommel cushion is a restraint. The DON said it should be care planned and would expect there to be a physician's order if a pommel cushion is used.

Based on interview and record review, the facility failed to report an allegation of resident to resident abuse to the state licensing agency as required for one resident (Resident #57) out of three sampled closed records. The facility's census was 59. Record review of the facility's policy titled, Abuse Prevention Program, dated December 16, 2016, showed: - Employees are required to report any incident, allegation, or suspicion of potential abuse, neglect, or misappropriation of property they observe, hear about, or suspect immediately to the administrator. Such reports may be made without fear of retaliation. Anonymous reports will also be thoroughly investigated; - Supervisors shall immediately inform the administrator of all reports of incidents, allegations, or suspicion of potential abuse, neglect, or misappropriation of property. Upon learning of the report, the administrator shall initiate an incident investigation; - The nursing staff is additionally responsible for reporting on facility incident report the appearance of suspicious bruises, lacerations, or other abnormalities as they occur. Upon report of such occurrences, the nursing supervisor is responsible for assessing the resident, reviewing documentation, and reporting to the administrator. If the resident complains of physical injuries, or if resident harm is suspected, the resident's physician will be contacted for further instructions; - Residents who allegedly mistreated another resident will be removed from the situation and will have limited contact with the targeted individual during the course of the investigation. The accused resident's condition shall be immediately evaluated to determine most suitable therapy, care approaches, and placement, considering his/her safety, as well as the safety of other residents and employees of the facility; - In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment are reported immediately, but not later than two hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures; - The allegation shall either be called or faxed in to the regional Public Health Office. Public health shall be informed that an occurrence of potential mistreatment has been reported and is being investigated and the report shall contain the following information: name, age, diagnosis, and mental status of the resident allegedly abused or neglected, type of abuse reported (physical, sexual, misappropriation, neglect, verbal or mental abuse), date, time, location, and circumstances of the alleged incident, any obvious injuries or complaints of injury, and steps the facility has taken to protect the resident; - Within five working days after the report of the occurrence, a complete written report of the conclusion of the investigation, including steps the facility has taken in response to the allegation, will be sent to the Department of Public Health. Record review of Resident #57's progress notes, dated 2/22/21 at 5:40 A.M., showed Certified Nurse Aide (CNA) reported to nurse that something is wrong with resident. Nurse in to assess and noted resident lying in bed holding back of head, crying, and saying hurt over and over. Noted to have a black eye on the left side and a knot on the back of his/her head. It is reported that resident went to another resident's room and got hit in the side of the head with a plastic stick used for grabbing items. Resident unable to stand or walk and baseline is independently ambulates/wanders through halls. Family notified of condition and in agreement of resident being sent to hospital. Physician notified via fax. The facility could not provide an investigation into Resident #57's injuries or the allegation that another resident struck Resident #57 in the head. During an interview on 3/24/21 at 4:05 P.M., the Administrator (ADM) said she would expect an allegation of resident to resident abuse to be reported to her and she would report it to the state agency. If it is a substantial injury, the abuse should be reported within 24 hours, for sure within five days. The Administrator said the Director of Nursing (DON) found the notes and brought them to her. The ADM told the DON to find out what happened. The ADM and DON talked to the resident and a couple of aides, but no one could verify that it happened so the time frame for reporting had passed. The ADM said she should have done a report even though it was out of the time frame. The ADM said staff got a list of the CNAs and spoke with them, who all said they reported it to the charge nurse. The charge nurse said it had not been reported. There is no way to know what really happened. The Administrator said she would expect a thorough investigation to be completed and corrective actions to be taken after an allegation of resident to resident abuse. During an interview on 3/24/21 at 4:05 P.M., the DON said they talked to two CNAs, but there was nothing documented, it was just internal. The aides saw it and reported it to the charge nurse and certified medication technician (CMT). The charge nurse said it was not reported to him/her and the CMT swears they did not say anything to him/her. The two are denying it as much as the other two are saying it happened. The charge nurse quit without notice. There was no formal investigation of the injuries or the allegation and nothing was reported to the appropriate entities.

Based on interview and record review, the facility failed to thoroughly investigate an allegation of resident to resident abuse for one resident (Resident #57) out of three closed records. The facility's census was 59. 1. Record review of the facility's policy titled, Abuse Prevention Program, dated December 16, 2016, showed: - Employees are required to report any incident, allegation, or suspicion of potential abuse, neglect, or misappropriation of property they observe, hear about, or suspect immediately to the administrator. Such reports may be made without fear of retaliation. Anonymous reports will also be thoroughly investigated; - Supervisors shall immediately inform the administrator of all reports of incidents, allegations, or suspicion of potential abuse, neglect, or misappropriation of property. Upon learning of the report, the administrator shall initiate an incident investigation; - The nursing staff is additionally responsible for reporting on facility incident report the appearance of suspicious bruises, lacerations, or other abnormalities as they occur. Upon report of such occurrences, the nursing supervisor is responsible for assessing the resident, reviewing documentation, and reporting to the administrator. If the resident complains of physical injuries, or if resident harm is suspected, the resident's physician will be contacted for further instructions; - Residents who allegedly mistreated another resident will be removed from the situation and will have limited contact with the targeted individual during the course of the investigation. The accused resident's condition shall be immediately evaluated to determine most suitable therapy, care approaches, and placement, considering his/her safety, as well as the safety of other residents and employees of the facility; - In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment are reported immediately, but not later than two hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures; - The allegation shall either be called or faxed in to the regional Public Health Office. Public health shall be informed that an occurrence of potential mistreatment has been reported and is being investigated and the report shall contain the following information: name, age, diagnosis, and mental status of the resident allegedly abused or neglected, type of abuse reported (physical, sexual, misappropriation, neglect, verbal or mental abuse), date, time, location, and circumstances of the alleged incident, any obvious injuries or complaints of injury, and steps the facility has taken to protect the resident; - Within five working days after the report of the occurrence, a complete written report of the conclusion of the investigation, including steps the facility has taken in response to the allegation, will be sent to the Department of Public Health. 