Borger Healthcare Center

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure each resident received food prepared in a form designed to meet individual needs for 1 (Resident #13) of 12 residents reviewed for dietary needs.The facility failed to prepare Resident #13's pureed diet appropriately.This failure could place residents at risk of aspiration, choking, and/or weight loss.Findings Included:Record Review of Resident #13's admission record dated 08/26/25 revealed a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included, but were not limited to, unspecified dementia severe (a group of thinking and social symptoms that interferes with daily functioning), unspecified protein-calorie malnutrition (state of inadequate intake of food), dysphagia oropharyngeal phase (swallowing disorder that makes it difficult or unsafe to move food from the mouth to the esophagus), and other dietary vitamin B12 deficiency anemia (a form of anemia that occurs when the body lacks sufficient vitamin B12 due to an inadequate intake of natural sources, such as meat and dairy, or fortified foods).Record review of Resident #13's quarterly MDS completed 08/22/25 revealed no BIMS score as Resident #13 was rarely to never understood. The staff assessment revealed her cognition was severely impaired. Section GG Functional Abilities revealed Resident #13 was dependent across all ADLs except for eating where she required substantial/maximal assistance. Section K Swallowing/Nutritional Status revealed she received a mechanically altered diet while a resident.Record review of Resident #13's care plan completed 08/20/25 revealed the following: Nutrition: . physician/NP diet orders, functional assistance level with eating, swallowing precautions as needed will be maintained until further nutritional evaluation is completed. Resident #13 was noted to have impaired functional abilities r/t severe dementia. One of the approaches to address this problem area was Eating: usual performance: dependent Staff assistance: X 1 Assistive device, if applicable: food separated into bowls. Resident #13 was noted to have a regular puree diet order. The goal for this problem area was I will be offered an appetizing meal . help me avoid choking on food that I cannot eat over the next 90 days. This goal was edited on 08/11/25. One of the approaches regarding this goal was My texture is puree.Record review of Resident #13's active orders as of 08/27/25 revealed the following order:Order start date of 06/05/25 Diet: regular diet Texture: PUREE . Special Instructions: Serve food in bowlsDuring an observation on 08/25/25 at 8:07 AM Resident #13 was seated in the dining room being fed by a CNA from bowls on the table in front of her.During an observation and interview on 08/26/25 at 07:26 AM DA B was taking temps of breakfast foods on the steam table. The breakfast was scrambled eggs, oatmeal, sausage patties, and toast. There were two bowls in a steam pan. One bowl contained a brown, dry, crumbly substance and the other contained a yellow substance that appeared to be the texture of cottage cheese. DA B stated the bowls were the puree diet and she had not added the gravy to the bowls yet.During an observation on 08/26/25 at 07:28 AM DA B asked DA A what liquid to add to the puree. DA A told DA B to add apple juice to the pureed sausage and eggs.During an observation on 08/26/25 at 07:32 AM DA B opened a small plastic, single serve container of apple juice and poured half of it into the bowl of ground eggs and half (approximately 1/4 cup) of it into the bowl of ground sausage. She then heated each bowl in the microwave.During an observation on 08/26/25 at 07:37 AM this surveyor tasted the pureed eggs and found them to be sweet from the addition of the applesauce. The flavor was not appetizing, and the texture was watery with small lumps of egg. This surveyor then tasted the pureed sausage patty. The sausage tasted better than the eggs but was still on the sweet side. The sausage texture was watery with grainy lumps and larger lumps. There was no pureed bread.During an observation on 08/26/25 at 07:49 AM The bowls of pureed food for Resident #13 were placed by DA A on the wrong tray and delivered to the wrong resident.During an observation on 08/26/25 at 07:53 AM DA B began to remake the puree. She placed a serving of eggs in the blender with approximately 1/4 cup of apple juice. DA B ran the blender for about 30 seconds and poured the egg mixture into a bowl.During an observation on 08/26/25 at 07:56 AM DA B rinsed the blender and added a sausage patty and approximately 1/4 cup of apple juice. She ran the blender for about 30 seconds and poured the sausage mixture into a bowl.During an observation on 08/26/25 at 07:58 AM DA B scooped oatmeal from the pan on the stove, added it to a bowl and placed the bowl of oatmeal, pureed eggs, and pureed sausage on a tray to be delivered to Resident #13.During an interview on 08/26/25 at 11:33 AM RD stated pureed food needed to be the consistency of thick pudding or mashed potatoes. She stated correctly pureed food should not fall through and fork and should fall off a spoon in one lump. She stated grainy or watery texture was not correct. RD stated regular oatmeal was not suitable for a pureed diet as it had lumps. She stated the liquid used to puree eggs should be milk or gravy. She stated the liquid used to puree sausage should be broth or gravy. RD stated apple juice was not an appropriate liquid to puree eggs or sausage. She stated water was never an appropriate liquid.During an interview on 08/26/25 at 03:22 AM RD stated if a pureed diet was not the correct texture it could be a choking hazard.During an interview on 08/27/25 at 07:26 AM CNA D stated she fed Resident #13 her breakfast yesterday and Resident #13 ate one hundred percent of her breakfast. CNA D stated Resident #13 did not seem to have any trouble swallowing her breakfast.During an observation on 08/27/25 at 07:42 AM Resident #13 was seated at a table in the DR. CNA D was stirring a sugar packet into the bowls of what appeared to be eggs and sausage in front of Resident #13. The pureed eggs appear to be watery and grainy. The pureed sausage appears to be watery and grainy. The liquid seems to have separated from the eggs and from the sausage. Resident #13 had a bowl of regular oatmeal as well and it appears to be lumpy. Resident #13 did not have pureed bread, though the other residents observed eating in the dining room did have toast with their eggs, sausage, and oatmeal.During an interview on 08/27/25 at 08:54 AM CC stated if a resident with a dietary order of pureed received food that was watery, grainy, or lumpy it could lead to aspiration.During an interview on 08/27/25 at 10:27 AM DA A stated she had worked for the facility as a DA for 3 years. She stated her dining manager was out on medical leave. DA A stated ADM had been in charge of the kitchen operation during his absence. She stated the facility had only 2 residents with pureed diets and one of them was currently in the hospital. She stated she was trained by her first boss on making pureed meals. She stated she was trained to use milk or water as the liquid added to pureed food. DA A stated she was trained more recently to use apple juice or water as the liquid added to pureed food. She stated if a pureed food was not the correct consistency a resident could choke. DA A stated pureed food was supposed to be the consistency of pudding. She stated she trained DA B to use water and apple juice when making pureed food.During an interview on 08/27/25 at 10:37 AM DA B stated she has been working for the facility for 3 weeks. She stated she was not trained to make pureed meals by this facility. DA B stated at her previous job she was trained to use water and a breakfast gravy as the liquid to puree breakfast food and a brown gravy as the liquid to puree lunch or dinner items. She stated pureed food was supposed to be smooth, no chunks. DA B stated pureed food that was not the correct consistency was a choking hazard and might lead to aspiration.During an interview on 08/27/25 at 10:46 AM CCM stated if a resident with a dietary order of pureed received food that was watery, grainy, or lumpy they could choke or get pneumonia, or it could cause an obstruction and/or death.During an interview on 08/27/25 at 11:06 AM LVN F stated a resident with a pureed diet order who received watery, grainy food would not have any issues unless they were ordered to have thickened liquids. She stated if a resident with a pureed diet order was given food with lumps it could cause choking or aspiration.During an interview on 08/27/25 at 11:14 AM ADM stated a resident with a pureed diet order who received food that was not the correct consistency could aspirate. She stated pureed food should be good and smooth like a baby food like texture. ADM stated she did not know why dietary staff did not make pureed bread for Resident #13 as they have bags of puree bread mix and puree pancake mix in the pantry.During an interview on 08/27/25 at 01:04 PM DON stated if a resident with a pureed diet order received watery, grainy, or lumpy food they could choke or aspirate.Record review of an in-service training titled F812 Kitchen Sanitation, Cook/Aide Responsibilities, Cleaning Schedules, RD Inspection, Food Storage, Infection Control, Dish Room provided to DA A and DA C by ADM and HR on 07/16/25 revealed the following: . Meal Service . Follow the recipe. Using incorrect ingredient measurements or changing/omitting ingredients can affect the overall quality or nutritive value of the food .Record review of an in-service provided to DA A and DA B by ADM on 08/27/25 revealed the following: . Employees will have knowledge and understanding on how to blend and prepare items for pureed ordered diets to include portions, consistency, acceptable liquids, and required temperatures. Pureed diet-is a regular diet that has been designed for residents who have difficulty chewing and/or swallowing. The texture of the food should be a smooth and moist consistency (mashed potato, pudding) and able to hold its shape. Pureed recipes are found in the recipe book. The recipe includes the type of liquid and additional ingredients to be used. It is important to pay attention to the type and amount of liquid. This helps ensure the puree food is the correct consistency and provides the appropriate nutrition. Examples of liquids: Milk, broth, gravy, apple juice. Water is typically not used because it will dilute flavors and nutrients in the food. Scrambled eggs do need to be pureed. Puree items on low until a paste consistency and then add the reciped [sic] fluid gradually until a smooth pudding consistency is achieved. If a pureed item is too thick, thickeners can be used . Pureed foods need to be served on a dinner plate for dignity and on in bowls or divided plate. Pureed foods should not be running together on the plate. If this is the case, then it is not the correct consistency. Taste the pureed food. Is it smooth? Does it taste like the regular food item?Record review of facility recipe for pureed pork breakfast sausage patty dated 08/26/25 revealed the following: . Ingredients 1 Sausage Pork Bkft (breakfast) Patty . 1 Tbsp Milk or appropriate liquid . Pureed foods should be soft and smooth without any lumps or visible particles. Liquids should not separate from the solids. Recipe liquid and thickener amounts, if needed, are an estimate only. NOTE: Cooking liquid, broth, gravy or other suitable liquid may be substituted for liquid in recipe with pureeing this food for PU4. Pureed Usually eaten with a spoon (a fork is possible) * Cannot be drunk from a cup because it does not flow easily * Cannot be sucked through a straw * Does not require chewing * Can be piped, layered or molded because it retains its shape . Shows some very slow movement under gravity but cannot be poured * Falls off spoon in a single spoonful when tilted and continues to hold its shape on a plate * No lumps * . Liquid must not separate from solid .Record review of facility recipe titled PU4 Milk or Appropriate Liquid (Milk or Other Appropriate Liquid) and dated 08/26/25 revealed the following: . Entrees - Broth or other appropriate sauce/gravy from menu .Record review of facility recipe for pureed scrambled eggs dated 08/26/25 revealed the following: . Ingredients 1 Tbsp Milk or Appropriate Liquid 1/4 Cup Egg Scrambled . NOTE: Cooking liquid, broth, gravy or other suitable liquid may be substituted for liquid in recipe with pureeing this food for PU4. NOTE: As this food item contains a high percentage of fluid, additional fluid may not be needed. Drain well before pureeing, and once the items in pureed, add additional liquid only if necessary. Thickener may also be needed to achieve the proper consistency for PU4.Record review of facility recipe for pureed oatmeal dated 08/26/25 revealed the following: . Ingredients 1/2 cup Cereal Oatmeal f/Quick Oats 1 Tbsp Milk or Appropriate Liquid . Drain any excess liquid from food. Place prepared recipe portion into a blender or food processor. Blend until smooth. Additional liquid and/or thickener may be needed to ensure puree is smooth, moist and appropriate for PU4.Record review of facility policy titled Puree Food Preparation and dated 08/01/25 revealed the following: . It is the policy of this facility to provide puree food that has been prepared in a manner to conserve nutritive value, palatable flavor, and attractive appearance. 'Puree' means that all food has been ground, pressed and/or strained to a consistency of a soft, smooth, thick paste similar to a thick pudding. 1. The facility should provide each resident food that is prepared by methods that conserve nutritive value, flavor, and appearance. 2. Puree foods should be prepared to prevent lumps or chunks. The goal is a smooth, soft, homogenous consistency similar to soft mashed potatoes. 3. If the food item requires chewing, it should be excluded from the puree diet and prepared in a way that preserved vitamins and a minimum loss of nutrients. 5. Follow the recipe to prepare puree foods. 7. Examples of items to use to puree foods: . Meats: broth or gravy .

