RISING STAR NURSING CENTER

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to develop and implement a comprehensive person -centered care plan for each resident, consistent with the resident rights, that included measurable objectives and timeframes to meet a residents medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for 3 of 8 residents (Residents #6, #25, #26, ) reviewed for care plans. 1. The facility failed to ensure a care plan was developed for Resident #6's scalp wound.2. The facility failed to ensure a care plan was developed for Resident #25's psychosocial issues 3. The facility failed to ensure a care plan was developed for Resident #26's psychosocial issues. Findings include:Resident #6Review of Resident #6's admission Record, dated 9/18/25, revealed he was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses including open wound of scalp, presence of other bone and tendon implants. Review of Resident #6's Quarterly MDS Assessment, dated 7/19/25, revealed the following:*Resident #6 scored 11 of 15 on his BIMS, indicating he was moderately cognitively impaired. *Resident #6 received Skin Treatments applications of ointments/medication other than to feet. Review of Resident #6's Order Summary Report, dated 9/18/25, revealed wound care orders for Right Scalp lesion, cleanse with wound cleanser. Pat Dry. Apply Protective Dressing order dated 4/9/25. Observation on 09/17/2025 at 3:18 PM, this surveyor observed wound care to Resident #6's skin graft on scalp. Review of Resident #6's Care Plan Report, initiated 4/11/25 and last revised on 5/13/25, revealed no care plan on Resident #6's scalp wound and related wound care. Resident #25Review of Resident #25's admission Record, dated 9/18/25, revealed she was a [AGE] year-old female admitted to the facility on [DATE] with diagnosis including Arthritis. Review of Resident #25's Quarterly MDS Assessment, dated 7/28/25, revealed the following: *Resident #25 had moderate difficulty with hearing.*Resident #25 scored 13 of 15 on her BIMS, indicating she was cognitively intact.*Resident #25 reported no signs of depression and showed no behaviors.*Resident #25 required moderate assistance with most activities of daily living. Review of Resident #25's Order Summary Report, dated 9/18/25 revealed no psychotropic medication. Interview on 9/16/25 at 2:37 PM Resident #25 said she was mourning her family and loss of independence. Resident #25 stated she had no choices here. Resident #25 said she felt forgotten about. Resident #25 said she was [AGE] year-old and demanded if surveyor knew what that was like. Resident #25 said all she wanted to do was die because everyone she knew was gone. Resident #25 stated her children came to visit but they did not need her anymore. Review of Resident #25's Care Plan showed a care plan initiated 2/10/22 for Chronic Pain, and pain due to age. There was no care plan regarding Resident #25's acute unhappiness related to her desire to die because she was lonely for initial family, felt useless, and loss of independence. Resident #26Review of Resident #26's admission Record, dated 9/18/25, revealed she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses including arthritis, traumatic brain injury (can cause temporary or short-term memory problems and the person may exhibit signs such as frustration, irritability, problems with impulse control, and depression), and major depressive disorder (a disorder causes persistent feeling of sadness, loss of interest, outbursts of irritation, loss of interest in most normal activities, sleep disturbances, lack of energy, agitation, fixating on past failures, trouble thinking or concentrating causing notable problems in day-to-day activities.) Review of Resident #26's Quarterly MDS Assessment revealed the following:*Resident #26 scored 15 of 15 on her BIMs, indicating she was cognitively intact.*Resident #26 did not report any indicators of depression. *Resident #26 exhibited delusions. *Resident #26 was on an anti-depressant and an anti-convulsant. Review of Resident #26's Care Plan revealed no care plan for the history of trauma, or PTSD. Review of Resident #26's Order Summary dated 9/18/25 revealed she received the following:*Citalopram 40 mg for neuropathic pain, dated 2/9/24 (an antidepressant also used to treat nerve pain)*Clonazepam 0.5 mg at bedtime for anxiety dated 7/16/25 (an antianxiety medication)*Venlafaxine 75 mg, 2 tablets by mouth twice a day for depressive disorder dated 9/16/25 (an antidepressant. Interview on 09/16/2025 11:16 AM Resident #26 stated how a CNA D did incontinent care triggered her history of trauma. Resident #26 stated she told the aide to stop and get out, but the CNA continued to do incontinent care. Resident #26 stated she rolled to punch the aide. Resident #26 stated it brought up unpleasant memories from her first marriage. Interview on 09/18/2025 at 11:17 AM, the ADON said Resident #26 was very happy when the ADON went to see her and the ADON was not aware of any complaints. The ADON stated she did Resident 26's care plan meetings and tried to keep Resident #26 very involved. The ADON said Resident #26 saw a therapist in a neighboring town for treatment of PTSD. The ADON stated Resident #26 said there was a history of PTSD from history, and she wanted to get started with therapy. The ADON stated she was not aware of the history of trauma when she was a nurse on floor. The ADON stated Resident #25 talked to the ADON about previous relationships. The ADON stated she did not believe there was a care plan for Resident #26's PTSD and Resident #26 disclosed the history probably end of May 2025. Interview on 09/18/2025 11:37 AM the ADON stated the previous ADON trained her to add skin issues, falls, code status, plans for discharge, Activities of Daily Living, medications and diagnoses, malnutrition or weight changes. The ADON said she looked at the resident, saw what they needed and added it to the care plan. The ADON said the needs of residents were communicated between staff members or she (the ADON) would talk to staff about how much help the residents needed. ADON said she did add care plans if something came up in-between care plan meetings. Interview on 09/18/2025 12:18 PM, the ADON stated she did not find care plans for Resident #6's wound care, #25's extreme unhappiness or #26's reported history of trauma and trigger management. Review of the facility's Policy on Comprehensive Care Plans, undated, revealed: the facility will develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights that include measurable objectives and timeframes to meet a resident' medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan will describe the followingThe services that are to be furnished to attain the resident's highest practicable physical, mental, and psychosocial well-being.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interview and record review the facility failed to ensure that certified nurse aide were able to demonstrate competency in skills and techniques to provide nursing and related services for 1 of 4 residents (Residents #36) by 1 of 2 certified staff (CNA A) reviewed for competent staff, in that: While providing incontinent care for Resident #36, CNA A did not perform peri-care to Resident #36's vaginal area. These failure could place residents at risk for not receiving nursing services by adequately trained and certified aides and could result in infections.The findings included: During record review of Resident #36's admission record, dated 09/16/2025, revealed an admission date of 08/31/2020, and a readmission date of 09/07/2025, with diagnoses which included: Dementia and muscle weakness. She was [AGE] years of age. During record review of Resident #36's annual MDS, dated [DATE], revealed the resident had a BIMS score of 5 indicating severe impairment. Resident #36 was frequently incontinent of bladder and bowel. During record review of Resident #36's care plan dated 12/20/25 indicated in part: Resident is at risk for skin breakdown r/t decreased mobility, incontinence, equipment, nutritional status. Resident will have no reports of skin breakdown through next review date. Provide assistance for toileting/incontinence checks every 2 hours and PRN. Provide peri--care as needed. Apply barrier cream to peri-care, buttocks are post incontinent episode per facility policy. During an observation on 09/16/2025 at 11:02 AM CNA A and NA B performed incontinent care for Resident #36. Both aides entered the resident's room, sanitized their hands, put on gloves and provided privacy for the resident. CNA A removed Resident #36's brief by turning the resident on her left side and NA B assisted by holding the resident on her side. Resident #36's brief was noted to be wet with urine. NA B handed CNA A some wet wipes and the CNA wiped the resident's buttocks and rectal area. NA B then took a pull up type of brief and put it on the resident. CNA A then removed her gloves, covered the resident with a blanket and was done with the care. CNA A did not perform peri-care to the resident's vaginal area before they fastened the new brief on the resident. During an interview on 09/18/2025 at 9:54 AM CNA A said when she had performed the incontinent care for Resident #36 she had mostly wiped the resident's bottom. CNA A said she was able to wipe some of the