2. Record review of Resident #57's progress notes, dated 2/22/21, showed Certified Nurse Aide (CNA) reported to nurse that something is wrong with resident. Nurse in to assess and noted resident lying in bed holding back of head, crying, and saying hurt over and over. Noted to have a black eye on the left side and a knot on the back of his/her head. It is reported that resident went to another resident's room and got hit in the side of the head with a plastic stick used for grabbing items. Resident unable to stand or walk and baseline is independently ambulates/wanders through halls. Family notified of condition and in agreement of resident being sent to hospital. Physician notified via fax. Record review of the facility's untitled document, written by the Social Service Director (SSD), dated 2/22/21, showed unnamed CNAs reported Resident #57 had walked into another resident's room and that resident hit Resident #57 with a plastic stick, telling him/her to get out. The CNAs redirected Resident #57 out of the other resident's room. The SSD went to the other resident's room. The other resident said Resident #57 came in my room and would not leave even after being told to get out. This resident denied hitting Resident #57 or even getting out of his/her chair. Resident #57 just stayed in the doorway when a resident across the hall went and got the CNAs. The resident repeated he/she did not hit Resident #57. The facility could not provide any other investigation into the incident allegedly witnessed by two unnamed CNAs, any investigation into the correlation of Resident #57 being struck and the black eye or knot on the back of the head and no evidence the report had been reported to the appropriate entities. Record review of the facility's inservice training for employees showed no abuse training since 12/2/20. During an interview on 3/24/21 at 4:05 P.M., the Administrator said she would expect an allegation of resident to resident abuse to be reported to her and she would report it to the state agency. The Administrator said she would expect a thorough investigation to be completed and corrective actions to be taken after an allegation of resident to resident abuse. The Administrator said she directed the SSD to go and speak with the aggressive resident about the allegation, but that was all of an investigation that occurred. During an interview on 3/24/21 at 4:05 P.M., the Director of Nursing (DON) said they talked to two CNAs, but there was nothing documented, it was just internal.

Based on interview and closed record review, the facility failed to complete a comprehensive discharge summary for one resident (Resident #59) out of two sampled discharged residents. The facility's census was 59. Record review of Resident #59's closed medical record showed: - Resident admitted to the facility 12/24/20 after a fall; - Diagnoses of unspecified fracture of lumbar vertebrae, (fracture of the lower back) fibromyalgia (widespread musculoskeletal pain accompanied by fatigue, memory, sleep and mood issues), Rheumatoid arthritis, (a chronic inflammatory disorder affecting many joints), need for assistance with personal care, difficulty in walking, unspecified lack of coordination, and repeated falls; - Resident discharged to another skilled nursing facility on 12/31/20. The staff did not complete a comprehensive discharge summary to include a final summary of the resident's status at the time of discharge and a post discharge plan to include current medical diagnoses, ability to perform activities of daily living (ADLs) and staff assistance needed, pain management, need for rehabilitation, Physical and Occupational therapy, and special treatments or procedures. During an interview on 3/23/21 at 2:30 P.M., Licensed Practical Nurse (LPN) W said they do not normally do a discharge summary and if the facility does, he/she had never seen it. During an interview on 3/24/21 at 4:05 P.M., the Director of Nursing (DON) said she would expect a discharge summary and plan to be completed on a resident being discharged . Record review of the facility's policy titled, Discharge Summary and Plan, dated July 2014, showed when a resident is discharged to another nursing facility, a discharge summary and a post discharge plan will be developed. The discharge summary will include a recapitulation of the resident's stay at the facility and a final summary of the resident's status at the time of discharge.

Based on observation, interview, and record review, the facility failed to follow restorative care and wound care orders for one resident (Resident #14) out of 15 sampled residents. The facility's census was 59. 1. Record review of Resident #14's Physician's Order Sheet (POS), dated 3/1/21 through 3/31/21, showed: - An order, dated 1/11/21, for Restorative Nurse Aide (RNA) for range of motion (ROM) to upper and lower extremities, bed mobility and positioning three times a week as tolerated; - An order, dated 2/22/21, for wound care to evaluate and treat; - An order, dated 3/15/21, for daily wound care to left buttock, cleanse wound with cleanser, pat dry. Apply collagen (structural protein to help with healing) cut to fit, use skin prep (a protective film) around peri wound bordered dressing daily and as needed; - An order, dated 3/15/21, for daily wound care to right buttock, cleanse wound with cleanser, pat dry. apply collagen cut to fit, use skin prep around peri wound bordered dressing daily and as needed. Record review on 3/19/21 of the resident's therapy notes, treatment administration record (TAR), and nurse progress notes showed: - No documentation of restorative care; - No documentation of wound care since order on 3/15/21. During an interview on 3/24/21 at 10:20 A.M., Restorative Nurse Aid (RNA) D said he/she does range of motion (ROM) to lower extremities and bed mobility three times a week. He/she does not make notes, he/she puts it in the electronic record if he/she can get in the computer. They don't have internet a lot of the time. If the internet is not working they do not chart. Either he/she or a Certified Nurse Assistant (CNA) can chart the process, it doesn't matter who does it. Record review of the resident's wound care company note, dated 3/22/21, showed: - Recommendations are: Wound #2 (right buttock) Cleanse wound with cleanser of facility choice. Use to irrigate or scrub the wound bed (mechanical debride). Protect per-wound with skin protectant, do not put on open area. Apply collagen pad (103 sq cm or less). Moisten if wound drainage is none or scant (full thickness wounds.) Cover with bordered gauze (103 sq cm or