Based on observation, interview, and record review, the facility failed to store, prepare, and serve food under sanitary conditions in the facility's only kitchen when they failed to:<BR/>A. Ensure foods were prepared and served under sanitary conditions.<BR/>B. Ensure all foods were labeled and dated<BR/>These failure placed residents who ate food served by the kitchen at risk of cross contamination and food-borne illness. <BR/>Findings include:<BR/>In an observation of the kitchen on 05/09/22 at 9:40 AM the following was observed in the freezer:<BR/>1. <BR/>Two bags of cubed chicken, no label or date, not in original box<BR/>2. <BR/>Six bags of mixed vegetables, no label or date, not in original box<BR/>3. <BR/>Nine bags of squash, no label or date, not in original box<BR/>4. <BR/>Six bags of 6 frozen mini pizzas, no label or date, not in original box<BR/>5. <BR/>Three packages of okra, no label or date, not in original box<BR/>In an observation and interview at 12:10 PM on 05/09/22, [NAME] A was observed touching rolls with her gloved hands after touching multiple surfaces in the kitchen and picking up plates for the resident's lunch. When [NAME] A was asked if she realized she was picking up bread with her gloved hands she stated she did not realize she did that. She stated she never used tongs as she has small hands and the tongs never fit her hands. [NAME] A stated she did not know she should be using tongs for bread. [NAME] A stated the consequences of this action were that she could transfer germs to the food when using her hands which would cause the residents to get sick from food poisoning. [NAME] A stated she had received training from the dietary manager on cleanliness in the kitchen. <BR/>In an observation of the kitchen on 05/10/22 at 8:45 AM, the following was observed in the freezer:<BR/>1. <BR/>Two bags of cubed chicken, no label or date, not in original box<BR/>2. <BR/>Eleven bags of mixed vegetables, no label or date, not in original box<BR/>3. <BR/>Nine bags of squash, no label or date, not in original box<BR/>4. <BR/>Six bags of 6 frozen mini pizzas, no label or date, not in original box<BR/>5. <BR/>Three packages of okra, no label or date, not in original box<BR/>6. <BR/>Three packages of tator tots, no label or date, not in original package<BR/>7. <BR/>Three packages of French fries, no label or date, not in original box<BR/>In an observation of the kitchen on 05/11/22 at 10:15 AM, the following was observed in the freezer:<BR/>1. <BR/>Two bags of cubed chicken, no label or date, not in original box<BR/>2. <BR/>Six bags of mixed vegetables, no label or date, not in original box<BR/>3. <BR/>Nine bags of squash, no label or date, not in original box<BR/>4. <BR/>Six bags of 6 frozen mini pizzas, no label or date, not in original box<BR/>5. <BR/>Three packages of okra, no label or date, not in original box<BR/>6. <BR/>One package of French toast, no label or date, not in original box<BR/>In an interview on 05/11/22 at 10:30 AM, the DM stated staff should be washing hands and changing gloves between tasks. The DM stated staff should not be touching food with hands. The staff should use tongs when serving food. The DM stated she is responsible for training staff in handwashing and glove use. The DM further stated all foods should be labeled and dated. She stated she will statr using stickers to label all foods. The DM stated she had training in hand washing and glove use as well as labeling and dating foods. <BR/>Record Review of the facility policy titled, Dining Services Policy Manual dated October 2019, revealed in part : All food items will be appropriately labeled and dated either through manufacturer packaging or staff notation . Food Service employees will minimize bare hand contact with food that is ready to eat .food employees may not contact ready to eat food with their bare hands .suitable utensils such as tongs must be used <BR/>Record Review of the US Food Code, dated 2017, revealed:<BR/>2-301.14 When to Wash.<BR/>FOOD EMPLOYEES shall clean their hands and exposed portions of their arms as specified under &sect; 2-301.12 immediately before engaging in FOOD preparation including working with exposed FOOD, clean EQUIPMENT and UTENSILS, and unwrapped SINGLE-SERVICE and SINGLE-USE ARTICLES and:<BR/>(E)<BR/>After handling soiled EQUIPMENT or UTENSILS. <BR/>(F)<BR/>During FOOD preparation, as often as necessary to remove soil and contamination and to prevent cross contamination when changing tasks; <BR/>(H)<BR/>Before donning gloves to initiate a task that involves working with FOOD. <BR/>(I)<BR/>After engaging in other activities that contaminate the hands.<BR/>Record review of the USDA Food Code, dated 2017, revealed:<BR/>3-501.17 <BR/> Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking.<BR/>(A) Except when PACKAGING FOOD using a REDUCED OXYGEN PACKAGING method as specified under &sect; 3-502.12, and except as specified in (E) and (F) of this section, refrigerated, READY-TOEAT, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and held in a FOOD ESTABLISHMENT for more than 24 hours shall be clearly marked to indicate the date or day by which the FOOD shall be consumed on the PREMISES, sold, or discarded when held at a temperature of 5&ordm;C (41&ordm;F) or less for a maximum of 7 days. The day of preparation shall be counted as Day 1.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews the facility failed to ensure that the resident's environment remained as free of accident hazards as possible, and that the resident received adequate supervision and assistive devices to prevent accidents for 1 of 5 residents (Resident #1) reviewed for accident hazards.<BR/>CNA A failed to use a transfer belt while attempting to transfer Resident #1 from the bed to the wheelchair. <BR/>This failure could place residents at risk of unsafe transfers, resulting in falls, injuries, and a decreased quality of life.<BR/>Findings included:<BR/>Record review of Resident #1's clinical records revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #1 had a diagnoses which included Unspecified Systolic (congestive) Heart Failure ( a condition of the heart where the heart is weak and the left ventricle cannot contract normally when the heart beats), Urinary Tract Infection, site not specified, Other Abnormalities of Gait and Mobility, Unspecified Dementia, moderate, with Anxiety, Muscle weakness (generalized), Cognitive Communication Deficit (communication difficulty cause by cognitive impairment), Cellulitis of Right Lower limb (Infection of the skin), Pain in unspecified shoulder, Dementia in other diseases classified elsewhere, Unspecified severity, with Other Behavioral Disturbance, Altered mental status, unspecified, Heart failure, unspecified, and Acute Respiratory Failure with Hypoxia (impairment of gas exchange between the lungs and the blood, causing shortness of breath, anxiety and confusion). Resident #1 had a BIMS score of 02, which indicated severe cognitive impairment. Her Morse Fall Scale dated 12/13/2024 revealed a history of falling related to a secondary diagnosis, the use of a walker for ambulation, a weak gate, and an overestimation of her physical limitations. <BR/>Record review of Resident #1's Quarterly MDS dated [DATE] revealed Resident #1's bed mobility and transfers were extensive assistance (resident involved in activity, staff provide weight-bearing support) with one-person physical assist. <BR/>Record review of Resident #1's Care Plan dated 01/02/2025 revealed Resident #1's Problem of ADL Functional Status/Rehabilitation Potential, a Goal of Resident will achieve maximum functional mobility and an Approach of Bed mobility amount of assist: extensive x 1 assist and Transferring amount of assist: extensive x 1 assist. Resident #1's Care Conference Notes indicated Resident #1 needed substantial assistance to both sit up and stand, as her condition was declining, and she received Hospice services. <BR/>In a phone interview 01/28/2025 at 2:27PM Resident #1's POA revealed she had video surveillance from a [NAME] which had been place in Resident #1's room, prior to her death in the facility on 01/11/2025. The POA stated the video clearly showed an improper transfer being done by CNA A, where she first lifts Resident #1 from a supine (laying on the back) position to a sitting position by lifting her from the back of her neck to aid Resident #1 in sitting up. The POA stated CNA A then helped Resident #1 to a sitting position on the edge of the bed and began to lift Resident #1 by pulling on the resident's outstretched arms, trying to bring Resident #1 to a standing position. The video was reviewed by the state surveyor and the POA's observations proved to be correct. The POA stated Resident #1 was not hurt in any way during the attempted transfer, but the manner in which the transfer was attempted, was concerning. <BR/>An interview with the Administrator, the DON and the Corporate Nurse on 01/29/2025 at 12:55PM revealed a competency checklist was used by the ADON and DON to evaluate CNA competency in transfers from bed to wheelchair and were to be done using a transfer belt. The administrator stated Resident #1 did not like the transfer belt but was told its use was for her safety. She stated she did not know why CNA A had not used a transfer belt, as was revealed in the supplied video from the resident's POA.<BR/>Phone interviews with CNA A were attempted on 01/29/2025 at 11:12AM and 1:22PM but were unsuccessful. She was unable to be reached and there was no voicemail set up to request a return call.<BR/>Record review of the CNA Transfers Competency Checklist read as follows:<BR/>Before assisting to stand, resident is assisted to a sitting position with feet flat on the floor.<BR/>Before assisting to stand, apply transfer belt securely at the waist over clothing/gown.<BR/>Before assisting to stand, provide instructions to enable resident to assist in the transfer including a prearranged signal to alert when to begin standing.<BR/>Stand facing the resident, positioning self to ensure safety of resident during transfer. Count to three (or say prearranged signal) to alert resident to begin standing.<BR/>On signal, gradually assist resident to stand by grasping transfer belt on both sides with an upward grasp (resident's hands are in an upward position) and maintain stability by standing knee-to-knee or toe-to- toe with the resident.<BR/>Record review of CNA A's checklist reflected it was signed by the ADON as competent on 12/26/2024. The ADON was not available for interview.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life for 2 (Resident #19 and #89) of 2 residents reviewed for catheter care in that:<BR/>Resident #19 was observed several times with his catheter bag not in a privacy bag. <BR/>Resident #89 was observed several times with his catheter bag not in a privacy bag. <BR/>This failure could cause residents to feel uncomfortable and disrespected leading to feeling of isolation and deterioration in general health conditions.<BR/>Findings include:<BR/>Resident #19<BR/>Record review of Resident #19's face sheet revealed he was a [AGE] year-old male resident admitted to the facility originally on 3-1-2023 and readmitted on [DATE] with diagnoses to include cerebral infarction (occurs as a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it), urinary tract infection (an infection in any part of the urinary system, the kidneys, bladder, or urethra), Schizoaffective disorder (a mental health condition including schizophrenia and mood disorder symptoms), intermittent explosive disorder (repeated sudden outbursts of anger), anxiety (a group of mental illnesses that cause constant fear and worry), long term use of antibiotics, aphasia (loss of the ability to understand or express speech caused by brain damage), acute kidney failure (longstanding disease of the kidneys leading to kidney failure), neuromuscular dysfunction of the bladder (the nerves and muscles of the bladder do not work well resulting in the bladder not filling or emptying well), and cognitive communication deficit (Impaired thought processes).<BR/>Record review of Resident #19's last MDS revealed a quarterly assessment completed on 6-25-2024 with a BIMS that was not completed because he is rarely/never understood, and he had a functional status of requiring setup or clean up assistance to substantial/maximal assistance with his activities of daily living. Resident #19 is marked as having an indwelling catheter. <BR/>Record review of the care plan with admission date of 03-01-2023 for Resident #19 revealed the following:<BR/>Problem: Behavioral Symptoms<BR/>-I become fixated on my catheter. I continue to remove the dignity bag and place the bag in the seat of my wheelchair, which increases my risk of UTI.<BR/>Approach:<BR/>-Place dignity bag over catheter bag when resident removes.<BR/>Problem: Indwelling Catheter<BR/>-I have a urinary catheter .<BR/>Approach:<BR/>- Provide catheter care and change catheter per policy.<BR/>During an observation on 07-22-2024 at 09:27 AM Resident #19 was in his room listening to music. Resident #19 was dressed well and in a specialized wheelchair. Resident #19 was alert but answered each questioned with Ya. No other response given other than a thumbs up when this surveyor was leaving the room. Resident #19 appeared in good condition with his catheter hanging from the far side of his wheelchair out of view. <BR/>During an observation and interview on 07-22-2024 at 09:39 AM Resident #19 was in the hallway in his wheelchair with his catheter bag hanging from the right side of his wheelchair with no privacy bag. A small amount of amber urine could be observed in the catheter bag. When questioned if he wanted the catheter bag in a privacy bag Resident #19 stated Ya.<BR/>During an observation on 07-22-2024 at 09:50 Resident #19 was at the nurse's station with his catheter bag hanging from his wheelchair with no privacy bag. Noted was a small amount of urine present in the catheter bag. This surveyor noted two residents present and 1 staff member present at the nurse's station.<BR/>During an observation on 07-22-2024 at 12:00 PM Resident #19 was in the dining room sitting at a table with 3 other residents. This surveyor noted that Resident #19's catheter bag could be observed with no privacy bag hanging from his wheelchair. This surveyor noted a small amount of amber urine in the catheter bag. A total of 17 residents were present in the dining room. <BR/>During an observation on 07-23-2024 08:09 AM Resident #19 was in the dining room finishing the AM meal with 9 other residents present. Resident #19's catheter bag was hanging from his wheelchair without a privacy bag. A small amount of amber urine was observed in the catheter bag. <BR/>Resident #89<BR/>Record review of Resident #89's face sheet revealed he was a [AGE] year-old male resident admitted to the facility on [DATE] with diagnoses to include heart failure (a chronic condition in which the heart dose not pump blood as well as it should), chronic obstructive pulmonary disease (a group of lung diseases that block airflow and make it difficult to breath), urinary tract infection (an infection in any part of the urinary system, the kidneys, bladder, or urethra), benign prostatic hyperplasia (age-associated prostate gland enlargement that can cause urinary dysfunction), obstructive and reflux uropathy, and diabetes. (a chronic condition that affects the way the body processes blood sugar (glucose).<BR/>Record review of Resident #89's clinical record revealed he had not been in the facility long enough for a MDS to be completed. <BR/>Record review of the care plan with admission date of 07-16-2024 for Resident #89 revealed a baseline/general care plan that was not specific for his catheter care.<BR/>During an observation and interview on 07-22-2024 at 09:54 AM Resident #89 was observed in his room in his bed with a catheter bag hanging from the side of his bed with no privacy bag. Resident #89 reported no concerns or issues with the catheter or catheter bag and that staff were good about emptying the catheter bag.