resident's vaginal area from the back but she should have turned the resident on her back and performed a more thorough peri-care of the vaginal area. CNA A said she had gotten nervous and that made her forget some of the steps. CNA A said not performing peri-care to the resident's vaginal area could lead to infections as it was not cleansed during the care. During an interview on 09/18/2025 at 1:10 PM the ADON said it was expected for the CNA to cleanse the vaginal area with some wipes to prevent the possibility of a urinary tract infection. The ADON said the CNAs received skills checks and at that time she would observe the staff perform the task such as incontinent care. The ADON said she believed the failure occurred because the CNA got nervous and did not perform the peri-care as needed. During a telephone interview on 09/18/2025 at 3:12 PM the DON said it was expected for the CNA to perform peri-care to the vaginal area to prevent any type of infections. The DON said each CNA knew how to do their job and the CNA probably got nervous and forgot to do the care correctly. The DON said the staff received yearly skills checks and they were done by the ADON. During an interview on 09/18/2025 at 4:38 PM the Administrator stated the CNA should have performed peri-care to the resident's vaginal area and that she probably failed to do it because she had gotten nervous. Record review of the certified nurse aide annual skills check for CNA A indicated CNA A passed competency for Perineal care/incontinent care female with or without catheter on 05/15/2025. Record review of facility undated policy, titled Perineal care, indicated in part: The purpose of this procedure are to provide cleanliness and comfort to the resident to prevent infections and skin irritation and to observe the resident's skin condition. Steps in procedure. Unfasten the used brief or underwear and begin perineal care. For a female resident. Clean perineal area, wiping from front to back. Use incontinence cleaner as needed. Separate labia and wash area downward from front to back. Continue to wash perineum moving from inside outward to and including thighs alternating from side to side and using downward strokes. Do not reuse the same wipe to clean the urethra or labia. Gently dry perineum, instruct or assist the resident to turn on her side with her top leg slightly bent if able. Cleanse the rectal area thoroughly, wiping from the base of the labia towards and extending over the buttocks. Do not use the same wipe to clean the labia. Record review of facility document titled Job description certified nursing assistant and dated 01/13/2025 indicated in part: The following is a non-exhaustive criterion that relates to the job of a certified nursing assistant, and it is consistent with the business needs of the facility. These are legitimate measures of the qualifications for a certified nursing assistant and are related to the functions that are essential to the job of a certified nursing assistant. Knowledge base: accountable for personal care (i.e., grooming, bathing, catheter care, peri-care and dressing.) and observations of residents within patient care policy guidelines. Identify and report any condition requiring management attention. Signed by CNA A.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to provide the necessary behavioral health care to maintain their highest level of practicable physical, mental and psychosocial well-being for 2 of 6 residents (Resident #25 and #26) reviewed for psychosocial adjustment.1. The facility failed to ensure Resident #25's had the services to cope with psychosocial issues related to statements of age-related wanting to die and feeling useless.2. The facility failed to ensure Resident #26's psychosocial triggers were addressed, the COTA failed to communicate a history of psychosocial distress that needed to be addressed. These failures could affect residents by placing them at risk of not receiving individualized care and services to meet their psychosocial needs.The findings included:Resident #25Review of Resident #25's admission Record, dated [DATE], revealed she was a [AGE] year-old female admitted to the facility on [DATE] with diagnosis including Arthritis. Review of Resident #25's Quarterly MDS Assessment, dated [DATE], revealed the following:*Resident #25 had moderate difficulty with hearing.*Resident #25 scored 13 of 15 on her BIMS, indicating she was cognitively intact.*Resident #25 reported no signs of depression and showed no behaviors.*Resident #25 required moderate assistance with most activities of daily living. Review of Resident #25's Order Summary Report, dated [DATE] revealed no psychotropic medication. Review of Resident #25's Care Plan showed a care plan initiated [DATE] for Chronic Pain, and pain due to age. There was no care plan regarding Resident #25's acute unhappiness related to her desire to die because she was lonely for initial family, felt useless, and loss of independence. Review of the Social Service assessment dated [DATE]: In reference to outliving all of her siblings she stated, That's my punishment here on earth. Family History She was married to her ex-husband for 50 years. She stated that 50 is the Year of the [NAME], and I decided it was a good time to get out. Resident #25 told the social worker that the ex-husband suffered from bipolar disorder which escalated after his mother's death. Resident #25 told the social worker, It is very hard to deal with, for the person and the family. Review of the Social Services quarterly assessment dated [DATE] revealed Resident #25 fluctuated between asking God why he keeps leaving her here and being socially engaged and attending competitive activities. The social worker documented Resident #25 celebrated her 103rd birthday. The social worker documented Resident #25 had a history of episodes of acute anxiety requiring medication intervention. Interview on [DATE] at 2:37 PM 6 B Resident #25 said she was sad because she was not the favorite of her mother and a loss of independence. Resident #25 said she had no choices in the facility and felt forgotten about. Resident #25 said she was 103 and all she wants to do is die because everyone she knew is gone. Interview on [DATE] 9:56 AM the ADON stated Resident #25 was pretty antisocial for the last couple of years. The ADON said Resident #25 was beginning to come out for activities. The ADON stated wanting not to be on earth at 103 was pretty normal and the facility talked to doctor about the wish several times. The ADON said they had Resident #25 on a mood stabilizers. The ADON said the facility did not know if Resident #25 had little melt downs or didn't want to live this and long didn't anticipate living this long The ADON said Resident #25 focused on everyone she knew was gone. The ADON said they talked to Resident #25 about antidepressant will have to go through notes and though it could make a difference. Interview on [DATE] at 11:12 AM, the ADON talked to the DON who said the facility had increased involvement and the Doctor had talked to Resident #25 constantly about it there. The ADON agreed there were no notes about it. Interview on [DATE] at 2:20 p.m. the DON stated Resident #25 attributed all her issues to her ex-husband or children. The DON said Resident #25 had an acute episode of anxiety and had to go to hospital. The DON Resident #25's distress may be from seizure-like activity. The DON stated Resident #25 needed everything to be very routine and absolute. Resident #26 Review of Resident #26's admission Record, dated [DATE], revealed she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses including arthritis, traumatic brain injury (can cause temporary or short-term memory problems and the person may exhibit signs such as frustration, irritability, problems with impulse control, and depression), and major depressive disorder (a disorder causes persistent feeling of sadness, loss of interest, outbursts of irritation, loss of interest in most normal activities, sleep disturbances, lack of energy, agitation, fixating on past failures, trouble thinking or concentrating causing notable problems in day-to-day activities.) Review of Resident #26's Quarterly MDS Assessment revealed the following:*Resident #26 scored 15 of 15 on her BIMS, indicating she was cognitively intact.