less). Change dressing daily and as needed for soiling, saturation, or unscheduled removal. Plan discussed with facility staff; - Wound #3 Cleanse wound #3 (left buttock) with cleanser of facility choice. Use to irrigate or scrub the wound bed (mechanical debride). Protect per-wound with skin protectant, do not put on open area. Apply collagen (a dressing used to stimulate new tissue growth) pad (103 sq cm or less). Moisten if wound drainage is none or scant (full thickness wounds.) Cover with bordered gauze (103 sq cm or less). Change dressing daily and as needed for soiling, saturation, or unscheduled removal. Plan discussed with facility staff; -HIGH RISK: Patient has multiple wounds elevating risk for more wound development/infections/risk to life/limb. Patient has many co-morbid conditions (more than two) and polypharmacy delaying wound healing, patient has a history of delayed wound healing, patient is no able to or does not comply with best practice standards for wound healing. Observations of the resident showed: - On 3/18/21 at 11:49 A.M., the left and right buttock without a dressing and covered with white ointment; - Resident reluctant to allow Registered Nurse (RN) X to see wound due to pain; - Upon inspection, RN X said it appears wound is healed. RN X touched the wound using wound cleanser on a 4x4 gauze pad four times; - On 3/23/21 at 10:30 A.M., resident lying in bed, Certified Nurse Assistant (CNA) A and Nurse Assistant (NA) L turned the resident to expose his/her left and right buttock, the area without a dressing and covered with white ointment, multiple areas of raw skin that were bright red, some bleeding; - On 3/29/21 at 9:26 A.M., the left and right buttock without a dressing and covered with white ointment. During interviews: - On 3/19/21 at 9:00 A.M., the Assistant Director of Nursing (ADON) said the order for resident's wound care is accurate, it was received on 3/15/21 and should be followed; - On 3/19/21 at 9:26 A.M., NA L said he/she has worked all week and the resident had a dressing on his/her bottom on Monday, but none since then. He/she has been putting phytoplex protectant cream (moisture barrier cream) on it, but nothing else; - On 3/19/21 at 9:56 A.M., the ADON said she is aware that the resident has a wound but is not aware that the orders are not being followed. While reviewing the record, the ADON said the wound company put an order in place on 3/15/21 when they saw the resident, it was entered on 3/17/21. It was discontinued on 3/18/21 because the wound was healed according to the nurse on the floor. There is no documentation of communication with the wound company or the physician for an order change and/or status update. It is not typical for the facility to change an order without talking with the wound care nurse or the physician; - On 3/19/21 at 10:34 A,M., the DON said she did the wound care on 3/17/21 and she normally documents when she does it but she didn't document it this time. She would be the one who would change orders if they need changed and since they were not doing the dressing like the orders said, she discontinued the order on 3/18/21; - On 3/19/21 at 10:56 A.M., the wound care company representative said the company's services are under the approval of the resident's Primary Care Physician (PCP). The company staff make recommendations and approved by the PCP. The facility cannot discontinue our orders without our approval and/or that of the of the resident's PCP. When an order starts, it stands for two weeks. The company rep said he/she did not see how the wound on this resident would heal in three days. The resident will be seen on 3/22/21, at a minimum we would expect the wound to be covered. As noted on the assessment, this resident is at high risk for wound development and healing. The facility should call a company rep or the resident's PCP for any new orders. At a minimum, the facility should notify the company that the wound has been healed; - On 3/19/21 at 1:36 P.M., the Licensed Practical Nurse (LPN) with the resident's PCP office, said the PCP has not received any information or requests for wound care orders in March. He/she did a telehealth visit with the resident on 3/4/21 and there was no mention of a wound. He/she has not approved any orders nor has he/she discontinued any orders from the facility related to wound care; - On 3/23/21 10:43 A.M., the wound care company representative said their provider did see the resident 3/22/21 and made recommendations. The provider entered the recommendations into the portal and it is up to the facility to retrieve the recommendations and send them to the resident's PCP for approval or denial; - On 3/23/21 at 2:51 P.M., the DON said the wound company does an evaluation and makes recommendations. The facility staff implement the recommendations. When the resident's physician makes rounds he/she signs the orders. There is usually an order to consult and treat wound care. No residents receive weekly skin assessments, their skin is assessed on the shower sheets. Record review of the facility's policy titled, Weekly Skin Assessment, dated August 2014, showed: - The facility requires centers to complete a weekly skin assessment. This assessment includes a head to toe visualization of the resident's skin; - Complete the weekly skin assessment weekly according to the treatment administration record; - Document the weekly skin assessment by (-) for no area(s) of impairment (+) for area(s) of impairment; - Document location, type and size of skin impairment using the left column box of the treatment administration record; - Monitor area(s) of skin impairment daily until healed using the TAR; - Place a triangle on the date a dressing change was completed using the TAR; - Monitor the area(s) of skin impairment weekly using the skin grid - pressure/venous insufficiency ulcer/other for area(s) including, but not limited to: Pressure ulcer, venous insufficiency ulcer, skin tear, other-significant area(s) of skin impairment e.g., surgical wound dehiscence; - Document significant change in the nursing progress note, note healed on the TAR; - Obtain physician's order for treatment protocol; - Communicate intervention to staff using skin integrity assessment prevention and treatment plan of care, care delivery guide/nursing assistant assignment sheet; - Implement physician's order for treatment protocol; - Notify the responsible party and document the notification. Record review of the facility's policy titled, Restorative Nursing, dated July 2014, showed: - It is the policy of the facility to provide restorative nursing which promotes the resident's ability to live as independently and safely as possible; - Every resident who receives restorative nursing has a care plan with individualized, measurable goals and interventions; - Restorative treatments are recorded on the Restorative Nursing Participation Daily Record.