<BR/>During an observation on 07-22-2024 12:00 PM, 17 residents were present in the dining room when the first tray was delivered. Resident #19 and Resident #89 were at a table in the middle of the dining room with two other residents present at that table. Residents #19 and #89 had catheter bags present that were not in privacy bags. Small amounts of amber urine could be noticed in each resident's catheter bag. <BR/>During an observation on 07-22-2024 at 12:46 AM Resident #89 was moved from the dining room in his wheelchair by a CNA to the day area of the facility with his catheter bag hanging from his wheelchair that did not have a privacy bag. [NAME] urine could be observed in the catheter bag. <BR/>During an interview on 07-23-2024 at 03:29 PM, CNA A and CNA B had just completed incontinent care for Resident #89. Both CNA A and CNA B verified that any resident who has a catheter should have their catheter bag in a privacy bag. CNA A stated, especially when out of their room or in the dining room since that it is a dignity issue and can be an embarrassment for the resident. Both CNA A and CNA B reported that other residents who observed the exposed catheter bags could be affected negatively. CNA A and CNA B reported they were not sure what negative outcomes would be from not placing the catheter in a privacy bag, but they knew it would not be good. CNA A stated that she worked on the hallway that Resident #19 was on during the day shift on 7-22-2024 and stated, I tried to put his catheter in a privacy bag once yesterday, but he just removed it. CNA A verified a second time that she only attempted one time to put Resident #19's catheter bag in a privacy bag. <BR/>During an interview on 07-24-2024 at 09:29 AM the CRN reported that catheter bags are supposed to be in privacy bags especially when residents are out of their rooms so other residents or visitors do not have to observe the resident's urine. The CRN reported that it could negatively affect the resident with the catheter or residents who observe the catheter by causing embarrassment for the resident with the catheter and affecting residents observing by causing affects like losing their appetites and not being able to eat. <BR/>Record review of facility provided policy titled, Dignity revised February 2021 revealed the following:<BR/>Policy Statement:<BR/>Each resident shall be care for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem. <BR/>12. Demeaning practices and standards of care that compromise dignity are prohibited. Staff are expected to promote dignity and assist resident; examples are:<BR/>a. helping the resident to keep urinary catheter bags covered.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide, based on the comprehensive assessment and care plan and the preferences of each resident, an ongoing program to support residents in their of activities; both facility-sponsored group and independent activities designed to meet the interests of and support the physical, mental, and psychological well-being of each resident, to encourage both independence and interaction in the community for 2 of 7 residents (Residents #2 and #3) reviewed for activities.<BR/>The facility failed to provide specific activities to Resident #2 and Resident #3 based on their preferences, abilities, and care plans.<BR/>This failure could place residents at risk of psychosocial decline, social isolation, and a decreased quality of life due to personal preferences not being met.<BR/>Findings Included:<BR/>Record review of Resident #2's face sheet revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #2 had diagnoses included but not limited to Parkinson's disease, other abnormalities of gait and mobility, muscle wasting and atrophy, muscle weakness, need for assistance with personal care, other reduced mobility, other lack of coordination, and type 2 diabetes mellitus. Resident #2 was admitted to hospice.<BR/>Record review of Resident #2's quarterly MDS dated [DATE], revealed a BIMS of 13, which indicated the resident was cognitively intact.<BR/>Record review of Resident #2's care plan, dated 5/2/22, indicated a problem with the category of activities. The goal for the plan stated, resident will attend/participate in 1 activity per week with an approach of introduce activities offered. Problem stated in care plan, dated 5/2/22, with category of mood state with a goal of resident will express/exhibit satisfaction. Approach to goal indicated to encourage group activities resident enjoys with no specific information provided to the approach.<BR/>Interview on 7/723 at 3:12 PM with Resident #2 and Resident family member stated that there was nothing planned for the fourth of July. Resident also stated that the only activities that are offered are individual and would like more group activities to take place. Resident #2 also stated that word searches and coloring pages do not interest her. Resident #2 did not indicate specific activities that they would like to take place in the facility. Resident #2 also indicated that there was no July 4th activity that took place in the facility. <BR/>Resident #3<BR/>Record review of Resident #3's face sheet revealed a [AGE] year-old female who was admitted to the facility on [DATE], with a current return date of 4/19/23. Resident #3 had diagnoses which included but not limited to Unspecified dementia (a conditions in which a person loses ability think, remember, learn and make decisions) unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, Muscle weakness (generalized), Insomnia (inability to sleep), Dysphagia (difficulty swallowing), Dementia in other diseases classified elsewhere, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, Generalized anxiety disorder, Other lack of coordination, Cognitive communication deficit (difficulty with thinking and using language), need for assistance with personal care, Unspecified lack of coordination, Difficulty in walking, other abnormalities of gait and mobility, muscle wasting and atrophy (decrease in size or wasting away of a body part or tissue). <BR/>Interview on 7/7/23 at 2:48 PM with Resident #3's family member stated that there is nothing for their family member to do but watch TV. Stated that understands Resident #3's memory is not great and needs guidance but wishes there was more for her to do than to watch T.V. all day. Family member did not specify specific activities that his family member can or should take part in.<BR/>Record review of Resident #3's MDS (Minimum Data Set), dated 5/5/2023, indicated a BIMS of 04, which indicated severe impairment.<BR/>Observation and record review on 7/7/23 at 4:10 PM revealed that four activities were scheduled for Friday, 7/7/23, of Music, Game of the Week, Tic Tac Toe, and Summer Color Pages and no activities took place while surveyors were in the facility. Investigations began at the facility from 9:02 AM to 5:10 PM. Activities scheduled for 7/7/23 were music on IN2L at 9 AM; Game of the week on IN2L at 1 PM, Tic Tac Toe at 2 PM, and Summer Color Pages at 4 PM. During tour and initial interviews, no activity was taking place at 9:02 AM in the dining room as this is where the IN2L is located. IN2L was not in working order and no alternate activity taking place.<BR/>Observation on 7/7/23 at 1 PM of dining room after lunch service revealed IN2L continued to be out of service and no additional activity taking place. <BR/>Observations of scheduled activities at 2 PM and 4PM did not take place and there was not alternate activity planned. <BR/>Interview on 7/7/23 at 4:10 PM with ACTD indicated there are four activities a day planned. Most are individual activities, such as coloring. Stated that no activities have taken place today due to the interactive system of games and puzzles which are on a large screen, not being in working order. ACTD also stated that ACTD stated that most of the activities are individual and placed in dining room such as coloring pages. Stated that alternate activities of coloring pages, paint by numbers, and word search are available should the scheduled activity not take place. <BR/>Exit conference on 7/7/23 at 4:53 PM with ADM, DON, ADON, and ACTD revealed that activities had been discussed with residents and a July 4th activity was planned. ACTD voiced that a July 4th activity took place. ADM asked if Surveyors would review council minutes and provided a copy for review.<BR/>Record review on 7/7/23 of Resident Council minutes from 4/14/23, 5/30/23, and 6/9/23 revealed activities were discussed in the month of April, which indicated that a Cinco de Mayo activity was planned for May 5, 2023. The minutes from May and June documented no upcoming activities for June and July.

Based on observation, interview, and record review, the facility failed to store, prepare, and serve food under sanitary conditions in the facility's only kitchen when they failed to:<BR/>A. Ensure foods were prepared and served under sanitary conditions.<BR/>B. Ensure all foods were labeled and dated<BR/>These failure placed residents who ate food served by the kitchen at risk of cross contamination and food-borne illness. <BR/>Findings include:<BR/>In an observation of the kitchen on 05/09/22 at 9:40 AM the following was observed in the freezer:<BR/>1. <BR/>Two bags of cubed chicken, no label or date, not in original box<BR/>2. <BR/>Six bags of mixed vegetables, no label or date, not in original box<BR/>3. <BR/>Nine bags of squash, no label or date, not in original box<BR/>4. <BR/>Six bags of 6 frozen mini pizzas, no label or date, not in original box<BR/>5. <BR/>Three packages of okra, no label or date, not in original box<BR/>In an observation and interview at 12:10 PM on 05/09/22, [NAME] A was observed touching rolls with her gloved hands after touching multiple surfaces in the kitchen and picking up plates for the resident's lunch. When [NAME] A was asked if she realized she was picking up bread with her gloved hands she stated she did not realize she did that. She stated she never used tongs as she has small hands and the tongs never fit her hands. [NAME] A stated she did not know she should be using tongs for bread. [NAME] A stated the consequences of this action were that she could transfer germs to the food when using her hands which would cause the residents to get sick from food poisoning. [NAME] A stated she had received training from the dietary manager on cleanliness in the kitchen. <BR/>In an observation of the kitchen on 05/10/22 at 8:45 AM, the following was observed in the freezer:<BR/>1. <BR/>Two bags of cubed chicken, no label or date, not in original box<BR/>2. <BR/>Eleven bags of mixed vegetables, no label or date, not in original box<BR/>3. <BR/>Nine bags of squash, no label or date, not in original box<BR/>4. <BR/>Six bags of 6 frozen mini pizzas, no label or date, not in original box<BR/>5. <BR/>Three packages of okra, no label or date, not in original box<BR/>6. <BR/>Three packages of tator tots, no label or date, not in original package<BR/>7. <BR/>Three packages of French fries, no label or date, not in original box<BR/>In an observation of the kitchen on 05/11/22 at 10:15 AM, the following was observed in the freezer:<BR/>1. <BR/>Two bags of cubed chicken, no label or date, not in original box<BR/>2. <BR/>Six bags of mixed vegetables, no label or date, not in original box<BR/>3. <BR/>Nine bags of squash, no label or date, not in original box<BR/>4. <BR/>Six bags of 6 frozen mini pizzas, no label or date, not in original box<BR/>5. <BR/>Three packages of okra, no label or date, not in original box<BR/>6. <BR/>One package of French toast, no label or date, not in original box<BR/>In an interview on 05/11/22 at 10:30 AM, the DM stated staff should be washing hands and changing gloves between tasks. The DM stated staff should not be touching food with hands. The staff should use tongs when serving food. The DM stated she is responsible for training staff in handwashing and glove use. The DM further stated all foods should be labeled and dated. She stated she will statr using stickers to label all foods. The DM stated she had training in hand washing and glove use as well as labeling and dating foods. <BR/>Record Review of the facility policy titled, Dining Services Policy Manual dated October 2019, revealed in part : All food items will be appropriately labeled and dated either through manufacturer packaging or staff notation . Food Service employees will minimize bare hand contact with food that is ready to eat .food employees may not contact ready to eat food with their bare hands .suitable utensils such as tongs must be used <BR/>Record Review of the US Food Code, dated 2017, revealed:<BR/>2-301.14 When to Wash.<BR/>FOOD EMPLOYEES shall clean their hands and exposed portions of their arms as specified under &sect; 2-301.12 immediately before engaging in FOOD preparation including working with exposed FOOD, clean EQUIPMENT and UTENSILS, and unwrapped SINGLE-SERVICE and SINGLE-USE ARTICLES and:<BR/>(E)<BR/>After handling soiled EQUIPMENT or UTENSILS. <BR/>(F)<BR/>During FOOD preparation, as often as necessary to remove soil and contamination and to prevent cross contamination when changing tasks; <BR/>(H)<BR/>Before donning gloves to initiate a task that involves working with FOOD. <BR/>(I)<BR/>After engaging in other activities that contaminate the hands.<BR/>Record review of the USDA Food Code, dated 2017, revealed:<BR/>3-501.17 <BR/> Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking.<BR/>(A) Except when PACKAGING FOOD using a REDUCED OXYGEN PACKAGING method as specified under &sect; 3-502.12, and except as specified in (E) and (F) of this section, refrigerated, READY-TOEAT, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and held in a FOOD ESTABLISHMENT for more than 24 hours shall be clearly marked to indicate the date or day by which the FOOD shall be consumed on the PREMISES, sold, or discarded when held at a temperature of 5&ordm;C (41&ordm;F) or less for a maximum of 7 days. The day of preparation shall be counted as Day 1.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure residents the right to be free from abuse and/or neglect for 1 (Resident #1) of 8 residents reviewed for abuse and/or neglect. <BR/>Observation revealed Resident #1's bed was saturated with urine. <BR/>This failure could affect residents resulting in physical or emotional harm resulting in in deterioration in their health condition, need for medical treatment, physical impairment, exacerbation of their condition, serious bodily harm, emotional distress, and feelings of isolation. <BR/>Findings include:<BR/>Record review of Resident #1's face sheet, printed 06/22/2024, revealed a [AGE] year-old female, who was admitted to the facility on [DATE] with the following diagnoses: Unspecified dementia, severe, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, Muscle weakness (generalized), Personal history of urinary (tract) infections, other reduced mobility, other lack of coordination, need for assistance with personal care, altered mental status, unspecified, cognitive communication deficit. <BR/>Record review of Resident #1's clinical record revealed her last MDS, completed on 05/20/2024, revealed Resident #1 did not have a BIMS score listed on her MDS. Resident #1's functionality revealed that she is totally dependent upon staff for activities of daily living. <BR/>Record review of Resident #1's care plan, last revision was 05/07/2024, revealed the following: <BR/>Problem Start Date: 12/04/2018<BR/>Category: Pressure Ulcer/Injury<BR/>Resident is at risk for pressure ulcers R/T<BR/>Incontinence.<BR/>Edited: 05/07/2024<BR/>Edited By: [Named RN], RN<BR/>Long Term Goal Target Date: 08/07/2024<BR/>Resident's skin will remain intact.<BR/>Edited: 05/07/2024<BR/>Edited By: [Named RN], RN<BR/>Approach Start Date: 12/04/2018<BR/>Conduct a systematic skin inspection Weekly.<BR/>Pay particular attention to the bony<BR/>prominences.<BR/>Created: 12/04/2018<BR/>Created By: [Unidentified staff]<BR/>Nurse Aides, Nursing<BR/>Approach Start Date: 12/04/2018<BR/>Keep clean and dry as possible. Minimize skin<BR/>exposure to moisture.<BR/>Created: 12/04/2018<BR/>Created By: [Unidentified Staff]<BR/>Nurse Aides, Nursing<BR/>Approach Start Date: 12/04/2018<BR/>Report any signs of skin breakdown (sore,<BR/>tender, red, or broken areas).<BR/>Created: 12/04/2018<BR/>Created By: [Unidentified Staff]<BR/>Problem Start Date: 05/30/2018<BR/>Category: Urinary Incontinence<BR/>Resident experiences bladder incontinence<BR/>Edited: 05/07/2024<BR/>Edited By: [Named RN], RN<BR/>Long Term Goal Target Date: 08/07/2024<BR/>Resident will maintain current level of bladder<BR/>continence.<BR/>Edited: 05/07/2024<BR/>Edited By: [Named RN], RN<BR/>Approach Start Date: 05/30/2018<BR/>Resident will wear briefs and pad r/t briefs are<BR/>saturated and does not hold all her urine<BR/>Every 6 Hours; 12:00 AM, 06:00 AM, 12:00 PM,<BR/>06:00 PM<BR/>Edited: 08/29/2019<BR/>Edited By: [name], LVN ADON<BR/>During an observation on 06/22/2024 at 3:14am Resident #1 was in her bed sleeping. Bed saturated to the touch. <BR/>During an observation on 06/22/2024 at 3:55am of Resident #1's bed still saturated and had not been changed as of yet.