*Resident #26 did not report any indicators of depression. *Resident #26 exhibited delusions. *Resident #26 was on an anti-depressant and an anti-convulsant. Review of Resident #26's Care Plan reviewed [DATE], revealed no care plan for the history of trauma. Review of Resident #26's Order Summary dated [DATE] revealed she had orders forCitalopram 40 mg for neuropathic pain, dated [DATE] (an antidepressant also used to treat nerve pain)Clonazepam 0.5 mg at bedtime for anxiety dated [DATE] (an antianxiety medication)Venlafaxine 75 mg, 2 tablets by mouth twice a day for depressive disorder dated [DATE] (an antidepressant. Interview on [DATE] 11:16 AM Resident #26 stated how a CNA D did incontinent care triggered her history of trauma. Resident #26 stated she told the aide to stop and get out, but the CNA continued to do incontinent care. Resident #26 stated she rolled to punch the aide. Resident #26 stated it brought up unpleasant memories from her first marriage and caused panic attacks. Resident #26 said she had to go back to therapy to get things (trauma) tidied up and put away again. Resident #26 stated she would make herself breathe slowly and it would sometimes help with the panic but it comes and goes. Resident #26 stated she requested help with setting up therapy, but it was too slow, so she did it herself. Interview on [DATE] 11:48 AM, the COTA described Resident #26 as a talker. The COTA said Resident #26 shared she experience a history of abuse prior to incident and then the incident really triggered Resident #26. The COTA stated Resident #26 indicated there was history of physical, emotional, and sexual abuse. The COTA said she did not report it because it was historical it had nothing to do with her. The COTA continued when the residents came to therapy, the residents told her things in confidence. The COTA said when Resident #26 made a current allegation she reported it to the DON immediately. Interview on [DATE] at 11:17 AM, the ADON said Resident #26 was very happy when the ADON went to see her and the ADON was not aware of any complaints. The ADON stated she did Resident 26's care plan meetings and tried to keep Resident #26 very involved. The ADON said Resident #26 saw a therapist in a neighboring town for treatment of PTSD. The ADON stated Resident #26 said there was a history of PTSD from history, and she wanted to get started with therapy. The ADON stated she was not aware of the history of trauma when she was a nurse on floor. The ADON stated Resident #25 talked to the ADON about previous relationships. The ADON stated she did not believe there was a care plan for Resident #26's PTSD and Resident #26 disclosed the history probably end of [DATE]. Interview on [DATE] at 2:20 PM, the DON said she assessed for trauma-informed care. The DON stated Resident #26 did not reveal her history to the DON until she reported the event. The DON stated Resident #26 did not historically discuss details about her trauma. Interview on [DATE] at 2:20 PM, the DON said she assessed for trauma-informed care: based on earmarks and signs and symptoms, and from the resident's triggers are activity and difficulty adjusting. The DON stated the new staff were trained by going with an existing staff until they learn the residents. The DON said additional information was communicated during stand-up meeting because it was a small facility and the staff communicated constantly, that there was not a lot of chain of command, then things were reported. The DON stated new issues were always taken into the morning meeting even if there were interventions by the morning because if there was a trigger the staff needed to know. The DON stated all department heads were in the morning meeting except for Therapy because it was too disruptive to the residents. The DON stated if something came up the therapist needed to know it was communicated and if something the department heads needed to know the Therapy department called nursing immediately. The DON said she was unaware that the COTA was aware history of trauma in residents overall prior to the conversation with surveyor. The DON stated the COTA immediately reported when a resident was in acute distress. Interview on [DATE] at 3:12 PM, the AIT and Administrator were informed of trauma-informed care concerns. The Administrator asked if the trauma informed care was the next step in culture change. Review of the facility's policy and procedure on Comprehensive Person Care Plans, undated, revealed: The facility will develop and implement a comprehensive person centered care plan for each resident, consistent with the resident rights that includes measurable objectives and timeframes to meet a resident' medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment.Trauma informed care and Trigger Identification.Care planning to address the past trauma, including the need for the facility to collaborate with the resident and their families is appropriate. Trigger-specific interventions with examples of such should be included. Key elements the facility is to ensure are: Identify cultural preferences in collaboration with the trauma survivor; Identify past history of trauma; Identify triggers to trauma and can cause traumatization; Approach trauma survivors with culturally competent and trauma-informed care.Identify and documentEvents that may have contributed may include the thread of physical or psychological harm and/or severe neglect. These could occur once or repeatedly over time. Experiences from what the resident determines as their traumatic event. A traumatic event for one may not be traumatic for another. Individual interpretation determines the experience as traumatic. Determine the result of the event. The long-lasting adverse effects are critical to the components of trauma. These events can be immediate or a delayed onset and can last a short or long term.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to develop a baseline care plan within 48 hours of a resident's admission that included the instructions needed to provide effective and person-centered care of 1 of 13 (Resident #133) residents reviewed for care plan completion.<BR/>The facility failed to include Resident #133's oxygen use, smoking status, and discharge goals in the baseline care plan within the required 48-hour timeframe. <BR/>This failure could place residents who were newly admitted at risk for not receiving necessary care and services or having important care needs identified.<BR/>Findings included:<BR/>Record review of Resident # 133's face sheet dated 08/09/2024 revealed a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses which included Chronic Obstructive Pulmonary Disease, Asthma, and hypertension (high blood pressure).<BR/>Record review of Resident #133's admission MDS assessment dated [DATE] revealed: Section C (Cognitive Patterns) BIMS score had not been completed. <BR/>Record review of Resident #133's Physician Orders dated 08/09/2024 revealed, Start date of 08/01/2024 Oxygen at 2 l/m to 5 l/m per nasal cannula prn SOB/respiratory compromise as needed for shortness of breath. <BR/>Record review of Resident #133's baseline care plan was completed on 08/01/2024 revealed Resident #133's oxygen use, smoking status, and discharge goals were not incorporated in the base-line care plan. <BR/>During an observation and interview on 08/08/2024 at 10:53 AM PM, Resident #133's door to her room did not have Oxygen in Use sign posted outside the entrance of her door. Resident #133 stated she was a smoker and did not wear her oxygen when she went outside to smoke.<BR/>During an interview on 08/09/24 at 3:24 PM, the ADON stated it was her responsibility to complete the base line care plan. The ADON stated her expectation was baseline care plans should have included all of a resident's care areas and there should not have been any blanks. The ADON stated Resident #133's oxygen use, smoking status and discharge goals should have been included in the baseline care plan. The ADON stated the DON and herself are responsible to monitor the accuracy of base line care plans. The ADON stated she did not feel there was an affect to Resident #133 because Resident #133 was cognitive, and staff knew she smoked, and the oxygen use was in her orders. The ADON stated what led to failure was she could have gotten into hurry and did not incorporate all areas into the baseline care plan.<BR/>During an interview on 08/09/24 at 3:46 PM, the DON stated her expectation was the baseline care plan should have been completed within 48 hours of admission and all blanks should have been completed on the baseline care plan. The DON stated the ADON and herself were responsible to completed baseline care plans and to ensure they were completed. The DON stated the effect on Resident #133 was there could have been a potential for a gap of comprehensive care and/or failure to meet a resident's need. The DON stated she did not feel there was a failure because care plans were an evolving process and if it was in the orders, they would follow the orders.<BR/>Record review of facility policy titled, Baseline Care Plan undated revealed: Nursing home staff will develop a baseline care plan for the residents care within 48 hours of admission to the facility . The baseline care plan will include, at a minimum, the following: a. Initial goals based on admission orders b. Physician orders c. Dietary orders d. Therapy services e. Social Services