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide a complete assessment after a fall with injury for one resident (Resident #57) out of three sampled closed records. The facility's census was 59. Record review of the facility's policy titled, Falls Management, dated July 2017, showed: - A Fall Risk Assessment will be completed on all residents upon admission, re-admission, after each fall and quarterly thereafter; - If a falls is unwitnessed or resident has evidence of head injury, complete neurological assessment per protocol; - Pain assessment will be completed after each fall. Record review of Resident #57's Physician's Order Sheet (POS), dated 3/1/21 through 3/19/21, showed: - admitted on [DATE]; - Diagnoses of unspecified dementia (loss of cognitive ability) with behavioral disturbance, major depressive disorder, bipolar disorder (a mental disorder with periods of elevated moods and depression), restlessness and agitation, and Alzheimer's disease (a brain disease that causes memory loss). Record review of Resident #57's quarterly Minimum Data Set (MDS; a federally mandated assessment instrument completed by the facility), dated 11/27/20, showed: - Severely impaired cognitive skills for daily decision making; - Wandering behaviors daily. - Two or more falls with no injury; - One fall with injury (except major). Record review of Resident #57's care plan, last reviewed 3/19/21, showed: - Category: Falls. Problem start date 8/30/19 with long term goal target date 6/5/21: Resident at risk for falling related to cognitive decline, gait, and his/her choice to ambulate frequently about the facility. Observe frequently when out of bed; - Category: Falls. Problem start date 2/16/21 with long term goal target date 5/19/21: Witnessed by staff falling out of chair, causing hematoma (an injury to the wall of a blood vessel, prompting blood to seep out of the blood vessel into the surrounding tissues. A hematoma can result from an injury to any type of blood vessel) to left forehead. Neurological (neuro; assessment of the nervous system) checks per orders. Record review of Resident #57's progress notes showed: - On 2/16/21 at 11:19 A.M., resident seen by housekeeping staff fall out of highback chair onto floor; - Resident resting on floor with pillow under his/her head; - Hematoma to left forehead; - Physician faxed with update and resident's family member called with update; - Resident will be monitored and neuro checks will be done. Record review of Resident #57's Fall Risk Assessments showed: - On 8/18/19, Fall Risk Assessment total fall risk score of 20 (level: high fall risk); - On 6/12/20, Fall Risk Assessment total fall risk score of 22 (level: high fall risk); - No additional Fall Risk Assessment completed following fall on 2/16/21. The resident's medical record did not contain documentation of pain assessments for the resident. Record review of Resident #57's medical record showed: - On 2/16/21 at 11:21 A.M., neuro assessment form titled Neuro Assessment section number One left blank and not completed; - No additional neurological assessments completed after the fall on 2/16/21. During an interview on 3/23/21 at 11:43 A.M., Licensed Practical Nurse (LPN) O said he/she the resident had been sleeping in a chair, then leaned over to reach for something in the floor and fell out of the chair. When LPN O came in the room, the resident was laying with his/her head near the foot of the bed and someone had put a pillow under his/her head. LPN O said the neuro checks should have been done on his/her shift, but he/she doesn't remember if it was completed. It should be in the system if it was done. The neuro checks are a running report and are passed on to the next shift. During an interview on 3/24/21 at 4:05 P.M., the Administrator said she would expect a resident who is at risk for falls to have a comprehensive care plan for falls and neuro checks/assessments completed.

Based on observation, interview, and record review, the facility failed to ensure residents diagnosed with dementia (a decline in memory or other thinking shills severe enough to reduce a person's ability to perform everyday activities) had a personalized plan of care to ensure services to promote the resident's highest level of functioning and psychosocial needs for one resident (Resident #6) out of 15 sampled residents. The facility's census was 59. Record review of Resident #6's quarterly Minimum Data Set (MDS; a federally mandated assessment instrument completed by the facility staff), dated 3/8/21, showed: - Diagnosis of dementia; - Brief Interview for Mental Status (BIMS; a short performance-based cognitive screener for nursing home (NH) residents) score of 15 out of 15 (no cognitive impairment). Record review of the resident's Physician's Order Sheet (POS), dated 3/1/21 through 3/31/21, showed diagnosis of dementia without behavioral disturbances. Record review of the resident's care plan, last reviewed 3/13/21, showed the care plan did not address dementia care. Record review of the facility's policy titled, Baseline Plan of Care, dated August, 2017 showed the comprehensive person-centered care plan for each resident must be consistent with the resident rights and include measurable objectives and timeframes to meet a resident medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the attending physician reviewed the Consultant Pharmacist's Gradual Dose Reduction (GDR) recommendations and document the action taken to address the GDR for three residents (Residents #12, #19 and #43) out of 15 sampled residents. The facility's census was 59. 1. Record review of the facility's policy titled, Drug Regimen Review, dated October 2017, showed: - The pharmacist will document any irregularities noted during the drug regimen review (DRR) to be sent to the attending physician, medical director, and director of nursing (DON); - The attending physician must respond to DRR recommendations in a timely manner; - Timely is defined within 30 days of the date of the DRR; - Requires the attending physician document in the patients' medical records that the identified irregularity has been reviewed and what, if any, action has been taken. Irregularities include unnecessary drugs. 2. Record review of Resident #12's Consultant Pharmacist Recommendation to Physician, dated 6/26/20, showed: - A recommendation for a trial reduction for quetiapine (an antipsychotic medication) from 12.5 milligrams (mg) twice daily to 12.5 mg once daily at bedtime if clinically appropriate; - No documentation by the attending physician of the rationale as to why the GDR was not attempted. The physician had not signed the recommendation. During an interview on 03/23/21 at 10:15 A.M., the Licensed Practical Nurse (LPN) with the resident's physician office said they never received any recommendations and there are no requests in his office chart. The physician has instructed the facility to make all recommendations available to him/her when rounds are made so that he/she can address them at that time. The facility has not provided the documents to the physician in the past and he/she has addressed with the facility. Record review of the resident's Physician's Order Sheet (POS), dated 3/1/21 through 3/31/21, showed: - Diagnoses of unspecified dementia (loss of cognitive ability) with behavioral disturbance and delusional disorders; - An order, dated 8/7/20, for Seroquel (quetiapine) 25 mg, amount: 1/2 tablet, oral. Special Instructions: give half tablet by mouth three times a day (TID), first of three daily 6:00 A.M. to 10:30 A.M., second of three daily 3:00 P.M. to 5:00 P.M., third of three daily 6:00 P.M. to 10:00 P.M. During an interview on 3/23/21 at 2:39 P.M., the resident's attending physician's office said the physician normally addresses the GDR recommendations when he/she makes his/her monthly rounds, but he/she does not show a record of having received any recommendations from June 2020 to the present. The facility has not provided the documents to the physician in the past and he/she has