<BR/>Interview/Observation on 06/22/2024 at 3:56am with CNA A on when the last time Resident #1 was changed. CNA A stated at 2am and that it was close to time to change her again. CNA A stated that residents were checked every 2 hours. Incontinent care was requested for Resident #1 at this time. Incontinent care was performed, and a total bed change took place during this resident care. <BR/>Observation on 06/22/2024 at 4:05am revealed CNA B came into assist CNA A with the remaining incontinent care of Resident #1. <BR/>During an interview on 06/22/2024 at 5:11am, CNA A was able to answer all abuse and neglect questions appropriately to include that leaving Resident #1 saturated would be considered neglect. CNA A stated that she had not been trained on abuse or neglect training since she started work in the facility three days ago. <BR/>During an interview on 06/22/2024 at 5:20 am, CNA B was able to answer all abuse and neglect questions appropriately to include that leaving Resident #1 saturated in urine would be considered neglect. CNA B could not confirm or deny any abuse, neglect, or exploitation training upon hire or in the past 6months of being employed in the facility. <BR/>During [NAME] nterview on 06/22/2024 at 5:33am, Regional RN was able to answer all abuse and neglect questions appropriately to include that leaving Resident #1 saturated in urine would be considered neglect. <BR/>Record Review revealed that CNA B did receive abuse, neglect, and exploitation training at date of hire. <BR/>During an interview on 06/22/2024 at 6:28am ADM was able to answer all abuse and neglect questions appropriately. ADM would not confirm that leaving a resident saturated in urine was neglect. ADM stated, It could be, depends on the last time the resident received prompt toileting and incontinence care and if there is a medication change, if the resident would need to be changed to a Q1 hour. We would have to look at all of those factors.<BR/>Record review of employee training for CNA A, dated 06/11/2024, revealed that CNA A was trained on abuse and neglect policy and procedure. <BR/>Record review of employee training for CNA B, dated 12/26/2023, revealed that CNA B was trained on abuse and neglect policy and procedure. <BR/>Record review of facility provided policy, Abuse, Neglect, and Exploitation, revised 10/2023, revealed the following:<BR/> .III. Identification of Abuse, Neglect, and Exploitation .<BR/> .B .Possible indicators of abuse, include, but are not limited to: .<BR/> .*. Failure to provide care needs such as comfort, safety, feeding, bathing, dressing, turning, and positioning; . <BR/>Record review of facility provided policy, Residents Rights, revised February 2021, revealed the following:<BR/>Policy Statement<BR/>Employees shall treat all residents with kindness, respect, and dignity. <BR/>Policy Interpretation and Implementation<BR/>1. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: <BR/>a. a dignified existence;<BR/>b. be treated with respect, kindness, and dignity; <BR/>c. be free from abuse, neglect, misappropriation of property, and exploitation; .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews the facility failed to ensure each resident was free from abuse, neglect, misappropriation of resident property and exploitation for 1 (Resident #1) of 5 residents reviewed for abuse, neglect, misappropriation of resident property and exploitation.<BR/>The facility failed to ensure a 15 ml bottle of morphine prescribed to Resident #1 was not misappropriated.<BR/>This failure could lead to residents not receiving their medication as prescribed and/or experiencing discomfort due to symptoms not being treated as ordered by a physician.<BR/>Findings Included:<BR/>Record review of Resident #1's admission record dated [DATE] revealed a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses that included, but were not limited to, heart disease (heart muscle fails to pump blood as it should), dementia with anxiety (a group of thinking and social symptoms that interferes with daily functioning), and type 2 diabetes (insufficient production of insulin, causing high blood sugar). Resident #1 expired on [DATE].<BR/>Record review of Resident #1's significant change MDS completed on [DATE] revealed no BIMS as Resident #1 was rarely to never understood. The staff assessment for mental status revealed Resident #1's cognitive skills for daily living were severely impaired. Section J revealed Resident #1 received PRN pain medication during the look-back period. The staff assessment for pain revealed staff knew Resident #1 was in pain over the look-back period due to facial expressions which were observed one or two days of the 5-day look-back period. Section N of the MDS revealed resident #1 received opioid medications. Section O revealed Resident #1 was receiving hospice care.<BR/>Record review of Resident #1's care plan last reviewed/revised on [DATE] revealed Resident #1 had a pressure ulcer. The approach included, Assess pain level before, during and after treatment. Medicate per physician's order and resident's need and Monitor for pain and medicate as needed per physician's order. The care plan had a goal of Death with dignity. This goal included approaches Medications as ordered by physician and Monitor for restlessness, grimacing . Provide comfort measures . medications as indicated. <BR/>Record review of Resident #1's order report dated [DATE] revealed in part:<BR/>An order for morphine concentrate schedule II solution; 100 mg/5mL (20 mg/mL) 0.1 every two hours as needed with a start date of [DATE] and an discontinue date of [DATE].<BR/>An order for morphine concentrate schedule II solution; 100 mg/5mL (20 mg/mL) 0.20 every four hours with start date of [DATE] and discontinue date of [DATE].<BR/>An order for morphine concentrate schedule II solution; 100 mg/5mL (20 mg/mL) 0.25 every four hours with start date of [DATE] and discontinue date of [DATE].<BR/>Record review of Resident #1's MAR with a run date of [DATE] revealed Resident #1 did not receive her 8 AM, 12 PM, 4 PM, and 8 PM doses of morphine as ordered due to the medication being unavailable.<BR/>Record review of the facility's investigation into Resident #1's missing morphine revealed the bottle of morphine was discovered missing at change of shift the morning of [DATE] when night nurse, RN D asked on-coming day nurse, LVN E to help her fax triplicate requests for a refill on Resident #1's morphine. LVN E had visualized the full bottle of morphine the day before. RN D told LVN E the bottle was not there any longer. The two of them looked in the medication cart and found the bottle missing as well as the sheet of paper in the narcotics book which documented the signing in and out of the cart and medication counts at shift changes regarding Resident #1's morphine. RN D then told ADON she was digging in the dumpster behind the facility looking for the bottle of morphine and she was going to go over all of her steps from the night before to be sure she did not leave the bottle anywhere in the facility. RN D told ADM she took the cart from LVN C the evening of [DATE]. ADM interviewed LVN C and she stated the bottle of morphine was in the cart each and every time she counted the cart. The facility investigation indicated the local police department was called and came out to investigate the missing morphine. <BR/>Record review of Resident #1's progress notes revealed no information regarding the missing bottle of morphine. A progress noted dated [DATE] at 09:13 PM written by LVN F revealed Resident #1's family members inquired about her morphine arriving earlier that day. LVN F told family that the morphine was not in the facility, and she called HRN B who was on-call for hospice that evening and HRN B stated she would pick up the morphine and bring it to the facility.<BR/>During an interview on [DATE] at 09:20 PM ADON stated the morphine was found to be missing when an agency nurse was counting with a facility nurse and the agency nurse realized it was not there. ADON stated she was 99.99% certain RN D took the morphine, but she had no proof. She stated RN D was one of the possible suspects in another drug diversion-that time it was hydrocodone-a few months ago but they had no proof RN D took the drugs at that time either. She said RN D was currently on suspension from the facility related to an altercation between two residents that RN D failed to report. ADON stated nurses were responsible for medications in the facility. ADON stated this was why nurses sign in and out on the medication carts with each other there to ensure nothing is missed. She stated the facility called the police department when they learned of the missing morphine and the police came to the facility and took a report. <BR/>During an interview on [DATE] at 10:03 AM Resident #1's family member stated Resident #1's morphine was taken from the facility and she was 12-24 hours without a dose. He stated two other family members of Resident #1 were in the facility when the morphine was found to be missing and they were told about the missing morphine. He stated they did not notice Resident #1 showing signs of being in pain. He stated they were with her 24 hours a day 7 days a week at that point.<BR/>During an interview on [DATE] at 02:11 PM LVN E stated she worked on [DATE] and during that shift she took the medication cart containing Resident #1's morphine from LVN C during LVN C's lunch break. She stated she and LVN C counted the cart together before she took it and again when LVN C came back from her lunch break. LVN E stated during the time she had the cart HRN A came to the facility and the two of them took the bottle of morphine out of the cart to visualize it and ensure Resident #1 had enough of the prescription. LVN E stated she worked the morning of [DATE] and when she came to work, she saw RN D attempting to fill out triplicate orders for Resident #1 for morphine. LVN E said she expressed surprise because there was a whole bottle yesterday. At that time RN D told LVN E there was no bottle in the cart. LVN E stated, The bottle and the paper were missing so there was no way to track who had it last.<BR/>During an interview on [DATE] at 03:02 PM LVN C stated Resident #1's bottle of morphine was on her medication cart on [DATE] when she left the cart with RN D around 9:30 or 10 PM.<BR/>During an interview on [DATE] at 12:51 PM HRN A stated she called the hospice doctor on [DATE] at 12:44 PM and explained the bottle of morphine was missing and asked him to sign a new order. She said she tried sending an order through, but the DEA would not let it go through because it was being refilled too soon. HRN A stated she and the doctor then changed the dose of morphine from .2 to .25 and at that point the Pharm P told her they would deliver the medication. She stated she was not sure when the medication was delivered. She stated her notes indicated the facility called hospice on-call on [DATE] at 08:42 PM and the message was read by on-call nurse HRN B at 08:47 PM and HRN B ordered the medication on [DATE] at 09:16 PM. HRN A stated she did not think Resident #1 was affected by missing doses of her morphine. She said she had instructed facility staff that if Resident #1 was sleeping or was not responsive they could hold the dose and document. She stated she was surprised Resident #1 did not pass away sooner as she was in the active stage of dying.<BR/>During an interview on [DATE] at 02:30 PM HRN B stated she dropped off the new bottle of morphine for Resident #1 to the facility between 12 and 12:30 AM on [DATE]. <BR/>During an interview on [DATE] at 03:02 PM LVN G stated nurses and medication aides were responsible for maintaining secure storage of medication.<BR/>During an interview on [DATE] at 03:05 PM ADON stated it was the responsibility of nurses to maintain secure storage of resident's medication.<BR/>During an interview on [DATE] at 03:10 PM ADM stated it was the responsibility of nurses to maintain secure storage of medications. She stated the facility's investigation into the missing morphine revealed the sign in and out sheet used by the nurses when turning the cart and narcotics over to one another was missing as well making it impossible to determine which nurse had the morphine last.<BR/>During an interview on [DATE] at 03:50 PM LVN F stated HRN B delivered the new bottle of morphine to the facility at about 12:30 AM on [DATE]. <BR/>During an interview on [DATE] at 04:19 PM LVN G stated a possible negative outcome of morphine being misappropriated was someone could drink the whole bottle thinking it was something else.<BR/>During an interview on [DATE] at 04:23 PM CNA L stated a possible negative outcome of morphine being misappropriated was it could cause behaviors and the patient suffers and can be in pain.<BR/>During an interview on [DATE] at 04:24 PM ADON stated a resident's morphine being misappropriated was abuse and inappropriate all around.<BR/>During an interview on [DATE] at 04:25 PM ADM stated a resident whose morphine was misappropriated could have increased pain and medical concerns.<BR/>During an interview on [DATE] at 11:03 AM RN D stated regarding Resident #1's bottle of morphine that was missing from her cart, I don't even remember the bottle being there, I will be honest. I know they said it came a few days before and I don't have a clue what happened to it. I don't remember even counting it. I did not take it and I will lay my life on that. I know another nurse told me we counted it together one of the days before it went missing but I do not remember that to be honest.<BR/>During an interview on [DATE] at 04:01 PM DON stated a possible negative outcome of a resident's morphine being misappropriated was, It could go to the wrong person; a resident would have to go without medication. He stated it was the responsibility of nurses to ensure medications are securely stored. <BR/>Record review of facility policy titled Abuse, Neglect, and Exploitation and dated 10-2023 revealed the following:<BR/> . The facility will provide protection for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, and exploitation and misappropriation of resident property. <BR/>(This policy was missing a page between point IV and point VII. This page was requested from ADM on [DATE] via email at 11:18 AM)<BR/>Record review of undated facility policy titled, Abuse and Neglect Policy and Procedure revealed the following:<BR/> . 1. Misappropriation of resident property - The deliberate misplacement, exploitation, or wrongful, temporary or permanent use of a resident's belongings or money without the resident's consent. <BR/>Record review of facility policy titled Controlled Substances and dated [DATE] revealed the following:<BR/> . The facility complies with all laws, regulations, and other requirements related to handling, storage, disposal, and documentation of controlled medications. 4. Access to controlled medications remains locked at all times and access is recorded 8. Controlled substances are reconciled upon receipt, administration, disposition, and at the end of each shift. 12. At the End of Each Shift: a. Controlled medications are counted at the end of each shift. The nurse coming on duty and the nurse going off duty determine the count together. <BR/>Record review of facility policy titled Storage of Medications and dated [DATE] revealed the following:<BR/> . The facility stores all drugs and biologicals in a safe, secure, and orderly manner. 1. Drugs and biologicals used in the facility are stored in locked compartments . Only persons authorized to prepare and administer medications have access to locked medications. 3. The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner. 6. Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes) containing drugs and biologicals are locked when not in use. Unlocked medication carts are not left unattended. 8. Schedule II-V controlled medications are stored in separately locked permanently affixed compartments. Access to controlled medication is separate from access to non-controlled medications.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to develop and implement written policies and procedures that ensure all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source are reported immediately, but not later than 2 hours after the allegation is made for 1 of 5 residents (Resident #1) reviewed for reportable incidents. <BR/>On 3/2/2024, Resident #1 had an unwitnessed fall with a laceration on the head requiring staples and the facility failed to report it to State Agency.