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews and record reviews the facility failed to ensure that residents receive care, consistent with professional standards of practice, to prevent pressure ulcers and do not develop pressure ulcers unless the individual's clinical condition demonstrates that they were unavoidable; and residents with pressure ulcers receive necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for 1 of 12 (Resident #27) residents reviewed for pressure ulcers.<BR/>The facility failed to assess Resident #27's pressure ulcer weekly.<BR/>The facility failed to assess Resident #27's skin weekly.<BR/>These failures could place residents at risk of infections and worsening of wounds.<BR/>Findings include:<BR/>Record review of Resident #27's electronic face sheet dated 08/09/2024 revealed a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses that included: pressure ulcer of left heel, unstageable (left heel pressure ulcer that is not able to show how deep or how many layers of tissue was damaged), unspecified protein-calorie malnutrition (low protein levels and calorie intake), cognitive communication deficit (inability to communicate effectively related to mental deficit), and muscle weakness. <BR/>Record review of Resident #27's quarterly MDS assessment dated [DATE] revealed Resident #27 had a BIMS score of 12, meaning moderate cognitive impairment. Further review of MDS section M - Skin Conditions revealed Resident #27 had 1 unhealed pressure ulcer and resident was at risk of developing pressure ulcers. <BR/>Record review of Resident #27's physician orders dated 08/06/2024 revealed: Cleanse left heel with soap and water, apply silver alginate to wound cand cover with heel border foam. Change on Tuesday and Fridays. every day shift every Tue, Fri for Left heel D.U. <BR/>Record review of Resident #27's care plan date initiated 03/06/2024 revealed Focus: Resident is at risk for skin breakdown r/t decreased mobility, incontinence, equipment, nutritional status Goal: Resident will have no reports of skin breakdown trough next review date Interventions: Encourage and assist resident to suspend heels when in bed with pillows. Further review of care plan date initiated 03/06/2024 revealed Focus: Resident entered facility with unstageable ulcer to L heel Goal: Area will have no S/S of complications and will show S/S of improving/healing through next review date .resident will have no S/S or reports of unrelieved pain to wound area through next review date Interventions: Assess wound condition weekly and with dressing change, Notify MD if noted with change in wound condition, (increased drainage, odor, eschar, warmth, decline/improvement in wound condition .keep dressing clean dry intact, replace as needed .Keep pressure off area. Use positioning devices as needed. <BR/>Record review of Resident #27's assessment record on 08/09/2024 revealed last weekly skin assessment documented was on 03/12/2024 and no evidence that any documented wound care sheets found.<BR/>During on observation and interview on 08/08/2024 at 9:57 a.m., Resident #27 was lying in bed watching television. He stated he had wound on his foot and went to wound clinic once a week. He did not voice concerns with how facility staff cared for wound but he was concerned the wound had not healed.<BR/>During an interview on 08/09/2024 at 2:21 p.m., the DON stated Resident #27 was admitted into nursing home with skilled nursing services. She stated during the time Resident #27 received skilled nursing services, which ended May 2024, the nurse documented daily in skilled services nursing note which included a skin assessment. The DON stated the skilled note showed that his skin was assessed during that time frame. was included in the skilled nurses note which showed that skin was assessed. She stated the electronic system that facility used did not trigger for weekly skin assessments when Resident #27 was removed from skilled nursing, and she did not know why system did not start triggering for weekly skin assessments. She stated she expected for skin assessments to be performed weekly by nurses and CNAs will look at resident's skin in between nurses' assessment. The DON stated CNAs are not allowed to perform assessments. She stated no proof was available that nurses performed skin assessments after May of 2024. She stated nurses should perform head to toe assessments and not just look at resident's wounds that the nurses provided treatment to. She stated she was who monitored weekly skin assessments were performed and did not know system had not been triggering. She stated no negative outcome occurred to the resident from weekly skin assessments not being performed. <BR/>Review of facility policy titled Skin Assessment with no date revealed Assess the resident head to toe to identify all skin concerns to include but not limited to: bruises, skin tears, rashes, burns, implanted ports, devices, stomas, pressure injuries of any type, or any other skin concerns. All NON-PRESSURE findings: complete weekly skin assessment in electronic medical chart. All PRESSURE findings: completed wound care sheet. If a resident has a pressure ulcer(s) or complicated wound(s) then the wound care sheet should be completed. This form may be utilized to address all skin concerns (in lieu of using the weekly skin assessment form in conjunction with the wound care sheet. A RN is to accompany the nurse providing wound care for the scheduled assessment where possible. The skin assessment schedule is to be implemented and followed weekly .Nursing management will periodically perform random checks on completed Skin Assessment for accuracy. The Director of Nursing or designee is to follow-up weekly in Standards of Care (SOC/IDT) to ensure completion and accuracy of assessments.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to maintain medical records on each resident, in accordance with accepted professional standards and practice, that were complete and accurate for 1 of 12 (Resident #11) residents reviewed for resident records.<BR/>The facility failed to ensure physician order parameters were accurate on Resident #11's cardiac medications (carvedilol. hydralazine and losartan potassium)<BR/>This failure could place residents at risk of having errors with their care and treatment. <BR/>Findings included:<BR/>Record review of Resident #11's face sheet dated 08/08/2024 revealed a [AGE] year-old female admitted on [DATE] with the following diagnosis heart failure (heart disease interfering with how much blood is pumped through heart with each beat), dementia, history of falling, weakness, unspecified atrial fibrillation (irregular heartbeat), edema (swelling), essential hypertension (high blood pressure), and long term use of anticoagulants (chronic blood thinner use). <BR/>Record review of Resident #11's annual MDS dated [DATE] revealed Section-C Cognitive Patterns Resident #11 had a BIMS score of 7 meaning severe cognitive impairment; Section N- Medications revealed Resident #1 had taken anticoagulant (medication to help prevent blood clots) and diuretic (medication to decrease fluid retention). <BR/>Record review of Resident #11's physician order dated 06/19/2024 revealed carvedilol tablet 6.25mg give 1 tablet by mouth two times a day for HTN hold is systolic is &lt; 100 and diastolic &lt; 60 and HR &lt; 60.<BR/>Record review of Resident #11's physician order dated 03/28/2022 revealed hydralazine tablet 25mg give 1 tablet by mouth two times a day for HTN hold is systolic is &lt; 100 and diastolic &lt; 60.<BR/>Record review of Resident #11's physician order dated 06/19/2024 revealed losartan potassium tablet 25mg give 12/5mg by mouth one time a day for HTN hold is systolic is &lt; 100 and diastolic &lt; 60 and HR &lt; 60.<BR/>During an observation on 08/08/2024 at 7:14 a.m., LVN A took Resident #11's vital signs. Blood pressure reading was 107 / 57 (systolic 107 and diastolic 57) and pulse reading was 64 beats per minute. LVN A held carvedilol, hydralazine, and losartan potassium medication.<BR/>During an interview on 08/08/2024 at 10:23 a.m., LVN A stated she did not give carvedilol, hydralazine, and losartan potassium medication due to parameters not being met in physician order. She stated in the past she had asked physician about parameters and had been instructed to give medication if one of the parameters were not met. She was unsure if order needed to be changed so that only one parameter needed to be met to hold medication but stated she would ask physician. <BR/>During an interview on 08/09/2024 at 9:26 a.m., the DON stated she expected parameters to be followed when administering medication but clarified that order had been entered into electronic medical system wrong. She stated that there should have been an or instead of and meaning that only one parameter needed to be out of range to hold the medications. She stated this occurred due to transcription error. She stated no negative affect occurred to the resident due to nurse had administered medication correctly. She stated she was responsible for ensuring orders in system were correct and had missed these orders due to when she scanned over the orders, she would look at numbers and not and instead of or. She stated order will be corrected in electronic medical record to prevent any medication error from occurring. <BR/>During an interview on 08/09/2024 at 2:28 p.m., the ADMN was not able to provide policy about accuracy of records. He stated the medication policy was all he could provide regarding physician orders accuracy. <BR/>Review or facility policy titled Receiving and Recording Medication Orders with no date revealed Telephone orders may be accepted by a licensed nurse only (i.e., RN, LPN, LVN). Telephone or verbal orders must be recorded on the Physicians' Order Sheet when received and must be recorded by the nurse receiving the order. Telephone or verbal orders for drugs must include: a. Name and strength of the drug b. Quantity or specific duration of the drug c. Dosage and frequency of administration d. Route of administration; and e. Date and time received. Telephone or verbal orders must be countersigned by the physician within forty-eight (48) hours of receiving the order.