addressed with the facility 3. Record review of Resident #19's Consultant Pharmacist Recommendation to Physician, dated 12/18/20, showed: - For nursing: Please clarify (with physician if necessary) the diagnosis for which the medication quetiapine is being prescribed; insomnia, unspecified is not a supported use for this medication. Suggest either major depressive D/O or unspecified dementia w/behavioral disturbance. Please add the diagnosis to the POS and Medication Administration Record (MAR). - For physician: In accordance with federal guidelines, it's time to assess if there is a potential for gradual dose reduction of any or all of the following psychotropic medications if clinically appropriate: - Oxcarbazepine (anticonvulsant) 75 mg TID; consider a trial reduction to 75 mg twice a day (BID); - Fluoxetine (antidepressant) 20 mg every morning (QAM); consider a trial reduction to 10 mg QAM. - Quetiapine (antipsychotic)100 mg every night (QHS); consider a trial reduction to 75 mg QHS. - No documentation by the attending physician of the rationale as to why the GDR was not attempted. The documentation did not contain the attending physician's signature to verify the physician had reviewed the document. Record review of the resident's POS, dated 3/1/21 through 3/31/21, showed: - No reduction to Oxcarbazepine, Fluoxetine or Quetiapine; - No response from physician documented. Record review of the resident's nurse progress notes showed no notes related to the GDR. During an interview on 3/22/21 at 8:45 A.M., the LPN with the resident's physician's office, said they did not receive any pharmacy recommendations on 12/18/20 or any other time. The doctor is very good about responding and would have taken care of that. The facility has not provided the documents to the physician in the past and he/she has addressed with the facility. 4. Record review of Resident #43's Consultant Pharmacist Recommendation to Physician showed: - On 7/23/20, Duloxetine (antidepressant) GDR suggested; - On 12/18/20, For physician: Alternate day dosing of iron supplements has been shown to result in greater absorption ([NAME] 2019; [NAME] et al 2020). Please consider changing resident's ferrous sulfate to every other day administration; - No documentation by the attending physician of the rationale as to why the GDR was not attempted. The documentation did not contain the attending physician's signature to verify the physician had reviewed the document. Record review of the resident's nurse progress notes showed no notes related to the GDR. During an interview on 3/18/21 at 2:30 P.M., the Director of Nurses (DON) said the doctor has not responded and she does not know if or when he will. 5. During an interview on 3/19/21 at 2:15 P.M., the pharmacist with the facility pharmacy said the actual monthly reviews are completed by an outsourced pharmacist. Any recommendations would be sent to them for changes. The pharmacy has not received any new orders on the residents. The pharmacist said they send the recommendations to the facility and the facility staff should make sure the physician sees the recommendations and then send the responses back to the pharmacist. Once the pharmacist receives the physician signed documentation, the pharmacist will make the adjustments as needed. 6. During an interview on 3/24/21 at 4:05 P.M., the DON said she would expect pharmacy recommendations to be communicated to the physician. She receives the recommendations via email, they are printed and taken to medical records to be faxed to the physician and she holds them until they are addressed. She has them to the doctors within 48 hours and if she doesn't get a response, she puts them with the POS to be addressed during their monthly rounds.

Based on interview and record review, the facility failed to ensure the resident's attending physician reviewed the pharmacist's recommendations and documented a rationale for continued use of an as needed (PRN) psychotropic medication ordered for longer than 14 days for one resident (Resident #12) out of 15 sampled residents. The facility's census was 59. Record review of the facility's policy titled, Antipsychotic Medication Use, dated October 2017, showed: - Residents do not receive psychotropic drugs pursuant to a PRN order unless that medication is necessary to treat a diagnosed specific condition that is documented in the clinical record; - PRN orders for psychotropic drugs are limited to 14 days. If the attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days, he or she should document their rationale in the resident's medical record and indicate the duration for the PRN order. Record review of the facility's policy titled, Drug Regimen Review, dated October 2017, showed: - The pharmacist will document any irregularities noted during the drug regimen review (DRR) to be sent to the attending physician, medical director, and director of nursing (DON); - The attending physician must respond to DRR recommendations in a timely manner; - Timely is defined within 30 days of the date of the DRR; - Requires the attending physician document in the patients' medical records that the identified irregularity has been reviewed and what, if any, action has been taken. Irregularities include unnecessary drugs. Record review of Resident #12's Physician's Order Sheet (POS), dated 3/1/21 through 3/31/21, showed: - Diagnoses of unspecified dementia (loss of cognitive ability) with behavioral disturbance, other mixed anxiety disorders, and restlessness and agitation; - An order, dated 6/16/19 with no end date, for lorazepam (an antianxiety medication) 0.5 milligram (mg) twice daily PRN for anxiety. Record review of the resident's Medication Administration Record (MAR) showed: - From 3/1/21 through 3/18/21, the resident received lorazepam once daily eight out of 18 days; - From 2/1/21 through 2/28/21, the resident received lorazepam once daily seven out of 28 days and twice daily one out of 28 days; - From 1/1/21 through 1/31/21, the resident received lorazepam once daily four out of 31 days; - From 12/1/20 through 12/31/20, the resident received lorazepam once daily two out of 31 days; - From 11/1/20 through 11/30/20, the resident received lorazepam once daily for four out of 30 days. Record review of the resident's Consultant Pharmacist Recommendations to Physician, showed on 6/26/20, 7/23/20, 8/21/20, 9/18/20, 10/23/20, 11/21/20, 12/18/20, and 2/15/21, the resident's PRN lorazepam must be written for a specific duration, cannot be indefinite in duration due to new Center for Medicare and Medicaid Services (CMS) regulations (they prefer a 14-day duration but may be written for longer if rationale for the longer duration is included in the medical record). During an interview on 3/23/21 at 2:39 P.M., the resident's attending physician's office nurse said the physician normally addresses the pharmacy recommendations when monthly rounds are made, and he/she does not show a record of having received any recommendations from June 2020 to the present. During an interview on 3/24/21 at 4:05 P.M., the DON said she would expect pharmacy recommendations to be communicated to the physician. She receives the recommendations via email, they are printed and taken to medical records to be faxed to the physician and she holds them until they are addressed. She has them to the doctors within 48 hours and if she doesn't get a response, she puts them with the POS to be addressed during their monthly rounds.