<BR/>This failure can result in physical or mental harm, physical or mental decline, and continued patient neglect.<BR/>Findings include:<BR/>Record review of Resident #1's face sheet, undated, revealed a [AGE] year-old female who was re-admitted to the facility on [DATE]. Diagnoses included but were not limited to Dementia (decline in cognitive abilities that impacts a person's ability to perform everyday activities), repeated falls, major depressive disorder (persistent feeling of sadness and loss of interest), and muscle weakness.<BR/>Record review of Resident #1's MDS, dated [DATE], revealed a BIMS score of 03 which indicated severe cognitive impairment. This MDS documented that Resident #1 had had two falls with no inuries.<BR/>Record review of Resident #1's care plan updated 3/8/24 revealed a goal that the resident would remain free of injuries and falls. Interventions included assess footwear for proper fit and non-skid soles or socks, wander alarm, physical therapy referral, encourage use of call light, instruct resident on safety measures and keep call light within reach.<BR/>Record review of Resident #1's event report, dated 3/2/24, reflected Resident #1 had an unwitnessed fall with a laceration to the back of the head. Record indicated Resident #1 was transferred to hospital for evaluations and treatment.<BR/>Record review of resident's progress note written by ADON, dated 3/12/24, reflected the ADON removed staples from resident.<BR/>In an interview on 3/13/24 at 3:24 PM, the FM of Resident #1 stated Resident #1 fell and hit her head a couple of weeks ago. The FM stated Resident #1 had to go to the emergency room.<BR/>In an interview on 3/13/24 at 4:30 PM, the DON stated Resident #1 had a fall with injury and received three staples. The DON stated RN A working that evening reported the incident to him. The DON stated he contacted the ADM, and the incident was not reported because it was not a significant injury. The DON stated the facility reported head bleeds, fractures, things like that from what he had understood.<BR/>In an interview on 3/13/24 at 4:46 PM with the ADM and CRN, the ADM stated the facility looked at all falls and the ones that are considered significant are reported. The ADM stated fractures, brain bleeds, hematomas, and others. The ADM stated an unwitnessed fall with a laceration to the head requiring three staples was not considered a significant injury. The ADM stated the DON consulted with her, the CRN and the vice president when falls are reported. The ADM stated the DON contacted her and reported Resident #1 sustained an injury. The ADM stated Resident #1 was found scooting across the floor. The CRN joined the interview via telephone and stated she was looking at the event that was created and progress notes. The CRN stated no additional charting was located. The ADM stated the DON received full report. The ADM confirmed Resident #1's injuries were sustained from an unwitnessed fall. The ADM stated a negative outcome of not reporting was the survey could result in a tag. <BR/>In an interview on 3/13/24 at 5:12 PM, the DON stated RN A reported Resident #1 had fallen, obtained a laceration, and Resident #1 was transferred to the hospital. The DON reviewed event record and verified Resident #1's fall was unwitnessed.<BR/>In an interview on 3/13/24 at 5:20 PM, Resident #1 stated she does not remember falling and does not remember how she hurt her head. Resident #1 stated she had staples, but they were taken out the day before. <BR/>In an interview on 3/13/24 at 5:27 PM, RN A stated two staff members notified her about Resident #1's fall. RN A stated Resident #1 was not able to tell her what had happened, and her head was bleeding. RN A stated Resident #1 was not aware she was bleeding. RN A stated Resident #1 never cried, said she was hurting, or realized she had fallen. RN A stated Resident #1 was attempting to use her wheelchair as a walker and that was how RN A assumed she fell. RN A stated she notified the DON, ADM, FMs, and NP. RN A stated the ambulance was called per her judgement since Resident #1 had hit her head and was bleeding. RN A stated she did advise DON it was an unwitnessed fall with injury.<BR/>On 3/13/24, ADM provided policy titled Accidents and Incidents- Investigating and Reporting , revised July 2017, and attached HHSC Long-Term Care Regulatory Provider Letter, Number: PL 19-17 (Replaces PL 17-18), Title Abuse, Neglect, Exploitation, Misappropriation of Resident Property and Other Incidents that a Nursing Facility (NF) Must Report to the Health and Human Services Commission (HHSC), Date Issued: July 10, 2019. The facility's policy did not address reporting incidents to the state agency.<BR/>Record review of TULIP, electronic system that increases the efficiency of the licensure process, revealed no report of Resident #1's fall.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to develop and implement written policies and procedures that ensure all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source are reported immediately, but not later than 2 hours after the allegation is made for 1 of 5 residents (Resident #1) reviewed for reportable incidents. <BR/>On 3/2/2024, Resident #1 had an unwitnessed fall with a laceration on the head requiring staples and the facility failed to report it to State Agency.<BR/>This failure can result in physical or mental harm, physical or mental decline, and continued patient neglect.<BR/>Findings include:<BR/>Record review of Resident #1's face sheet, undated, revealed a [AGE] year-old female who was re-admitted to the facility on [DATE]. Diagnoses included but were not limited to Dementia (decline in cognitive abilities that impacts a person's ability to perform everyday activities), repeated falls, major depressive disorder (persistent feeling of sadness and loss of interest), and muscle weakness.<BR/>Record review of Resident #1's MDS, dated [DATE], revealed a BIMS score of 03 which indicated severe cognitive impairment. This MDS documented that Resident #1 had had two falls with no inuries.<BR/>Record review of Resident #1's care plan updated 3/8/24 revealed a goal that the resident would remain free of injuries and falls. Interventions included assess footwear for proper fit and non-skid soles or socks, wander alarm, physical therapy referral, encourage use of call light, instruct resident on safety measures and keep call light within reach.<BR/>Record review of Resident #1's event report, dated 3/2/24, reflected Resident #1 had an unwitnessed fall with a laceration to the back of the head. Record indicated Resident #1 was transferred to hospital for evaluations and treatment.<BR/>Record review of resident's progress note written by ADON, dated 3/12/24, reflected the ADON removed staples from resident.<BR/>In an interview on 3/13/24 at 3:24 PM, the FM of Resident #1 stated Resident #1 fell and hit her head a couple of weeks ago. The FM stated Resident #1 had to go to the emergency room.<BR/>In an interview on 3/13/24 at 4:30 PM, the DON stated Resident #1 had a fall with injury and received three staples. The DON stated RN A working that evening reported the incident to him. The DON stated he contacted the ADM, and the incident was not reported because it was not a significant injury. The DON stated the facility reported head bleeds, fractures, things like that from what he had understood.<BR/>In an interview on 3/13/24 at 4:46 PM with the ADM and CRN, the ADM stated the facility looked at all falls and the ones that are considered significant are reported. The ADM stated fractures, brain bleeds, hematomas, and others. The ADM stated an unwitnessed fall with a laceration to the head requiring three staples was not considered a significant injury. The ADM stated the DON consulted with her, the CRN and the vice president when falls are reported. The ADM stated the DON contacted her and reported Resident #1 sustained an injury. The ADM stated Resident #1 was found scooting across the floor. The CRN joined the interview via telephone and stated she was looking at the event that was created and progress notes. The CRN stated no additional charting was located. The ADM stated the DON received full report. The ADM confirmed Resident #1's injuries were sustained from an unwitnessed fall. The ADM stated a negative outcome of not reporting was the survey could result in a tag. <BR/>In an interview on 3/13/24 at 5:12 PM, the DON stated RN A reported Resident #1 had fallen, obtained a laceration, and Resident #1 was transferred to the hospital. The DON reviewed event record and verified Resident #1's fall was unwitnessed.<BR/>In an interview on 3/13/24 at 5:20 PM, Resident #1 stated she does not remember falling and does not remember how she hurt her head. Resident #1 stated she had staples, but they were taken out the day before. <BR/>In an interview on 3/13/24 at 5:27 PM, RN A stated two staff members notified her about Resident #1's fall. RN A stated Resident #1 was not able to tell her what had happened, and her head was bleeding. RN A stated Resident #1 was not aware she was bleeding. RN A stated Resident #1 never cried, said she was hurting, or realized she had fallen. RN A stated Resident #1 was attempting to use her wheelchair as a walker and that was how RN A assumed she fell. RN A stated she notified the DON, ADM, FMs, and NP. RN A stated the ambulance was called per her judgement since Resident #1 had hit her head and was bleeding. RN A stated she did advise DON it was an unwitnessed fall with injury.<BR/>On 3/13/24, ADM provided policy titled Accidents and Incidents- Investigating and Reporting , revised July 2017, and attached HHSC Long-Term Care Regulatory Provider Letter, Number: PL 19-17 (Replaces PL 17-18), Title Abuse, Neglect, Exploitation, Misappropriation of Resident Property and Other Incidents that a Nursing Facility (NF) Must Report to the Health and Human Services Commission (HHSC), Date Issued: July 10, 2019. The facility's policy did not address reporting incidents to the state agency.<BR/>Record review of TULIP, electronic system that increases the efficiency of the licensure process, revealed no report of Resident #1's fall.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to implement a comprehensive care plan for each resident that includes measurable objectives and timeframes to meet a resident's medical, nursing, mental, and psychosocial needs that are identified in the comprehensive assessment and describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 3 (Resident #2, #14, and #18) of 12 Residents reviewed for comprehensive care plans.<BR/>-The facility failed to include care plans for Resident #2's correct code status (Advanced Directive) and for her hospice care. <BR/>-The facility failed to include care plans for Resident #14's correct code status (Advanced Directive).<BR/>-The facility failed to include care plans for Resident #18's hospice care.<BR/>This failure could affect all residents in the facility receiving care per comprehensive person-centered care plans resulting in resident not being able to attain or maintain their highest practicable physical, mental, and psychosocial well-being. <BR/>Finding include:<BR/>Resident #2<BR/>Record review of Resident #2's face sheet printed 6-5-2023 revealed she was a [AGE] year-old female resident admitted to the facility originally on 10-4-2022 and readmitted on [DATE] with diagnoses to include atherosclerotic heart disease (a buildup of fat, cholesterol, and other substances in the artery walls), urinary tract infection (an infection in any part of the urinary system, the kidneys, bladder, or urethra), muscle weakness (a lack of muscle strength), acute pain, dementia (a group of thinking and social symptoms that interferes with daily functioning), and congestive heart failure (a chronic condition in which the heart dose not pump blood as well as it should). Section: Directives Resident #2 is listed was a Do Not Resuscitate (DNR). <BR/>Record review of Resident #2's clinical record revealed her last MDS assessment was a significant change of condition completed 3-10-2023 listing her with a BIMS of 3 indicating she was severely cognitively impaired, and she had a functionality of requiring one-person assistance with most of her activities of daily living. Section O Special Treatments, Procedures, and Programs: K-Hospice Care-Resident #2 is listed as having Hospice While a Resident.<BR/>Record review of Resident #2's Orders form (undated) revealed the following orders:<BR/>Code Status: Do Not Resuscitate (DNR) - start date 5-9-2023<BR/>Admit to Hospice. Diagnose of Alzheimer's - start date of 3-6-2023<BR/>Record review completed 06-05-2023 at 03:34 PM of Resident #2's clinical record revealed a correctly filled out OOH-DNR dated 5-9-2023<BR/>Record review of Resident #2's care plan with admission date of 10-4-2022 revealed the following:<BR/>Problem: Advanced Directives/Advanced Care Planning: I am a FULL CODE; I wish to be resuscitated if I should stop breathing. - start date of 10-4-2022, edited 4-25-2023.<BR/>Goal: The Resident and/or Responsible Party will communicate their wishes regarding Advanced Directives / Advanced Care Planning and facility staff will honor their stated preferences. - edited 4-25-2023<BR/>Record review of Resident #2's care plan with admission date of 10-4-2022 revealed there was no care plan for Hospice care.<BR/>Resident #14<BR/>Record review of Resident #14's face sheet printed 6-5-2023 revealed she was a [AGE] year-old female resident admitted to the facility on [DATE] with diagnoses to include Parkinson's (a disorder of the central nervous system that affects movements to include tremors), muscle weakness (a lack of muscle strength), and type 2 diabetes (a chronic condition that affects the way the body processes blood sugar (glucose). Section: Directives Resident #2 is listed as a Do Not Resuscitate (DNR). <BR/>Record review of Resident #14's clinical record revealed her last MDS assessment was a quarterly completed 3-12-2023 listing her with a BIMS of 14 indicating she was cognitively intact, and she had a functionality of requiring one-person assistance with most of her activities of daily living. <BR/>Record review of Resident #14's Orders form (undated) revealed the following orders:<BR/>Code Status: Do Not Resuscitate (DNR) - start date 9-22-2022<BR/>Record review completed on 06-06-2023 at 09:26 AM of Resident #14's clinical record revealed a correctly filled out OOH-DNR dated 9-22-2022<BR/>Record review of Resident #14's care plan with admission date of 2-1-2022 revealed the following:<BR/>Problem: Advanced Directives/Advanced Care Planning: I am a FULL CODE; I wish to be resuscitated if I should stop breathing. - start dated of 2-2-2022, edited 5-2-2023<BR/>Goal: The Resident and/or Responsible Party will communicate their wishes regarding Advanced Directives / Advanced Care Planning and facility staff will honor their stated preferences. - edited 5-2-2023<BR/>Resident #18<BR/>Record review of Resident #18's face sheet printed 6-6-2023 revealed she was a [AGE] year-old female resident admitted to the facility originally on 10-4-2022 and readmitted on [DATE] with diagnoses to include atherosclerotic heart disease (a buildup of fat, cholesterol, and other substances in the artery walls), Buerger's disease (thromboangiitis obliterans-affects blood vessels in the body, most commonly the legs and arms resulting in vessels swelling which can prevent blood flow resulting in blood clots), peripheral vascular disease (a circulatory condition in which narrowed blood vessels recue blood flow to the limbs), and malnutrition (lack of proper nutrition).<BR/>Record review of Resident #18's clinical record revealed her last MDS assessment was a significant change of condition completed 4-5-2023 listing her with a BIMS of 5 indicating she was severely cognitively impaired, and she had a functionality of requiring one to two-person assistance with her activities of daily living. Section O Special Treatments, Procedures, and Programs: K-Hospice Care-Resident #2 is listed as having Hospice While a Resident.<BR/>Record review of Resident #18's Orders form (undated) revealed the following orders:<BR/>Admit to Hospice. Primary Diagnoses-Atherosclerotic Heart Disease - start date of 4-5-2023<BR/>Record review of Resident #18's care plan with admission date of 2-7-2022 revealed the following:<BR/>There was no care plan for Hospice care.