Based on observation, interview and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 1 (CNA-C) staff observed for infection control.<BR/>The facility failed to ensure CNA-C performed proper hand hygiene while providing incontinent care.<BR/>These failures could place residents at risk for unnecessary infections.<BR/>Findings include:<BR/>During observation on 06/21/23 at 02:09 PM, CNA C performed peri care on Resident 29. CNA C entered the room without performing hand hygiene. CNA C pulled the privacy curtain and donned gloves without performing hand hygiene. CNA C unfastened brief and pushed the front in between the residents' legs. CNA C wiped the front center peri-area from front to back and placed the wipe in the brief between the residents legs. CNA C wiped the front center peri- area from front to back with another wipe and placed it in the brief. CNA C rolled the resident on her left side. CNA C wiped the residents right buttocks with BM from front to back and placed the wipe in the brief. CNA C grabbed a new wipe and wiped center buttock crack from front to back then folded wipe and wiped back to front in a zig-zag motion then discarded wipe into brief. CNA C removed brief and placed it in a plastic bag that had fallen on the floor. CNA C doffed gloves and did not perform hand hygiene. CNA C looked in two drawers opening them with her bare hands then when into the hall and returned with moisture cream. CNA C did not perform hand hygiene and donned gloves. CNA C placed a clean brief under the resident and applied moisture cream. CNA C placed moisture cream on her gloved hand and wiped all over the residents' buttocks in a zig-zag motion and then wiped the cream on the clean brief. CNA C rolled resident onto her back and fastened the clean brief. CNA C doffed gloves and did not perform hand hygiene. CNA C repositioned the resident and exited the room with the plastic bag which contained the dirty brief and walked down the hall to place it in the trash. <BR/>In an interview on 06/22/23 at 03:35 PM, CNA C explained how to perform Peri care and stated he would go to the linen closet to get his supplies (basin, washcloth, brief peri wash and creams). Go to the resident's room, knock and explain what he was doing. Put water in basin (check for water temperature), Setup basin and supplies. CNA C then stated he would put his gloves on and begin peri care using the four corners method with his washcloth (he said also calls it flowering). CNA C stated he received his training by the DON. He stated she taught the four corners method in peri care training. <BR/>In an interview on 06/22/23 at 04:41 PM, the DON stated she did most all trainings for nursing services. The DON stated the ADON did trainings for the CNA's. The DON stated she started doing their trainings beginning in early April. The DON stated she did audits and observed the CNA's techniques after their training was completed. The DON stated all the retraining for CNA's were done by the ADON. The DON stated the washcloths were hygiene wipes. The DON described them as a premoisten disposable cleaning wipes. The DON stated there were some CNAs that were originally trained by her utilizing an actual cloth, washcloths. The DON stated staff could use the hygiene wipes if they folded and used a clean side. The DON stated the four corners method was not appropriate with the hygiene wipes. Most especially because of the size and consistency they were not designed for the fold four corner method. The DON stated the effect of improper peri care on a resident would depend on where the deficient practice was within the process. The DON stated the failure to perform hand washing or hand sanitizer hygiene had the potential to lead to cross contamination. The DON stated the effect could expose the residents to opportunist pathogen with associated with potential infection. <BR/>Record review of the facility policy titled Perineal Care reflected the following: <BR/> 2. Assemble the equipment and supplies as needed.<BR/>Equipment and Supplies<BR/>The following equipment and supplies will be necessary when performing this procedure:<BR/>1. <BR/>Incontinence product such as brief or underwear<BR/>2. <BR/>Barrier cream or moisturizer as directed by the nurse<BR/>3. <BR/>Incontinence cleanser (as needed)<BR/>4. <BR/>Under pad<BR/>5. <BR/>Plastic trash bag<BR/>6. <BR/>Gloves<BR/>Step in Procedure<BR/>1. <BR/>Arrange the supplies as they can be easily reached.<BR/>2. <BR/>Wash and dry your hands thoroughly or use hand sanitizer.<BR/>Record review of the facility policy titled Hand Washing reflecting the following: <BR/>Section 12-Infection Control<BR/>Purpose: Hand washing will be regarded by this facility as the single most important means of preventing the spread of infections.<BR/>Procedure:<BR/>1. <BR/>All personnel will follow the facility's established handwashing procedures using current CDC Hand Hygiene Guidance protocols to prevent the spread of infections and disease to other personnel, residents, and visitors.<BR/>2. <BR/>Hands should be washed 20 seconds under the following conditions<BR/> .<BR/>c. <BR/>Before performing invasive procedures<BR/> .<BR/>e. <BR/>Before handling clean or soiled dressings, gauze pads, etc<BR/>f. <BR/>After handling used dressings, contaminated equipment, etc<BR/>g. <BR/>After contact with blood, body fluids, excretions, secretions, mucous membranes, or nonintact skin<BR/>h. <BR/>After handling items potentially contaminated with blood,. body fluids, excretions, or secretions<BR/>i. <BR/>After using the toilet, blowing or wiping the nose, smoking, combing the hair, etc<BR/>j. <BR/>After removing gloves <BR/>Record review of the facility policy labeled Hand Hygiene Guidance, (CDC Centers for Disease Control and Prevention) reflected the following:<BR/>The core infection prevention and control practices in All . <BR/>2. All personnel shall follow the hand washing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors <BR/> .7. Use of an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations<BR/> .b. Before and after direct contact with residents;<BR/>c. Before preparing or handling medications <BR/> .k. After handling used dressings, contaminated equipment, etc .9. The use of gloves does not replace hand washing/hand hygiene. Integration of glove use along with routine hand hygiene is recognized as the best practice for preventing healthcare associated infection.<BR/>

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to attempt to use alternatives prior to installing a side or bed rail, assess the resident for risk of entrapment from bed rails prior to installation for 6 of 6 residents (Resident #7, Resident #14, Resident #18, Resident #20, Resident #22, and Resident #232) reviewed for bed rails. <BR/>The facility failed to assess residents for entrapment risks and attempt less restrictive measures prior to installing bed rails.<BR/>These failures could place residents at risk for injury.<BR/>The findings include:<BR/>Resident #7<BR/>Record review of Resident #7's electronic face sheet revealed an [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses which included post-operative hip replacement, weakness, left ankle pain, Parkinson's disease (a brain disorder that causes unintended and uncontrollable body movements) and stroke. <BR/>Record review of Resident #7's quarterly MDS, dated [DATE], Section C. Brief Interview of Mental Status assessment revealed a score of 7 out of 15which indicated severe mental impairment and Section P. Restraints and Alarms P0100 Physical Restraints A. Bed Rail 0. Not Used was selected as the answer. <BR/>Record review of Resident #7's comprehensive care plan, reviewed 05/25/2023, revealed the resident was at risk for falls due to unsteady gait (walking), decreased balance, medications, poor safety awareness, and suffered a recent fall which resulted in a broken hip. Resident #7's care plan noted the resident required extensive assistance with bed mobility. There was no evidence of interventions for placement and/or use of bed rails. <BR/>Record review of Resident #7's electronic physician orders revealed no order for the use of bed rails.<BR/>Record review of Resident #7's electronic records revealed no documentation of an attempt to use alternatives to bed rails or assessment for the risk of entrapment.<BR/>Observation of Resident #7 on 06/21/23 at 01:30 PM revealed Resident #7 was lying in bed. Resident #7 had a hospital bed with a half bed rail on the left.<BR/>Resident #14<BR/>Record review of Resident #14's electronic face sheet revealed an [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses which included dementia (a condition the impairs the ability to remember, think, or make decisions that interferes with doing everyday activities), weakness, broken right arm, and kidney disease. <BR/>Record review of Resident #14's quarterly MDS, dated [DATE] Section C. Brief Interview of Mental Status assessment revealed a score of 11 out of 15 which indicated moderate mental impairment and Section P. Restraints and Alarms P0100 Physical Restraints A. Bed Rail 0. Not Used was selected as the answer. <BR/>Record review of Resident #14's comprehensive care plan, revised 05/15/2023, revealed the resident was at risk for falls due to unsteady gait (walking), decreased balance, medications, and poor safety awareness. Resident #14's care plan noted the resident required supervision and limited assistance with bed mobility. Interventions listed did not include placement and/or use of bed rails. <BR/>Record review of Resident #14's electronic physician orders revealed no order for the use of bed rails.