Based on interview and record review, the facility failed to perform periodic checks of the Employee Disqualification List (EDL, a listing maintained by the Department of Health and Senior Services (DHSS) of individuals who have been determined to have abused or neglected a resident, patient, client, or consumer or misappropriated funds or property belonging to a resident, patient, client, or consumer) for eight out of ten current employees. This deficient practice had the potential to affect all residents in the facility. The facility's census was 59. Record review of the facility's untitled policy, dated 4/26/18, for new employee hiring process showed: - EDL will be checked quarterly on all current employees and check randomly. If employee has been added to the above listed organization, their employment here will be terminated; - Each quarter each employee, contracted employee, and/or volunteer will have his or her name and Social Security number ran against a state approved EDL; - If a name or Social Security number is listed on the EDL, this person shall not work in this facility. Record review of the facility's current employee files showed the following staff had no documentation of quarterly or random EDL checks since their hire dates: - Housekeeper F with a hire date of 6/16/20; - Laundry Aide G with a hire date of 8/5/20; - Certified Nursing Assistant (CNA) H with a hire date of 10/31/20; - CNA I with a hire date of 11/6/20; - CNA J with a hire date of 7/27/20; - CNA K with a hire date of 8/20/20; - Nurse Aide (NA) L with a hire date of 9/21/20; - Housekeeper M with a hire date of 11/28/20. During an interview on 3/24/21 at 4:05 P.M., the Administrator said she would expect staff to check the EDL upon hire, quarterly, randomly and as needed for new hires and established employees.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop and implement a baseline resident care plan consistent with the resident's specific conditions, needs, and risks within 48 hours of admission nor did they ensure the resident or representative were informed of the initial plan of care for three residents (Resident #60, #159, and #209) out of 15 sampled residents and one resident (Resident #259) outside of the sample. The facility's census was 59. 1. Closed record review of Resident #60's admission diagnoses on 1/4/21 showed: - Pneumonia (infection in the lungs which inflames air sacks in one or both lungs which may fill with fluid or pus) due to methacillin-resistant staphlococcus aureus (MRSA; a bacteria which is resistant to many antibiotics); - Klebsiella pneumonia (lung infection caused by a bacteria); - Severe protein calorie malnutrition (>two of the following characteristics: Obvious significant muscle wasting, loss of subcutaneous fat, nutritional intake of <50% of recommended intake for two or more weeks, weight loss of >1% in one week, bedridden or significantly reduced functional capacity); - Chronic Obstructive Pulmonary Disease (COPD; chronic lung diseases that block airflow and make it difficult to breathe); - Dependence on supplemental oxygen; - Stage III pressure ulcer of the sacral region ( full thickness skin loss involving damage or necrosis of subcutaneous tissue that may extend down to but not through the fascia, a connective tissue that surrounds and holds bone and muscle in place); - Management of vascular access device (any device utilized for venous access regardless of location) for intravenous medications to be administered through. Record review of the resident's baseline care plan, dated 1/5/21, showed the resident at risk for pressure ulcer due to nutrition. The baseline care plan did not address oxygen needs, intravenous medication or pressure ulcer. Record review of the resident's progress notes, dated 1/4/21-1/8/21, showed the facility did not review the baseline care plan with the resident or the responsible party. 2. Record review of Resident #159's medical record showed: - admitted on [DATE] at 11:28 A.M.; - admission diagnoses to include: - Thrombocytopenia (low blood platelet count, platelets help blood clot); - Obstructive sleep apnea (a condition in which breathing stops involuntarily for brief periods of time during sleep); - History of falling; - Presence of a cardiac pacemaker (a device that signals the heart to beat properly); - Dependence on supplemental oxygen; - No baseline care plan. During an interview on 3/17/21 at 11:00 A.M. ,the MDS (Minimum Data Set; a federally mandated assessment instrument completed by the facility) Coordinator said the baseline care plan had not been done. 3. Record review of Resident #209's medical record showed: - admission date of 2/26/21; - Diagnoses to include: - Atherosclerotic heart disease (artery walls narrow or harden due to plaque build up); - Parkinson's disease (a progressive nervous system disorder that affects movement); - Chronic viral hepatitis (inflammation of the liver lasting at least 6 months); - Dysphagia (difficulty swallowing); - Resident admitted to hospice on 2/26/21; - No baseline care plan. During an interview on 3/18/21 at 10:01 A.M., the Administrator said the baseline care plan had not been done. 4. Closed record review of Resident #259's admission MDS, dated [DATE], showed: - admitted on [DATE]; - admission diagnoses to include: - Fractures and other multiple trauma (hip fracture and other fracture); - Diabetes mellitus (high blood sugar); - Alzheimer's disease (a progressive disorder that causes brain cells to waste away); - Two unstageable deep tissue injury (a deep bruised area where the tissue deteriorates and forms a pressure ulcer). Record review of the resident's baseline care plan, dated 4/14/20, did not show: - At risk for skin breakdown or any skin condition; - A signature of the resident or resident representative that the baseline care plan was reviewed. Record review of the resident's progress notes, dated 4/14/20-4/16/20, showed the facility did not review the baseline care plan with the resident or the responsible party. 