<BR/>During an interview on 06-07-2023 at 08:17 AM the CRN verified that Resident #2 was on hospice and had a DNR per Resident #2's orders and stated that she updated Resident #2's care plan the evening of 6-6-2023 due to the care plan did not include that Resident #2 was on hospice and the care plan reported Resident #2 as a full code. The CRN verified that Resident #14 was a DNR per Resident #14's orders but Resident #14's current care plan was for a full code. The CRN reported that she would update Resident #13's care plan right now to reflect her DNR status. The CRN reported that Resident #14 had a problem with her DNR, and it was corrected on 4-20-2023 but Resident #14's care plan should have been update on 4-20-2023 to reflect Resident #14's correct code status. The CRN verified that Resident #18 was on Hospice per Resident #18's orders and stated that she updated Resident #18's care plan to include and address Resident #18's hospice the evening of 6-6-2023 because Resident #18 was not care planned for her hospice. The CRN reported that the previous DON was supposed to be doing the care plans and updating the care plans, but the facility has since found out that the previous DON was not taking care of the care plans. The CRN reported that the previous DON resigned approximately 3 weeks ago and that she (the CRN) had been attempting to keep up with the care plans but had not had enough time to address them properly. When asked what problems can occur when care plans do not reflect the resident's needs, the CRN reported that residents can receive inappropriate care and they can have poor outcomes. <BR/>During an interview on 06-07-2023 at 09:00 AM when asked what problems could occur when care plans do not reflect the resident's needed care the Administrator reported that staff will not be able to follow care correctly if the care plan is not accurate, that the care plan should always be updated, and resident care could be affected. <BR/>Record review of facility provided policy titled Care Plans, Comprehensive Person-Centered, revised December 2020, revealed the following:<BR/>Policy Interpretation and Implementation-<BR/>8. The comprehensive, person-centered care plan will<BR/>-b. Describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being.<BR/>-g. Incorporate identified problem area<BR/>9. Areas of concern that are identified during the resident assessment will be evaluated before interventions are added to the care plan.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews the facility failed to ensure that the resident's environment remained as free of accident hazards as possible, and that the resident received adequate supervision and assistive devices to prevent accidents for 1 of 5 residents (Resident #1) reviewed for accident hazards.<BR/>CNA A failed to use a transfer belt while attempting to transfer Resident #1 from the bed to the wheelchair. <BR/>This failure could place residents at risk of unsafe transfers, resulting in falls, injuries, and a decreased quality of life.<BR/>Findings included:<BR/>Record review of Resident #1's clinical records revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #1 had a diagnoses which included Unspecified Systolic (congestive) Heart Failure ( a condition of the heart where the heart is weak and the left ventricle cannot contract normally when the heart beats), Urinary Tract Infection, site not specified, Other Abnormalities of Gait and Mobility, Unspecified Dementia, moderate, with Anxiety, Muscle weakness (generalized), Cognitive Communication Deficit (communication difficulty cause by cognitive impairment), Cellulitis of Right Lower limb (Infection of the skin), Pain in unspecified shoulder, Dementia in other diseases classified elsewhere, Unspecified severity, with Other Behavioral Disturbance, Altered mental status, unspecified, Heart failure, unspecified, and Acute Respiratory Failure with Hypoxia (impairment of gas exchange between the lungs and the blood, causing shortness of breath, anxiety and confusion). Resident #1 had a BIMS score of 02, which indicated severe cognitive impairment. Her Morse Fall Scale dated 12/13/2024 revealed a history of falling related to a secondary diagnosis, the use of a walker for ambulation, a weak gate, and an overestimation of her physical limitations. <BR/>Record review of Resident #1's Quarterly MDS dated [DATE] revealed Resident #1's bed mobility and transfers were extensive assistance (resident involved in activity, staff provide weight-bearing support) with one-person physical assist. <BR/>Record review of Resident #1's Care Plan dated 01/02/2025 revealed Resident #1's Problem of ADL Functional Status/Rehabilitation Potential, a Goal of Resident will achieve maximum functional mobility and an Approach of Bed mobility amount of assist: extensive x 1 assist and Transferring amount of assist: extensive x 1 assist. Resident #1's Care Conference Notes indicated Resident #1 needed substantial assistance to both sit up and stand, as her condition was declining, and she received Hospice services. <BR/>In a phone interview 01/28/2025 at 2:27PM Resident #1's POA revealed she had video surveillance from a [NAME] which had been place in Resident #1's room, prior to her death in the facility on 01/11/2025. The POA stated the video clearly showed an improper transfer being done by CNA A, where she first lifts Resident #1 from a supine (laying on the back) position to a sitting position by lifting her from the back of her neck to aid Resident #1 in sitting up. The POA stated CNA A then helped Resident #1 to a sitting position on the edge of the bed and began to lift Resident #1 by pulling on the resident's outstretched arms, trying to bring Resident #1 to a standing position. The video was reviewed by the state surveyor and the POA's observations proved to be correct. The POA stated Resident #1 was not hurt in any way during the attempted transfer, but the manner in which the transfer was attempted, was concerning. <BR/>An interview with the Administrator, the DON and the Corporate Nurse on 01/29/2025 at 12:55PM revealed a competency checklist was used by the ADON and DON to evaluate CNA competency in transfers from bed to wheelchair and were to be done using a transfer belt. The administrator stated Resident #1 did not like the transfer belt but was told its use was for her safety. She stated she did not know why CNA A had not used a transfer belt, as was revealed in the supplied video from the resident's POA.<BR/>Phone interviews with CNA A were attempted on 01/29/2025 at 11:12AM and 1:22PM but were unsuccessful. She was unable to be reached and there was no voicemail set up to request a return call.<BR/>Record review of the CNA Transfers Competency Checklist read as follows:<BR/>Before assisting to stand, resident is assisted to a sitting position with feet flat on the floor.<BR/>Before assisting to stand, apply transfer belt securely at the waist over clothing/gown.<BR/>Before assisting to stand, provide instructions to enable resident to assist in the transfer including a prearranged signal to alert when to begin standing.<BR/>Stand facing the resident, positioning self to ensure safety of resident during transfer. Count to three (or say prearranged signal) to alert resident to begin standing.<BR/>On signal, gradually assist resident to stand by grasping transfer belt on both sides with an upward grasp (resident's hands are in an upward position) and maintain stability by standing knee-to-knee or toe-to- toe with the resident.<BR/>Record review of CNA A's checklist reflected it was signed by the ADON as competent on 12/26/2024. The ADON was not available for interview.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure resident had the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences except when to do so would endanger the health or safety of the resident or other residents for 1 of 7 Residents (Resident #1) reviewed for reasonable accommodations.<BR/>The facility failed to ensure Resident #1's call light was within reach and able to use if desired.<BR/>This failure could place residents at risk of not maintaining the resident's independence and provide necessary assistance if needed. <BR/>Findings included:<BR/>Record review of Resident #1's face sheet reflected a [AGE] year-old female who was readmitted to the facility on [DATE] with an initial admit date of 7/9/21. Resident #1 had diagnoses which included but were not limited to alcohol dependence with alcohol-induced persisting dementia (alcohol contributing to memory loss), type 2 diabetes mellitus without complications, essential (primary) hypertension, heart failure, unspecified, unspecified atrial fibrillation, Hyperlipidemia (high cholesterol), atherosclerotic heart disease of native coronary artery without angina pectoris (chest pains associated with narrowing or blocked arteries), chronic obstructive pulmonary disease (COPD; airflow blockage), unspecified, psychotic disorder with delusions due to known physiological condition, major depressive disorder, recurrent severe without psychotic features, anxiety disorder, unspecified, absolute glaucoma (eye disease causing vision loss or blindness) other abnormalities of gait and mobility, Other lack of coordination, other reduced mobility, difficulty in walking, need for assistance with personal care. Resident #1 was identified as being on hospice. <BR/>Record review of Resident #1's MDS reflected a BIMS score of 2, which indicated severe cognitive impairment (which is a condition that significantly limits the individual's physical or mental abilities so that he or she is unable to perform basic work activities.)<BR/>Record review of Resident #1's care plan, dated 4/22/23 last reviewed or revised on 7/7/23, indicated this goal: Resident will remain free from falls/injuries with an approach to keep call light in reach at all times.<BR/>Observation on 7/7/23 at 3:30 PM revealed Resident #1 lying in bed. The resident's call light was located by the bedside table located to the left of the bed next to privacy curtain, and out of the resident's reach.<BR/>Interview on 7/7/23 at 2:10 PM with CNA A revealed the call light was out of reach, a negative outcome for the resident would be she could injure herself and would be unable to call for help.<BR/>Interview on 7/7/23 at 2:12 PM with CNA B revealed a negative outcome of the call light being out of reach would be the resident could have been hurt and waited for a while.<BR/>Interview on 7/7/23 at 2:32 PM with the DON revealed call lights were to be within reach anytime residents were in their room. The DON stated a negative outcome of the call light not being within reach would be the resident wouldn't receive care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide, based on the comprehensive assessment and care plan and the preferences of each resident, an ongoing program to support residents in their of activities; both facility-sponsored group and independent activities designed to meet the interests of and support the physical, mental, and psychological well-being of each resident, to encourage both independence and interaction in the community for 2 of 7 residents (Residents #2 and #3) reviewed for activities.<BR/>The facility failed to provide specific activities to Resident #2 and Resident #3 based on their preferences, abilities, and care plans.<BR/>This failure could place residents at risk of psychosocial decline, social isolation, and a decreased quality of life due to personal preferences not being met.<BR/>Findings Included:<BR/>Record review of Resident #2's face sheet revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #2 had diagnoses included but not limited to Parkinson's disease, other abnormalities of gait and mobility, muscle wasting and atrophy, muscle weakness, need for assistance with personal care, other reduced mobility, other lack of coordination, and type 2 diabetes mellitus. Resident #2 was admitted to hospice.<BR/>Record review of Resident #2's quarterly MDS dated [DATE], revealed a BIMS of 13, which indicated the resident was cognitively intact.<BR/>Record review of Resident #2's care plan, dated 5/2/22, indicated a problem with the category of activities. The goal for the plan stated, resident will attend/participate in 1 activity per week with an approach of introduce activities offered. Problem stated in care plan, dated 5/2/22, with category of mood state with a goal of resident will express/exhibit satisfaction. Approach to goal indicated to encourage group activities resident enjoys with no specific information provided to the approach.<BR/>Interview on 7/723 at 3:12 PM with Resident #2 and Resident family member stated that there was nothing planned for the fourth of July. Resident also stated that the only activities that are offered are individual and would like more group activities to take place. Resident #2 also stated that word searches and coloring pages do not interest her. Resident #2 did not indicate specific activities that they would like to take place in the facility. Resident #2 also indicated that there was no July 4th activity that took place in the facility. <BR/>Resident #3<BR/>Record review of Resident #3's face sheet revealed a [AGE] year-old female who was admitted to the facility on [DATE], with a current return date of 4/19/23. Resident #3 had diagnoses which included but not limited to Unspecified dementia (a conditions in which a person loses ability think, remember, learn and make decisions) unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, Muscle weakness (generalized), Insomnia (inability to sleep), Dysphagia (difficulty swallowing), Dementia in other diseases classified elsewhere, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, Generalized anxiety disorder, Other lack of coordination, Cognitive communication deficit (difficulty with thinking and using language), need for assistance with personal care, Unspecified lack of coordination, Difficulty in walking, other abnormalities of gait and mobility, muscle wasting and atrophy (decrease in size or wasting away of a body part or tissue). <BR/>Interview on 7/7/23 at 2:48 PM with Resident #3's family member stated that there is nothing for their family member to do but watch TV. Stated that understands Resident #3's memory is not great and needs guidance but wishes there was more for her to do than to watch T.V. all day. Family member did not specify specific activities that his family member can or should take part in.<BR/>Record review of Resident #3's MDS (Minimum Data Set), dated 5/5/2023, indicated a BIMS of 04, which indicated severe impairment.<BR/>Observation and record review on 7/7/23 at 4:10 PM revealed that four activities were scheduled for Friday, 7/7/23, of Music, Game of the Week, Tic Tac Toe, and Summer Color Pages and no activities took place while surveyors were in the facility. Investigations began at the facility from 9:02 AM to 5:10 PM. Activities scheduled for 7/7/23 were music on IN2L at 9 AM; Game of the week on IN2L at 1 PM, Tic Tac Toe at 2 PM, and Summer Color Pages at 4 PM. During tour and initial interviews, no activity was taking place at 9:02 AM in the dining room as this is where the IN2L is located. IN2L was not in working order and no alternate activity taking place.<BR/>Observation on 7/7/23 at 1 PM of dining room after lunch service revealed IN2L continued to be out of service and no additional activity taking place. <BR/>Observations of scheduled activities at 2 PM and 4PM did not take place and there was not alternate activity planned. <BR/>Interview on 7/7/23 at 4:10 PM with ACTD indicated there are four activities a day planned. Most are individual activities, such as coloring. Stated that no activities have taken place today due to the interactive system of games and puzzles which are on a large screen, not being in working order. ACTD also stated that ACTD stated that most of the activities are individual and placed in dining room such as coloring pages. Stated that alternate activities of coloring pages, paint by numbers, and word search are available should the scheduled activity not take place. <BR/>Exit conference on 7/7/23 at 4:53 PM with ADM, DON, ADON, and ACTD revealed that activities had been discussed with residents and a July 4th activity was planned. ACTD voiced that a July 4th activity took place. ADM asked if Surveyors would review council minutes and provided a copy for review.<BR/>Record review on 7/7/23 of Resident Council minutes from 4/14/23, 5/30/23, and 6/9/23 revealed activities were discussed in the month of April, which indicated that a Cinco de Mayo activity was planned for May 5, 2023. The minutes from May and June documented no upcoming activities for June and July.