<BR/>Record review of Resident #14's Occupational Therapy Treatment Encounter Notes, dated 03/27/2022, revealed no documentation on assessment and training for siderail use for independence with transfers. <BR/>Record review of Resident #14's electronic records revealed no documentation of an attempt to use alternatives to bed rails or assessment for the risk of entrapment.<BR/>Observation of Resident #14's room on 06/20/23 at 11:30 AM revealed the bed had half bed rails in place.<BR/>During an interview on 06/22/23 at 10:15 AM, Resident #14 stated she used her bed rail to assist in transferring.<BR/>Resident #18<BR/>Record review of Resident #18's electronic face sheet revealed an [AGE] year-old female who was admitted to the facility on [DATE] with an initial admission date of 09/23/2022. Resident #19 had diagnoses which included dementia, weakness, broken right hip, and repeated falls. <BR/>Record review of Resident #18's discharge - return anticipated MDS, dated [DATE], revealed Section C. Brief Interview of Mental Status assessment revealed a score of 14 out of 15, which indicated no mental impairment and Section P. Restraints and Alarms P0100 Physical Restraints A. Bed Rail 0. Not Used was selected as the answer. <BR/>Record review of Resident #18's comprehensive care plan, revised 10/12/2022, revealed the resident was at risk for falls due to an unsteady gait, decreased balance and medications. Resident #18's care plan noted the resident required assistance with transfers. Interventions listed did not include placement and/or use of bed rails. <BR/>Record review of Resident #18's electronic physician orders revealed no order for the use of bed rails.<BR/>Record review of Resident #18's Occupational Therapy Treatment Encounter Notes, dated 06/21/2023, revealed no documentation on assessment and training for siderail use for independence with transfers. <BR/>Record review of Resident #18's electronic records revealed no documentation of an attempt to use alternatives to bed rails or assessment for the risk of entrapment.<BR/>Observation of Resident #18's room on 06/20/23 at 11:22 AM revealed the bed had half bed rails in place. <BR/>Resident #20<BR/>Record review of Resident #20's electronic face sheet revealed a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses which included weakness and dementia.<BR/>Record review of Resident #20's significant change in status MDS, dated [DATE], revealed Section C. Brief Interview of Mental Status assessment revealed a score of 9 out of 15 which indicated moderate mental impairment and Section P. Restraints and Alarms P0100 Physical Restraints A. Bed Rail 0. Not Used was selected as the answer. <BR/>Record review of Resident #20's comprehensive care plan, reviewed 04/28/2023, revealed the resident was at risk for falls due to weakness, unsteady gait, decreased balance, medications, and poor safety awareness. Resident #20's care plan noted the resident required assistance with bed mobility. Interventions listed did not include placement and/or use of bed rails. <BR/>Record review of Resident #20's Occupational Therapy Treatment Encounter Notes, dated 06/13/2023, revealed no documentation on assessment and training for siderail use for independence with transfers. <BR/>Record review of Resident #20's electronic records, accessed 06/21/2023, revealed no documentation of an attempt to use alternatives to bed rails or assessment for the risk of entrapment.<BR/>Observation of Resident #20's room on 06/20/23 at 12:10 PM, the bed had one half bed rail in place on the right.<BR/>Resident #22<BR/>Record review of Resident #22's electronic face sheet revealed an [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses which included weakness and gout (a condition that affects the joints.) <BR/>Record review of Resident #22's significant change in status MDS, dated [DATE], revealed Section C. Brief Interview of Mental Status assessment revealed a score of 15 out of 15, which indicated no mental impairment and Section P. Restraints and Alarms P0100 Physical Restraints A. Bed Rail 0. Not Used was selected as the answer. <BR/>Record review of Resident #22's comprehensive care plan, revised 05/23/2023, revealed the resident was at risk for falls due to unsteady gait and decreased balance. Resident #22's care plan noted the resident required assistance with bed mobility. Interventions listed did not include placement and/or use of bed rails. <BR/>Record review of Resident #22's electronic physician orders revealed no order for the use of bed rails.<BR/>Record review of Resident #22's Occupational Therapy Treatment Encounter Notes, dated 03/02/2023, revealed no documentation on assessment and training for siderail use for independence with transfers. <BR/>Record review of Resident #22's electronic records revealed no documentation of an attempt to use alternatives to bed rails or assessment for the risk of entrapment.<BR/>Observation of Resident #22 on 06/20/23 at 10:58 AM revealed the resident was lying in bed, eyes closed, respirations even and unlabored. Resident #22's bed had one bed rail in place on the left. <BR/>Resident #232<BR/>Record review of Resident #232's electronic face sheet revealed an [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses which included fainting, weakness, and difficulty walking. <BR/>Record review of Resident #232's quarterly MDS, dated [DATE], revealed Section C. Brief Interview of Mental Status assessment revealed a score of 14 out of 15, which indicated no mental impairment and Section P. Restraints and Alarms P0100 Physical Restraints A. Bed Rail 0. Not Used was selected as the answer. <BR/>Record review of Resident #232's comprehensive care plan revealed the resident was at risk for falls due to an unsteady gait, decreased balance, medications, poor safety awareness. Interventions listed did not include placement and/or use of bed rails. <BR/>Record review of Resident #232's electronic physician orders revealed no order for the use of bed rails.<BR/>Record review of Resident #232's electronic records revealed no documentation of an attempt to use alternatives to bed rails or assessment for the risk of entrapment.<BR/>Observation of Resident #232 on 06/20/23 at 11:10 AM, revealed the resident sitting in a wheelchair in her room watching TV. Resident #232's bed had one bed rail in place on the right. <BR/>During an interview on 06/22/23 at 10:10 AM, the DON stated bed rails were usually installed when a resident requested to use as enabler bars. The DON stated assessments were not performed prior to installing bed rails on beds for Resident #7, Resident #14, Resident #18, Resident #20 Resident #22, or Resident #232. She stated obtaining a physician's order was not specified in the facility policy. The DON stated bed rails should be addressed on the care plan and did not know why bed rails were not included on the care plan. <BR/>During an interview and record review on 06/22/23 at 10:51 AM, LVN A stated the nurses had a list of 6 residents who had bed rails. Review of the list provided by LVN A revealed Resident #4, Resident #16, Resident #18, Resident #20, Resident #133, and Resident #232 were listed. LVN A stated she did not know why the failure to obtain a physician's order or include the bed rails on the care plan occurred. <BR/>During an interview on 06/22/23 at 10:53 AM, LVN B stated effect on residents of not having a physician's order for bed rails or including bed rails on the care plan could affect residents' mobility, or ability to transfer in and out of bed. LVN B stated residents who were not used to having bed rails may get confused and could get hurt.<BR/>During an interview on 06/22/23 at 02:15 PM, the Maintenance Director stated he inspected bed rails when they were installed. He stated he inspected the bed rails the day before. The Maintenance Director stated if staff noticed a problem with a bed rail it was logged in the maintenance book for him to fix.<BR/>During an interview on 06/22/23 at 03:27 PM, the ADON stated she was responsible for entering data for the MDS. She stated bed rails were not selected on the MDS because the facility did not consider them restraints. The ADON stated they were a restraint free facility. She explained the consequences to a resident of failing to document bed rails on the MDS was because bed rails were the wording made it confusing on where to put data in the MDS. The ADON described her training for the position as trained by the former MDS nurse, and the facility paid for her to attend a Resource Utilization Group (RUG) course. The RUG is a system that groups residents based on health status and care needs. The ADON stated she was confused on how to enter the bed rail used as mobilization equipment on the MDS.<BR/>Record review of the facility's, undated, policy titled Bed Rails revealed To ensure the appropriate use of Bed or Side rails at all times. Procedure: The facility will attempt the use appropriate alternatives prior to installing a side or bed rail. If a bed or side rail is used, the facility will ensure correct installation, use, and maintenance of bed rails, including but not limited to the following: 1. Assessing the resident for risk of entrapment from bed rails prior to installation with the TMF Side Rail Assessment form. 2. Review the risks and benefits of bed rails with the cognizant resident or resident representative and obtain informed consent prior to installation. 3. Ensure that the bed's dimensions are appropriate for the resident's size and weight. 4. Follow the manufacturer's recommendations and specifications for installing and maintaining be rails. 5. Utilizing the TMF Side Rail Utilization Assessment to comply with state regulations for safety. 6. Consult with Therapy regarding assessment and training for siderail use for independence with transfers. 7. The maintenance director will supervise the maintenance of all bed siderails.