5. During an interview on 3/24/21 at 4:05 P.M., the Administrator and Director of Nursing (DON) said they would expect a complete baseline care plan to be in place and the resident or responsible party to be given a copy of it within 48 hours of admission. Record review of the facility's policy titled Baseline Plan of Care, revision date August 2017, showed: - The facility will develop and implement a Baseline Plan of Care for each resident that includes the instructions needed to provide effective person-centered care of the resident that meet professional standards of quality care; - The baseline care plan will include the minimum healthcare information necessary to properly care for each resident immediately upon their admission, which would address resident-specific health and safety concerns to prevent decline or injury, such as elopement or fall risk, and will identify needs for supervision, behavioral interventions, and assistance with activities of daily living, as necessary; - The baseline plan of care will be developed within 48 hours of resident's admission and will include the minimum healthcare information necessary to properly care for the resident including, but not limited to initial goals based on admission orders, physician orders, dietary orders, therapy services, social services, PASARR recommendation, if applicable; - The facility must provide the resident and their representative with a summary of the baseline care plan, in a language and conveyed in a manner the resident and/or the representative can understand that includes but is not limited to the initial goals of the resident, a summary of the resident's medications and dietary instructions, any services and treatments to be administered by the facility and personnel acting on behalf of the facility, any updated information based on the details of the comprehensive care plan, as necessary, discharge plans in the comprehensive care plan as appropriate; - The medical record must contain evidence that the summary was given to the resident and resident representative, if applicable by the completion of the comprehensive care plan. The facility may choose to provide a copy of the baseline care plan itself as the summary, if it meets the requirements of the summary. Complaint #MO00169902

Based on observation, interview, and record review, the facility failed to maintain infection control practices to prevent the development and transmission of infection for two residents (Resident #4 and #14) out of 15 sampled residents and eight residents (Resident #2, #9, #13, #25, #40, #41, #47 and #54) outside of the resident sample. The facility's census was 59. Record review of the facility's policy titled, Handwashing, last revised April 2015, showed: - All staff to thoroughly cleanse hands with friction, soap and water to control infection and reduce transmission of organisms; - Hand antiseptic/sanitizer is a supplement or alternative to the use of soap and water when hands are not visibly soiled. 1. Observation of medication administration on 3/18/21 from 11:16 A.M., through 12:15 P.M., showed: - Licensed Practical Nurse (LPN) AA, with gloved hands, pushed the cart, opened drawers, documented, opened medication, adjusted Resident #54's facemask, wore soiled gloves, gave medication to Resident #25, then removed gloves; - LPN AA did not wash hands, obtained medications from cart, gave Resident #13's medication, and returned the contaminated medication cards to the cart; - LPN AA did not wash hands, obtained medications from cart, gave Resident #41's medication, and returned the contaminated medication cards to the cart, documented, and pushed the cart; - LPN AA with soiled hands, gave Resident #40's medication, and returned the contaminated medication cards to the cart. During an interview on 3/18/21 at 12:21 P.M., LPN AA said it is his/her normal practice to sanitize hands between each resident. He/She may have missed some. Sometimes he/she wears gloves. 2. Record review of the facility's policy titled, Cleaning of Durable Medical Equipment, revised 1/18/21, showed: - All durable medical equipment (including but not limited to glucometers, pulse oximeters, thermometers, etc), will be disinfected with appropriate disinfectant (Hospital Cleaner Disinfectant Towels with Bleach), between resident uses; - Gross soil must be removed prior to disinfecting; - Wipe surface with towel until completely wet; - Allow to remain wet for one minute at room temperature. To kill tuberculosis, (an infectious disease of the lungs), allow two minutes, for clostridium difficile colitis, (an inflammation of the colon that causes damage to the intestines), allow three minutes wet time. Wipe dry or allow to air dry; - Perform hand hygiene with soap and water or alcohol hand sanitizer immediately after removal of gloves and before touching medical supplies intended for use on other residents. Record review of the disinfectant wipe manufacturer's guidelines showed: - The disinfectant wipe is made of heavy-duty fabric that stands up to hard-surface scrubbing and can be used to clean and disinfect most hard, non-porous surfaces; - Recommended the surface area must remain wet with the product to achieve disinfection for a full two minutes; - The disinfectant wipe disinfects blood glucose meters, patient care equipment, point-of-care equipment and hard, non-porous healthcare surfaces such as countertops, exam tables and carts. 3. Observation of Registered Nurse (RN) X on 3/18/21 at 11:40 A.M., showed: - RN X sanitized hands and prepared the glucometer (a small portable machine used to measure the amount of sugar in the blood) with a glucometer strip (a disposable test strip used in the glucometer to calculate the blood sugar levels) ; - RN X gloved hands, entered Resident #2's room and placed the glucometer on the bedside table without preparing a clean surface; - RN X performed the blood sugar check; - RN X returned the glucometer to the top of the medication cart outside the room; - RN X did not clean the top of the medication cart before placing the glucometer on the cart; - RN X did not clean the glucometer with the wipe, wrapped a disinfectant wipe partially around the glucometer, placed it on top of the contaminated medication cart, and left the posterior of the glucometer exposed. The glucometer did not remain in the disinfectant wipe for the full two minutes. 4. Observation of RN X on 3/18/21 at 11:45 A.M. showed: - RN X sanitized his/her hands and prepared the contaminated glucometer with a glucometer strip; - RN X gloved hands, entered Resident #4's room and placed the glucometer on the bedside table without preparing a clean surface; - RN X performed the blood sugar check; - RN X returned the glucometer to the top of the contaminated medication cart outside the room; - RN X did not clean the glucometer, wrapped a disinfectant wipe partially around the glucometer, placed it on top of the contaminated medication cart, and left the anterior portion exposed. The glucometer did not remain in the disinfectant wipe for the full two minutes. 