Based on observation, interview, and record review, the facility failed to store, prepare, and serve food under sanitary conditions in the facility's only kitchen when they failed to:<BR/>A. Ensure foods were prepared and served under sanitary conditions.<BR/>B. Ensure all foods were labeled and dated<BR/>These failure placed residents who ate food served by the kitchen at risk of cross contamination and food-borne illness. <BR/>Findings include:<BR/>In an observation of the kitchen on 05/09/22 at 9:40 AM the following was observed in the freezer:<BR/>1. <BR/>Two bags of cubed chicken, no label or date, not in original box<BR/>2. <BR/>Six bags of mixed vegetables, no label or date, not in original box<BR/>3. <BR/>Nine bags of squash, no label or date, not in original box<BR/>4. <BR/>Six bags of 6 frozen mini pizzas, no label or date, not in original box<BR/>5. <BR/>Three packages of okra, no label or date, not in original box<BR/>In an observation and interview at 12:10 PM on 05/09/22, [NAME] A was observed touching rolls with her gloved hands after touching multiple surfaces in the kitchen and picking up plates for the resident's lunch. When [NAME] A was asked if she realized she was picking up bread with her gloved hands she stated she did not realize she did that. She stated she never used tongs as she has small hands and the tongs never fit her hands. [NAME] A stated she did not know she should be using tongs for bread. [NAME] A stated the consequences of this action were that she could transfer germs to the food when using her hands which would cause the residents to get sick from food poisoning. [NAME] A stated she had received training from the dietary manager on cleanliness in the kitchen. <BR/>In an observation of the kitchen on 05/10/22 at 8:45 AM, the following was observed in the freezer:<BR/>1. <BR/>Two bags of cubed chicken, no label or date, not in original box<BR/>2. <BR/>Eleven bags of mixed vegetables, no label or date, not in original box<BR/>3. <BR/>Nine bags of squash, no label or date, not in original box<BR/>4. <BR/>Six bags of 6 frozen mini pizzas, no label or date, not in original box<BR/>5. <BR/>Three packages of okra, no label or date, not in original box<BR/>6. <BR/>Three packages of tator tots, no label or date, not in original package<BR/>7. <BR/>Three packages of French fries, no label or date, not in original box<BR/>In an observation of the kitchen on 05/11/22 at 10:15 AM, the following was observed in the freezer:<BR/>1. <BR/>Two bags of cubed chicken, no label or date, not in original box<BR/>2. <BR/>Six bags of mixed vegetables, no label or date, not in original box<BR/>3. <BR/>Nine bags of squash, no label or date, not in original box<BR/>4. <BR/>Six bags of 6 frozen mini pizzas, no label or date, not in original box<BR/>5. <BR/>Three packages of okra, no label or date, not in original box<BR/>6. <BR/>One package of French toast, no label or date, not in original box<BR/>In an interview on 05/11/22 at 10:30 AM, the DM stated staff should be washing hands and changing gloves between tasks. The DM stated staff should not be touching food with hands. The staff should use tongs when serving food. The DM stated she is responsible for training staff in handwashing and glove use. The DM further stated all foods should be labeled and dated. She stated she will statr using stickers to label all foods. The DM stated she had training in hand washing and glove use as well as labeling and dating foods. <BR/>Record Review of the facility policy titled, Dining Services Policy Manual dated October 2019, revealed in part : All food items will be appropriately labeled and dated either through manufacturer packaging or staff notation . Food Service employees will minimize bare hand contact with food that is ready to eat .food employees may not contact ready to eat food with their bare hands .suitable utensils such as tongs must be used <BR/>Record Review of the US Food Code, dated 2017, revealed:<BR/>2-301.14 When to Wash.<BR/>FOOD EMPLOYEES shall clean their hands and exposed portions of their arms as specified under &sect; 2-301.12 immediately before engaging in FOOD preparation including working with exposed FOOD, clean EQUIPMENT and UTENSILS, and unwrapped SINGLE-SERVICE and SINGLE-USE ARTICLES and:<BR/>(E)<BR/>After handling soiled EQUIPMENT or UTENSILS. <BR/>(F)<BR/>During FOOD preparation, as often as necessary to remove soil and contamination and to prevent cross contamination when changing tasks; <BR/>(H)<BR/>Before donning gloves to initiate a task that involves working with FOOD. <BR/>(I)<BR/>After engaging in other activities that contaminate the hands.<BR/>Record review of the USDA Food Code, dated 2017, revealed:<BR/>3-501.17 <BR/> Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking.<BR/>(A) Except when PACKAGING FOOD using a REDUCED OXYGEN PACKAGING method as specified under &sect; 3-502.12, and except as specified in (E) and (F) of this section, refrigerated, READY-TOEAT, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and held in a FOOD ESTABLISHMENT for more than 24 hours shall be clearly marked to indicate the date or day by which the FOOD shall be consumed on the PREMISES, sold, or discarded when held at a temperature of 5&ordm;C (41&ordm;F) or less for a maximum of 7 days. The day of preparation shall be counted as Day 1.

Based on observation, interview, and record review the facility failed to store all drugs and biologicals in accordance with State and Federal laws in locked compartments for 1 (200 hall cart) of 3 medication carts reviewed for medication storage.<BR/>The facility failed to lock the medication cart in hall 200.<BR/>This failure could place residents at risk for obtaining medications not prescribed to them and experiencing adverse reactions.<BR/>Findings Included:<BR/>During an observation on 04/24/24 at 08:49 PM the medication cart in hall 200 was unlocked. All three drawers were easily opened and full of medications. The double locked drawers to the right of the medication cart were unlocked on the first lock but the second lock of each drawer was still locked. A resident was awake and seated in his recliner in his room in line of sight of the medication cart. No staff members were in sight.<BR/>During an observation on 04/24/24 at 08:54 PM the unlocked medication cart in hall 200 was unattended and no staff members were in sight.<BR/>During an interview and observation on 04/29/24 at 03:02 PM LVN G stated an unlocked medication cart could lead to residents taking medication that was not prescribed to them. She stated it was the nurse's responsibility to keep the medication cart lock and medications secured.<BR/>During an interview on 04/29/24 at 03:05 PM ADON stated if a medication cart was left unlocked residents could get hold of medication. She stated it was the responsibility of nurses to keep the medication carts locked when not in use.<BR/>During an interview on 04/29/24 at 03:06 PM CNA L stated if a medication cart was left unlocked patients have access to meds and staff freely have access to meds. She stated, Someone can get poisoned.<BR/>During an interview on 04/29/24 at 03:10 PM ADM stated if a medication cart was left unlocked medications could be taken and residents might not be able to receive the medications they have been prescribed. She stated the facility was responsible for the overall security of medication we have been entrusted with.<BR/>During an interview on 04/29/24 at 03:50 PM LVN F stated it was the responsibility of the nurse to keep the medication cart locked. She said if a medication cart was left unlocked medications could be taken.<BR/>During an interview on 04/30/24 at 11:03 AM LVN D stated it was the nurse's responsibility to keep medication carts locked to keep residents out of the medication.<BR/>During an interview on 05/01/24 at 04:01 PM DON stated he did not remember leaving the medication cart unlocked during the evening of 04/24/24. He stated nurses were responsible for ensuring medication carts were locked. DON stated a possible negative outcome of an unlocked medication cart was anyone could get in the medication cart.<BR/>Record review of facility policy titled Controlled Substances and dated April 2019 revealed the following:<BR/> . The facility complies with all laws, regulations, and other requirements related to handling, storage, disposal, and documentation of controlled medications.<BR/>Record review of facility policy titled Storage of Medications and dated November 2020 revealed the following:<BR/> . The facility stores all drugs and biologicals in a safe, secure, and orderly manner. 1. Drugs and biologicals used in the facility are stored in locked compartments . Only persons authorized to prepare and administer medications have access to locked medications. 3. The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner. 6. Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes) containing drugs and biologicals are locked when not in use. Unlocked medication carts are not left unattended.

Based on interview, and record review, the facility failed to use the services of a registered nurse for at least 8 consecutive hours a day, 7 days a week for 21 (4-2-2023, 4-9-2023, 4-16-2023, 4-23-2023, 4-30-2023, 5-7-2023, 5-14-2023, 5-15-2023, 5-16-2023, 5-17-2023, 5-18-2023, 5-19-2023, 5-21-2023, 5-22-2023, 5-23-2023, 5-26-2023, 5-28-2023, 5-29-2023, 6-1-2023, 6-2-2023, and 6-4-2023) of the last 90 days reviewed.<BR/>The facility did not have an RN working in the facility for 21 (4-2-2023, 4-9-2023, 4-16-2023, 4-23-2023, 4-30-2023, 5-7-2023, 5-14-2023, 5-15-2023, 5-16-2023, 5-17-2023, 5-18-2023, 5-19-2023, 5-21-2023, 5-22-2023, 5-23-2023, 5-26-2023, 5-28-2023, 5-29-2023, 6-1-2023, 6-2-2023, and 6-4-2023) of the last 90 days reviewed. <BR/>This deficient practice had the potential to affect residents in the facility by leaving staff without supervisory coverage for coordination of events such as hospice care, emergency care and disasters such as with flooding, power outage, tornado, fire, etc. <BR/>Findings include: <BR/>Record review of the facility's last 90 days (3-7-2023 to 6-4-2023) of RN coverage provide by the Administrator revealed the facility had no RN working in the facility for the following dates:<BR/>4-2-2023, 4-9-2023, 4-16-2023, 4-23-2023, 4-30-2023, 5-7-2023, 5-14-2023, 5-15-2023, 5-16-2023, 5-17-2023, 5-18-2023, 5-19-2023, 5-21-2023, 5-22-2023, 5-23-2023, 5-26-2023, 5-28-2023, 5-29-2023, 6-1-2023, 6-2-2023, and 6-4-2023.<BR/>During an interview on 06-07-2023 at 07:55 AM the Administrator verified that the facility did not have an RN working in the facility for 21 out of the last 90 days mostly due to not having a DON for the previous 3 weeks and the Administrator reported that the Clinical Resource Nurse was having cover for the facility. The Administrator reported that they would not and did not have any issues with not having RN coverage because if staff needed an RN, they could call her or the Clinical Resource Nurse for information or to come check on something if needed. The Administrator reported that the Clinical Resource Nurse lived 30 minutes from the facility. The Administrator reported that they have been evaluating resident and not accepting any if they had a skill that required an RN such as a resident that required a ventilator. The Administrator reported that the residents that were on Hospice if they coded staff would call the hospice nurse to come and call the code. The Administrator reported that she felt there would be no negative outcomes with not having RN coverage in the building. <BR/>During an interview on 06-07-2023 08:41 AM the CRN verified that the facility did not have an RN working in the facility for 21 of the last 90 days and reported the if the facility did not have the needed RN coverage residents could have poor clinical outcomes. The CRN reported that staff do call her if needed and that she can be at the facility within 25 minutes if needed.<BR/>During an interview on 06-07-2023 at 10:46 AM the CRN reported that for RN coverage the facility does not have a specific RN coverage policy, that the facility follows federal guidelines.

Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communication diseases and infections for 4 (#13, #11, #29, and #21) of 25 Residents. <BR/> LVN A failed to use proper hand hygiene techniques when preparing and administering medications to Residents. <BR/>These failures had the potential to affect all residents in the facility by placing them at risk of contracting, spreading, and/or exposing them to bacterial or viral infections that could lead to the spread of communicable diseases.<BR/>Findings included: <BR/>During an observation 06/05/23 11:26 AM observation of LVN A was preparing medication for Resident #13. Medication was being prepared; hand hygiene did not take place before the preparation of Resident #13's insulin.<BR/>During an observation on 06/05/23 11:40 AM Observed LVN A preparing medication for Resident #11, medication was Furosemide 40mg. No hand hygiene was performed before preparing this medication or after LVN A returned to medication cart. <BR/>During observation on 06/05/23 11:44 AM Observed LVN A preparing medication for Resident #29, medication was Gabapentin 100mg/2 capsules. No hand hygiene was performed before preparing this medication or after medication was administered. <BR/>During observation on 06/05/2023 11:51 AM Observed LVN A preparing medication for Resident #21, medication was Buspirone HCL 10mg tablet and Dicyclomine 10mg tablet. No hand hygiene was performed before medication was administered to Resident #21. <BR/>During an interview 06/06/23 10:25 AM with LVN A was asked why hand hygiene did not take place before and after the preparation and administration of medication for Residents. LVN A stated that there was no specific reason why she performed hand hygiene some of the time and not all of the time. LVN A was asked what a negative outcome would be if she didn't wash hands and LVN A stated the spread of infection. <BR/>During an interview 06/07/23 08:14 AM with CRN was asked what a negative outcome would be when hand washing didn't occur before and after preparation of medications. CRN stated that it could contribute to the spread of infection.<BR/>Record review of facility policy dated/revised 01/20/2023 titled Hand Washing/Hand Hygiene revealed the following: <BR/>Does not address the issue of hand hygiene during medication administration and preparation of medications.

Based on interviews and record reviews, the facility failed to ensure to employ sufficient staff with the appropriate competencies and skill sets to provide quality care to 1 of 5 residents (Resident #1) who were reviewed for mechanical lifts.<BR/>The facility failed to provide or confirm training for LVN A on proper use of mechanical lifts.<BR/>This failure can place residents at risk of physical or psychosocial harm, severe injury, or death while receiving care at the facility. <BR/>Findings included: <BR/>In an interview on 11/7/23 at 2:02 PM, CLNS indicated that staff was not trained on specific equipment. CLNS stated she was unsure if AGNY trained for specific equipment. CLNS provided training packet for agency nurses located at the nurse's station and stated she would attempt to get AGNY training for LVN A.<BR/>In an interview on 11/7/23 at 2:09 PM, CLNS stated ADM had not received training for LVN A from AGNY. <BR/>In an interview on 11/8/2023 at 12:28 PM, ADM stated there have been no changes to the written training material that is provided to agency staff, but no one has worked the floor until they have had training. <BR/>In an interview on 11/8/23 at 2:58 PM, ADM stated CLNS is in charge or training staff. Facility is currently working with AGNY. ADM stated staff is selected on who comes into the facility and they will be trained before they work by RN if it is a weekend shift and they have not worked the facility before. ADM stated no changes will be made to the written training material provided to agency nurses or aides. <BR/>Record review of training material provided to agency nurses, not dated, did not have instructions or guidance with mechanical lifts in the facility.<BR/>On 11/7/23 at 3:11 PM, records were requested of trainings completed by LVN A from AGNY. No response was received.