Based on observation, interview and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen surveyed for kitchen sanitation.<BR/>1. The facility failed to ensure food items were disposed after the use by or expiration date.<BR/>2. The facility failed to ensure dinnerware was stored in a way to prevent contamination. <BR/>These failures could place residents at risk of foodborne illness and a decline in health status.<BR/>The findings included:<BR/>Observation in the kitchen area on 06/20/23 between 09:30 AM and 10:15 AM, revealed the following: <BR/>-One 35.3 oz. plastic jar of dry coffee creamer in a cabinet did not have an opened date and had an expiration date of 10/21/21. <BR/>-One 1 gallon 2% milk approx. 1/3 full in the door of the refrigerator with an expiration date of 06/18/23. <BR/>-Two stacks of dinner plates above the steam table were turned right side up without a cover. <BR/>-Several small plastic bowls and plastic storage containers on a shelf to the right of the sink were turned right side up without a cover. <BR/>-In the commercial freezer, one opened clear plastic bag tied in a knot contained slices of garlic bread with no date opened or expiration date. <BR/>-Three 5 lb. bags labeled pancake mix did not have an expiration date. <BR/>During an interview on 06/22/23 at 10:46 AM, the DC did not have a reason the 2% milk was in the refrigerator past the expiration date. She stated usually milk was used too fast for it to come close to the expiration date. The DC stated when the big refrigerator went out, items had to be moved to another refrigerator and that may have been part of the problem. She stated she routinely checked for expired and past use by date food items and the dishwasher monitored the drinks. The DC explained she was initially trained by a night cook. She stated she also completed the food handlers' course, and her certification was current. The DC stated the DM did frequent face-to-face trainings to refresh the staff on procedures or to pass on new information. She stated the effect receiving out of date food on the residents was that it could make them sick.<BR/>During an interview on 06/22/23 at 01:37 PM, the DM stated she was ultimately responsible for checking for expired food stock and past use by dates. She stated the staff were very good about checking frequently but occasionally items were missed. She attributed the issue with the gallon of 2% milk to the refrigerator going out and having to transfer refrigerated foods to a residential refrigerator and it was missed. The DM did not have an explanation for why coffee creamer had not been disposed of. She explained training was done at hire and monthly. The DM stated the effect on residents receiving an expired food item was that the resident(s) could get sick.<BR/>Record review of the dietary staff's certifications revealed all certificates were current. <BR/>Record review of the facility's, undated, policy titled Storage of Food in Refrigerators, revealed: Procedure 4. All containers must be labeled with the contents and date food item was placed in storage.<BR/>Record review of the Federal Food Code, dated 2002 Chapter 4 Equipment, Utensils, and Linens section 4-903.11.(B)(2) revealed: Clean equpment and utensils shall be stored . covered or inverted.<BR/>Record review of the Federal Food Code, dated 2022, Annex 6: Food Processing Criteria (2) (K) Disposition of Expired Product at Retail, revealed .foods that exceed the use-by date or manufacturer's pull date . must be disposed of in a proper manner.

Based on observation, interview and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 1 (CNA-C) staff observed for infection control.<BR/>The facility failed to ensure CNA-C performed proper hand hygiene while providing incontinent care.<BR/>These failures could place residents at risk for unnecessary infections.<BR/>Findings include:<BR/>During observation on 06/21/23 at 02:09 PM, CNA C performed peri care on Resident 29. CNA C entered the room without performing hand hygiene. CNA C pulled the privacy curtain and donned gloves without performing hand hygiene. CNA C unfastened brief and pushed the front in between the residents' legs. CNA C wiped the front center peri-area from front to back and placed the wipe in the brief between the residents legs. CNA C wiped the front center peri- area from front to back with another wipe and placed it in the brief. CNA C rolled the resident on her left side. CNA C wiped the residents right buttocks with BM from front to back and placed the wipe in the brief. CNA C grabbed a new wipe and wiped center buttock crack from front to back then folded wipe and wiped back to front in a zig-zag motion then discarded wipe into brief. CNA C removed brief and placed it in a plastic bag that had fallen on the floor. CNA C doffed gloves and did not perform hand hygiene. CNA C looked in two drawers opening them with her bare hands then when into the hall and returned with moisture cream. CNA C did not perform hand hygiene and donned gloves. CNA C placed a clean brief under the resident and applied moisture cream. CNA C placed moisture cream on her gloved hand and wiped all over the residents' buttocks in a zig-zag motion and then wiped the cream on the clean brief. CNA C rolled resident onto her back and fastened the clean brief. CNA C doffed gloves and did not perform hand hygiene. CNA C repositioned the resident and exited the room with the plastic bag which contained the dirty brief and walked down the hall to place it in the trash. <BR/>In an interview on 06/22/23 at 03:35 PM, CNA C explained how to perform Peri care and stated he would go to the linen closet to get his supplies (basin, washcloth, brief peri wash and creams). Go to the resident's room, knock and explain what he was doing. Put water in basin (check for water temperature), Setup basin and supplies. CNA C then stated he would put his gloves on and begin peri care using the four corners method with his washcloth (he said also calls it flowering). CNA C stated he received his training by the DON. He stated she taught the four corners method in peri care training. <BR/>In an interview on 06/22/23 at 04:41 PM, the DON stated she did most all trainings for nursing services. The DON stated the ADON did trainings for the CNA's. The DON stated she started doing their trainings beginning in early April. The DON stated she did audits and observed the CNA's techniques after their training was completed. The DON stated all the retraining for CNA's were done by the ADON. The DON stated the washcloths were hygiene wipes. The DON described them as a premoisten disposable cleaning wipes. The DON stated there were some CNAs that were originally trained by her utilizing an actual cloth, washcloths. The DON stated staff could use the hygiene wipes if they folded and used a clean side. The DON stated the four corners method was not appropriate with the hygiene wipes. Most especially because of the size and consistency they were not designed for the fold four corner method. The DON stated the effect of improper peri care on a resident would depend on where the deficient practice was within the process. The DON stated the failure to perform hand washing or hand sanitizer hygiene had the potential to lead to cross contamination. The DON stated the effect could expose the residents to opportunist pathogen with associated with potential infection. <BR/>Record review of the facility policy titled Perineal Care reflected the following: <BR/> 2. Assemble the equipment and supplies as needed.<BR/>Equipment and Supplies<BR/>The following equipment and supplies will be necessary when performing this procedure:<BR/>1. <BR/>Incontinence product such as brief or underwear<BR/>2. <BR/>Barrier cream or moisturizer as directed by the nurse<BR/>3. <BR/>Incontinence cleanser (as needed)<BR/>4. <BR/>Under pad<BR/>5. <BR/>Plastic trash bag<BR/>6. <BR/>Gloves<BR/>Step in Procedure<BR/>1. <BR/>Arrange the supplies as they can be easily reached.<BR/>2. <BR/>Wash and dry your hands thoroughly or use hand sanitizer.<BR/>Record review of the facility policy titled Hand Washing reflecting the following: <BR/>Section 12-Infection Control<BR/>Purpose: Hand washing will be regarded by this facility as the single most important means of preventing the spread of infections.<BR/>Procedure:<BR/>1. <BR/>All personnel will follow the facility's established handwashing procedures using current CDC Hand Hygiene Guidance protocols to prevent the spread of infections and disease to other personnel, residents, and visitors.<BR/>2. <BR/>Hands should be washed 20 seconds under the following conditions<BR/> .<BR/>c. <BR/>Before performing invasive procedures<BR/> .<BR/>e. <BR/>Before handling clean or soiled dressings, gauze pads, etc<BR/>f. <BR/>After handling used dressings, contaminated equipment, etc<BR/>g. <BR/>After contact with blood, body fluids, excretions, secretions, mucous membranes, or nonintact skin<BR/>h. <BR/>After handling items potentially contaminated with blood,. body fluids, excretions, or secretions<BR/>i. <BR/>After using the toilet, blowing or wiping the nose, smoking, combing the hair, etc<BR/>j. <BR/>After removing gloves <BR/>Record review of the facility policy labeled Hand Hygiene Guidance, (CDC Centers for Disease Control and Prevention) reflected the following:<BR/>The core infection prevention and control practices in All . <BR/>2. All personnel shall follow the hand washing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors <BR/> .7. Use of an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations<BR/> .b. Before and after direct contact with residents;<BR/>c. Before preparing or handling medications <BR/> .k. After handling used dressings, contaminated equipment, etc .9. The use of gloves does not replace hand washing/hand hygiene. Integration of glove use along with routine hand hygiene is recognized as the best practice for preventing healthcare associated infection.<BR/>