5. Observation of RN X on 3/18/21 at 11:50 A.M., showed: - RN X sanitized hands and prepared the contaminated glucometer with the strip; - RN X gloved hands, entered Resident # 9's room, and placed the glucometer on the bedside table without preparing a clean surface; - RN X performed the blood sugar check; - RN X returned the glucometer to the top of the contaminated medication cart outside the room; - RN X did not clean the glucometer with the wipe, wrapped a disinfectant wipe partially around the glucometer, placed it on top of the contaminated medication cart, and left the posterior of the glucometer exposed. The glucometer did not remain in the disinfectant wipe for the full two minutes. During an interview on 3/18/21 at 11:50 A.M., RN X said the disinfectant wipes are used to disinfect the glucometer between uses. The glucometer needs to be in the wipe for two minutes. 6. Observation of wound care for Resident #47 on 3/18/21 at 2:40 P.M., showed: - The Assistant Director of Nursing (ADON) donned gloves, placed wound cleanser bottle on the resident's bed and attempted to remove the dressing from Resident #47's right shin. The dressing had adhered to the wound; - The ADON wore soiled gloves, picked up the wound cleanser bottle and sprayed onto the soiled dressing to moisten; - The ADON wore gloves, placed the contaminated wound cleanser bottle back onto the resident's bed and removed the soiled dressing; - The ADON wore gloves, placed the calcium alginate dressing (a type of dressing that aids in healing) to the wound bed which caused a bloody fluid to adhere to the dressing; - The ADON removed the calcium alginate dressing from the wound, removed scissors from his/her pocket, cut the soiled dressing to fit the wound better, placed contaminated scissors back into his/her pocket, and finished dressing the wound; - The ADON washed his/her hands, then picked up the contaminated wound cleanser bottle and placed it on the treatment cart outside of the resident's room. During an interview on 3/18/21 at 2:55 P.M., the ADON said the cleanser is used for other residents in the facility and should have been left in the resident's room since it had been on the bed, and the scissors should have been disinfected after using them to trim a soiled dressing as that was cross contamination. 7. Observation of incontinent care for Resident #14 on 3/24/21 at 8:35 A.M., showed: - Certified Nurse Aide (CNA) Z and CNA Y did not wash their hands, applied gloves, arranged plastic bags for linens, wet wash cloths and put them in one bag for use, and removed the resident's pants and brief; - CNA Y wore soiled gloves, used the wet wash cloth and wiped the coccyx (a small triangular bone at the base of the spinal column) wound, put the wash cloth in bag, chose another wet wash cloth and washed the wound; - CNA Y and CNA Z removed the soiled gloves and with bare hands disposed of the linens. During an interview on 3/24/21 at 8:44 A.M., CNA Y and CNA Z said they should have changed gloves between dirty and clean tasks, but they did not have any more gloves in the room. 8. Observation of wound care for Resident #14 on 3/24/21 at 10:47 A.M., showed the following: - LPN O did not wash his/her hands, entered the resident's room and applied gloves; - LPN O wore soiled gloves and gathered supplies from the wound treatment cart; - LPN O sat supplies on top of the contaminated cart; - LPN O removed his/her gloves and gathered more supplies; - LPN O did not wash his/her hands and applied gloves; - LPN O wore soiled gloves, went through the cart and gathered more supplies, did not clean the bedside table, sat the supplies on the contaminated bedside table and lay the keys to the cart on the contaminated bedside table; - LPN O removed his/her gloves, went through the cart again and went down the hall to get plastic bags; - LPN O picked up the keys off of the bedside table and went through the cart again; - LPN O brought gloves and bags in the room and sat them on the contaminated bedside table; - LPN O prepared the plastic bags; - LPN O washed his/her hands with water for five seconds, gloved his/her left hand; - LPN O closed the door with the bare right hand and gloved the right hand; - LPN O wore soiled gloves, turned the resident to his/her side by pulling on the soiled bed pad; - LPN O wore soiled gloves, picked up the wound cleanser bottle and sprayed the cleanser on a 4 x 4 gauze pad and cleaned the wound; - LPN O wore soiled gloves, picked up the wound cleanser bottle, and sprayed the wound directly, and dabbed it with another 4 x 4 gauze pad; - LPN O wore soiled gloves, and placed the contaminated wound cleanser bottle on the contaminated bedside table; - LPN O wore soiled gloves and went through supplies on the contaminated bedside table; - LPN O removed gloves, did not wash his/her hands, picked up the keys that sat on the contaminated bedside table and went to the treatment cart for scissors; - LPN O did not wash his/her hands, applied gloves, did not clean the scissors, used contaminated scissors to cut the collagen (a dressing that supports a moist wound healing environment and supports new tissue growth) pad; - LPN O wore soiled gloves, and put the collagen pad on the wound in three places; - LPN O wore soiled gloves, picked up and opened the optifoam (a non-adhesive foam dressing) package, took a pen from his/her hair, and wrote the date on the pad and removed the backing on the pad; - CNA Y wore soiled gloves, asked for the wet wipes from LPN O. LPN O handed CNA Y the package of wet wipes, CNA Y removed the wipes, cleaned the feces from the resident; - One piece of collagen fell off onto the bed, LPN O did not replace it; - LPN O wore soiled gloves and placed the contaminated optifoam over the wound; - LPN O wore soiled gloves, collected the paper wrappers, placed them in the plastic bag, and removed his/her gloves; - LPN O washed his/her hands for seven seconds with water. During an interview on 3/24/21 at 11:02 A.M., LPN O said he/she does not use soap or hand sanitizer because it bothers his/her hands. In reviewing the process, LPN O said he/she did not always change his/her gloves when he/she should have, and does not wash his/her hands properly. LPN O said he/she did not, but should have cleaned the equipment including the cleanser bottle, with a proper cleaning solution/wipe, but he/she did not. 9. During an interview on 3/24/21 at 4:05 P.M., the Administrator said she would expect equipment(such as scissors and glucometers) to be cleaned between residents' use, as recommended by the manufacturer, and not sat on surfaces (such as bedside tables or treatment carts) without the surfaces being first covered or cleaned. The Administrator said she would also expect staff to sanitize hands, using soap or sanitizer, during care or the medication pass, and to change gloves between dirty and clean tasks.