Based on observation, interview, and record review the facility failed to ensure residents have the right to personal privacy and confidentiality of his or her personal and medical records for 7 (Residents #1, #2, #3, #4, #5, #6, #7) of 40 residents observed for personal privacy and confidentiality in that: <BR/>RN A did not lock the nurse's station computer that contained sensitive resident information such as medication administered, name, room numbers, and advance directives for Residents #1, #2, #3, #4, #5,#6 and #7.<BR/>This failure could place residents at risk for having their personal and medical information exposed.<BR/>Findings Included:<BR/>An observation on 1/17/24 at 1:18 PM revealed a medication cart at the nurse's station with the computer on and unlocked. On the screen was Resident #1's personal information including name, date of birth , medication administered, and code status. On the left side of the screen, Residents #2, #3, #4, #5, and #6 were listed with room numbers listed below the names. Observed RN A walking in from the front door of the facility, around the nurse's station, stopped at the medication cart with the opened computer, used ABHR, and walked into the nurse's station to another computer.<BR/>An observation on 1/17/24 at 1:28 PM revealed the same computer on the medication cart open with Resident #7's information on the screen indicating that Resident #7 had received Tylenol (acetaminophen) 325 mg tablet, oral, as needed and can be administered every 6 hours. <BR/>In an interview and observation on 1/17/24 at 1:31 PM with CRN, CRN walked down three hall and identified the unlocked computer. CRN stated the computer was to be locked after every use. CRN stated locking the computer after each use was taught during orientation. CRN stated there was no paper or online training available for HIPAA documentation. CRN stated RN A oversaw the medication cart containing the computer. CRN stated a negative outcome was it released HIPAA information.<BR/>In an interview on 1/17/24 at 3:02 PM, RN A stated he forgot to close the computer after working on it. Indicated he has been trained on locking the computer since back in nursing school. RN A stated he did learn the procedure at the facility, and he just completed another in-service on HIPAA information. RN A stated a negative outcome could be patient information could be stolen, used, or transferred to someone it doesn't belong to. <BR/>No policy related to HIPAA privacy and documentation was provided by the facility

Based on observation, interview, and record review the facility failed to store all drugs and biologicals in accordance with State and Federal laws in locked compartments for 1 (200 hall cart) of 3 medication carts reviewed for medication storage.<BR/>The facility failed to lock the medication cart in hall 200.<BR/>This failure could place residents at risk for obtaining medications not prescribed to them and experiencing adverse reactions.<BR/>Findings Included:<BR/>During an observation on 04/24/24 at 08:49 PM the medication cart in hall 200 was unlocked. All three drawers were easily opened and full of medications. The double locked drawers to the right of the medication cart were unlocked on the first lock but the second lock of each drawer was still locked. A resident was awake and seated in his recliner in his room in line of sight of the medication cart. No staff members were in sight.<BR/>During an observation on 04/24/24 at 08:54 PM the unlocked medication cart in hall 200 was unattended and no staff members were in sight.<BR/>During an interview and observation on 04/29/24 at 03:02 PM LVN G stated an unlocked medication cart could lead to residents taking medication that was not prescribed to them. She stated it was the nurse's responsibility to keep the medication cart lock and medications secured.<BR/>During an interview on 04/29/24 at 03:05 PM ADON stated if a medication cart was left unlocked residents could get hold of medication. She stated it was the responsibility of nurses to keep the medication carts locked when not in use.<BR/>During an interview on 04/29/24 at 03:06 PM CNA L stated if a medication cart was left unlocked patients have access to meds and staff freely have access to meds. She stated, Someone can get poisoned.<BR/>During an interview on 04/29/24 at 03:10 PM ADM stated if a medication cart was left unlocked medications could be taken and residents might not be able to receive the medications they have been prescribed. She stated the facility was responsible for the overall security of medication we have been entrusted with.<BR/>During an interview on 04/29/24 at 03:50 PM LVN F stated it was the responsibility of the nurse to keep the medication cart locked. She said if a medication cart was left unlocked medications could be taken.<BR/>During an interview on 04/30/24 at 11:03 AM LVN D stated it was the nurse's responsibility to keep medication carts locked to keep residents out of the medication.<BR/>During an interview on 05/01/24 at 04:01 PM DON stated he did not remember leaving the medication cart unlocked during the evening of 04/24/24. He stated nurses were responsible for ensuring medication carts were locked. DON stated a possible negative outcome of an unlocked medication cart was anyone could get in the medication cart.<BR/>Record review of facility policy titled Controlled Substances and dated April 2019 revealed the following:<BR/> . The facility complies with all laws, regulations, and other requirements related to handling, storage, disposal, and documentation of controlled medications.<BR/>Record review of facility policy titled Storage of Medications and dated November 2020 revealed the following:<BR/> . The facility stores all drugs and biologicals in a safe, secure, and orderly manner. 1. Drugs and biologicals used in the facility are stored in locked compartments . Only persons authorized to prepare and administer medications have access to locked medications. 3. The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner. 6. Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes) containing drugs and biologicals are locked when not in use. Unlocked medication carts are not left unattended.

Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communication diseases and infections for 4 (#13, #11, #29, and #21) of 25 Residents. <BR/> LVN A failed to use proper hand hygiene techniques when preparing and administering medications to Residents. <BR/>These failures had the potential to affect all residents in the facility by placing them at risk of contracting, spreading, and/or exposing them to bacterial or viral infections that could lead to the spread of communicable diseases.<BR/>Findings included: <BR/>During an observation 06/05/23 11:26 AM observation of LVN A was preparing medication for Resident #13. Medication was being prepared; hand hygiene did not take place before the preparation of Resident #13's insulin.<BR/>During an observation on 06/05/23 11:40 AM Observed LVN A preparing medication for Resident #11, medication was Furosemide 40mg. No hand hygiene was performed before preparing this medication or after LVN A returned to medication cart. <BR/>During observation on 06/05/23 11:44 AM Observed LVN A preparing medication for Resident #29, medication was Gabapentin 100mg/2 capsules. No hand hygiene was performed before preparing this medication or after medication was administered. <BR/>During observation on 06/05/2023 11:51 AM Observed LVN A preparing medication for Resident #21, medication was Buspirone HCL 10mg tablet and Dicyclomine 10mg tablet. No hand hygiene was performed before medication was administered to Resident #21. <BR/>During an interview 06/06/23 10:25 AM with LVN A was asked why hand hygiene did not take place before and after the preparation and administration of medication for Residents. LVN A stated that there was no specific reason why she performed hand hygiene some of the time and not all of the time. LVN A was asked what a negative outcome would be if she didn't wash hands and LVN A stated the spread of infection. <BR/>During an interview 06/07/23 08:14 AM with CRN was asked what a negative outcome would be when hand washing didn't occur before and after preparation of medications. CRN stated that it could contribute to the spread of infection.<BR/>Record review of facility policy dated/revised 01/20/2023 titled Hand Washing/Hand Hygiene revealed the following: <BR/>Does not address the issue of hand hygiene during medication administration and preparation of medications.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and record review; it was determined the facility failed to ensure drugs and biologicals were stored and labeled in accordance with currently accepted professional principles to include the appropriate accessory and cautionary instructions, and the expiration date when applicable on 1 of 1 medication cart.<BR/>1 bottle of expired medication was found in medication cart. <BR/>The facility's failure to ensure drugs and biologicals were stored and labeled in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable could place all residents receiving medication at risk for drug diversion, drug overdose, and accidental or intentional administration to the wrong resident.<BR/>Findings include:<BR/>During observation on [DATE] at 09:28AM of Medication cart revealed an unopened bottle of Sodium Bicarbonate 10g tablets, the bottle expired 05/2023. The bottle was for general use, not for an individual resident. LVN A removed bottle of medication from medication cart. <BR/>No interviews were obtained.<BR/>Record review of facility policy titled Storage of Medication dated/revised [DATE] states:<BR/>4. Drug containers that have missing, incomplete, improper, or incorrect labels are returned to the pharmacy for proper labeling before storing. Discontinued, outdated, or deteriorated drugs or biologicals are returned to the dispensing pharmacy or destroyed.

Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communication diseases and infections for 4 (#13, #11, #29, and #21) of 25 Residents. <BR/> LVN A failed to use proper hand hygiene techniques when preparing and administering medications to Residents. <BR/>These failures had the potential to affect all residents in the facility by placing them at risk of contracting, spreading, and/or exposing them to bacterial or viral infections that could lead to the spread of communicable diseases.<BR/>Findings included: <BR/>During an observation 06/05/23 11:26 AM observation of LVN A was preparing medication for Resident #13. Medication was being prepared; hand hygiene did not take place before the preparation of Resident #13's insulin.<BR/>During an observation on 06/05/23 11:40 AM Observed LVN A preparing medication for Resident #11, medication was Furosemide 40mg. No hand hygiene was performed before preparing this medication or after LVN A returned to medication cart. <BR/>During observation on 06/05/23 11:44 AM Observed LVN A preparing medication for Resident #29, medication was Gabapentin 100mg/2 capsules. No hand hygiene was performed before preparing this medication or after medication was administered. <BR/>During observation on 06/05/2023 11:51 AM Observed LVN A preparing medication for Resident #21, medication was Buspirone HCL 10mg tablet and Dicyclomine 10mg tablet. No hand hygiene was performed before medication was administered to Resident #21. <BR/>During an interview 06/06/23 10:25 AM with LVN A was asked why hand hygiene did not take place before and after the preparation and administration of medication for Residents. LVN A stated that there was no specific reason why she performed hand hygiene some of the time and not all of the time. LVN A was asked what a negative outcome would be if she didn't wash hands and LVN A stated the spread of infection. <BR/>During an interview 06/07/23 08:14 AM with CRN was asked what a negative outcome would be when hand washing didn't occur before and after preparation of medications. CRN stated that it could contribute to the spread of infection.<BR/>Record review of facility policy dated/revised 01/20/2023 titled Hand Washing/Hand Hygiene revealed the following: <BR/>Does not address the issue of hand hygiene during medication administration and preparation of medications.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and record review; it was determined the facility failed to ensure drugs and biologicals were stored and labeled in accordance with currently accepted professional principles to include the appropriate accessory and cautionary instructions, and the expiration date when applicable on 1 of 1 medication cart.<BR/>1 bottle of expired medication was found in medication cart. <BR/>The facility's failure to ensure drugs and biologicals were stored and labeled in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable could place all residents receiving medication at risk for drug diversion, drug overdose, and accidental or intentional administration to the wrong resident.<BR/>Findings include:<BR/>During observation on [DATE] at 09:28AM of Medication cart revealed an unopened bottle of Sodium Bicarbonate 10g tablets, the bottle expired 05/2023. The bottle was for general use, not for an individual resident. LVN A removed bottle of medication from medication cart. <BR/>No interviews were obtained.<BR/>Record review of facility policy titled Storage of Medication dated/revised [DATE] states:<BR/>4. Drug containers that have missing, incomplete, improper, or incorrect labels are returned to the pharmacy for proper labeling before storing. Discontinued, outdated, or deteriorated drugs or biologicals are returned to the dispensing pharmacy or destroyed.

Based on observation, interview, and record review the facility failed to store all drugs and biologicals in accordance with State and Federal laws in locked compartments for 1 (200 hall cart) of 3 medication carts reviewed for medication storage.<BR/>The facility failed to lock the medication cart in hall 200.<BR/>This failure could place residents at risk for obtaining medications not prescribed to them and experiencing adverse reactions.<BR/>Findings Included:<BR/>During an observation on 04/24/24 at 08:49 PM the medication cart in hall 200 was unlocked. All three drawers were easily opened and full of medications. The double locked drawers to the right of the medication cart were unlocked on the first lock but the second lock of each drawer was still locked. A resident was awake and seated in his recliner in his room in line of sight of the medication cart. No staff members were in sight.<BR/>During an observation on 04/24/24 at 08:54 PM the unlocked medication cart in hall 200 was unattended and no staff members were in sight.<BR/>During an interview and observation on 04/29/24 at 03:02 PM LVN G stated an unlocked medication cart could lead to residents taking medication that was not prescribed to them. She stated it was the nurse's responsibility to keep the medication cart lock and medications secured.<BR/>During an interview on 04/29/24 at 03:05 PM ADON stated if a medication cart was left unlocked residents could get hold of medication. She stated it was the responsibility of nurses to keep the medication carts locked when not in use.<BR/>During an interview on 04/29/24 at 03:06 PM CNA L stated if a medication cart was left unlocked patients have access to meds and staff freely have access to meds. She stated, Someone can get poisoned.<BR/>During an interview on 04/29/24 at 03:10 PM ADM stated if a medication cart was left unlocked medications could be taken and residents might not be able to receive the medications they have been prescribed. She stated the facility was responsible for the overall security of medication we have been entrusted with.<BR/>During an interview on 04/29/24 at 03:50 PM LVN F stated it was the responsibility of the nurse to keep the medication cart locked. She said if a medication cart was left unlocked medications could be taken.<BR/>During an interview on 04/30/24 at 11:03 AM LVN D stated it was the nurse's responsibility to keep medication carts locked to keep residents out of the medication.<BR/>During an interview on 05/01/24 at 04:01 PM DON stated he did not remember leaving the medication cart unlocked during the evening of 04/24/24. He stated nurses were responsible for ensuring medication carts were locked. DON stated a possible negative outcome of an unlocked medication cart was anyone could get in the medication cart.<BR/>Record review of facility policy titled Controlled Substances and dated April 2019 revealed the following:<BR/> . The facility complies with all laws, regulations, and other requirements related to handling, storage, disposal, and documentation of controlled medications.<BR/>Record review of facility policy titled Storage of Medications and dated November 2020 revealed the following:<BR/> . The facility stores all drugs and biologicals in a safe, secure, and orderly manner. 1. Drugs and biologicals used in the facility are stored in locked compartments . Only persons authorized to prepare and administer medications have access to locked medications. 3. The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner. 6. Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes) containing drugs and biologicals are locked when not in use. Unlocked medication carts are not left unattended.