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to ensure residents who needed respiratory care were provided respiratory care consistent with professional standards of practice for 1 of 13 residents (Resident #133) reviewed for oxygen administration.<BR/>The facility failed to ensure an Oxygen in Use sign was posted on the outside of Resident #133's door. <BR/>These deficient practices could place residents who received oxygen and treatments at risk of respiratory infection.<BR/>The findings include: <BR/>Record review of Resident # 133's face sheet dated 08/09/2024 revealed a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses which included Chronic Obstructive Pulmonary Disease, Asthma, and hypertension (high blood pressure).<BR/>Record review of Resident #133's admission MDS assessment dated [DATE] revealed: Section C (Cognitive Patterns) BIMS score had not been completed. <BR/>Record review of Resident #133's Physician Orders dated 08/09/2024 revealed, Start date of 08/01/2024 Oxygen at 2 l/m to 5 l/m per nasal cannula prn SOB/respiratory compromise as needed for shortness of breath. <BR/>During an observation on 08/07/2024 at 3:35 PM, Resident #133's door to her room did not have Oxygen in Use sign posted outside the entrance of her door. <BR/>During an observation and interview on 08/08/2024 at 10:53 AM PM, Resident #133's door to her room did not have Oxygen in Use sign posted outside the entrance of her door. Resident #133 stated she was a smoker and did not wear her oxygen when she went outside to smoke. <BR/>During an interview on 08/09/24 at 03:25 PM, the ADON stated her expectation was that a Oxygen in Use sign should have been placed on the outside of door of residents who smoked. The ADON stated no one specific was responsible for ensuring the sign was posted on the door, the person who set up the concentrator should have posted the sign. The ADON stated all staff should have monitored the doors to ensure the signs were on the doors. The ADON stated the DON and herself make random rounds daily throughout the facility. The ADON stated what led to failure was staff were in a rush. <BR/>During an interview on 08/09/2024 at 3:46 PM, the DON stated her expectation was that each room where a resident was using an oxygen concentrator should have had an Oxygen in Use sign on the door. The DON stated the maintenance supervisor was responsible to ensure a sign was placed on the door and all staff should have monitored to ensure each room had an Oxygen in Use Sign on the door. The DON stated the effect on the residents could have been a safety issue if they were not aware that oxygen was in use in a room. The DON stated what led to failure was Resident #133 was admitted on [DATE] late in the day, and staff were focused on the admission, care, and assessment of Resident #133. The DON stated ultimately it was an oversight of staff. <BR/>Record review of facility policy titled Oxygen Administration dated March 2004, revealed: Place an Oxygen in Use sign on the outside of the room entrance door.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to ensure the comprehensive care plan was developed within 7 days after completion of the comprehensive assessment for 1 of 13 (Resident #28) residents reviewed for comprehensive person-centered care plans. <BR/>The facility failed to develop Resident #28 comprehensive care plan within 7 days of the completion of the comprehensive assessment. <BR/>This failure could affect the residents by placing them at risk for not receiving care and services to attain or maintain the residents highest practicable physical, mental, and psychosocial well-being.<BR/>Findings include:<BR/>Record review of Resident #28 dated 08/09/2024 revealed a [AGE] year-old female admitted on [DATE] with the diagnosis of Acute Transverse Myelitis in Demyelinating Disease of Central Nervous System (Inflammation of spinal cord that causes neurological affects) Rheumatoid Arthritis, Bartter's Syndrome (an inherited disease that results in low potassium and increased blood acidity and low blood pressure), Chronic Kidney Disease and high blood pressure. <BR/>Record review of Resident #28's admission MDS revealed a completion date of 02/16/2024. <BR/>Record review of Resident #28's Quarterly MDS dated [DATE] revealed: Section C- Cognitive Patterns revealed a BIMS score of 15 which means cognitively intact. <BR/>Record review of Resident #28's comprehensive care plan revealed an initiation date of 04/16/2024. <BR/>During an interview on 08/09/24 at 3:25 PM, the ADON stated her expectation was that comprehensive care plans should have been completed within 7 days of the completion of the comprehensive assessment. The ADON stated she was responsible to complete and monitor the comprehensive care plan. The ADON stated the effect on residents could have been care area could have been missed. The ADON stated Resident #28's comprehensive care plan should have been initiated by February 23, 2024, The ADON stated what led to failure of the care plan not being initiated until 4/16/2024 was oversight on her part, she had returned from medical leave about that time and had a lot of things to catch up on.<BR/>During an interview on 08/09/2024 at 3:46 PM, the DON stated her expectation was that compressive care plans be completed within 21 days of admission. The DON stated the ADON and herself were responsible to complete care plans. The DON stated the effect on residents could have been a lapse in compressive care. The DON stated what led to failure was oversight by the DON and ADON. <BR/>Record review of facility policy titled, Comprehensive Care Plans not dated, revealed: The comprehensive care plan will be developed within 7 days after completion of the comprehensive assessment.

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, seven days a week for one of one facility reviewed for RN services.<BR/>The facility failed to provide evidence a Registered Nurse (RN) worked 8 consecutive hours a day, seven days a week for 6 days (1/1/23, 1/14/23, 1/15/23, 1/28/23, 1/29/23, and 2/12/23) of the FY Quarter 2 (January1- March31) out of 4 Quarters. <BR/>This failure could place residents at risk for altered physical, mental, and psychological well-being due to decisions that would have required an RN to make in the management of the residents' healthcare needs and in managing and monitoring the direct care staff. <BR/>Findings include:<BR/>Record review of the facility's Staffing Data Report for FY Quarter 2 revealed no RN coverage on 1/1/23, 1/14/23, 1/15/23, 1/28/23, 1/29/23, and 2/12/23. <BR/>During an interview on 06/22/23 at 1:34 PM the DON stated her expectation was there should have been an RN at least 8 hours per day in the facility. The DON stated she was responsible for making the RN schedule and the ADMN and herself were responsible for monitoring the RN coverage. The ADMN was responsible to make the staffing report. The DON stated that schedules and when they did not have RN coverage the DON or ADON would work, the DON and the ADON did clock in when they worked. The DON stated she was not sure of the dates on staffing report were not covered. One of the weekend RN's was on leave and the DON and the ADON split their schedules. The DON stated she only thought there were 2 days that were not covered .<BR/>During an interview on 06/22/23 at 1:47 PM the ADMN stated his expectation was to have 8 hours RN coverage daily. The ADMN stated he did not think there was a negative impact on residents for not having an RN in the building because nursing staff had access to an on-call RN who could be at the facility within 30 minutes. The ADMN stated LVNs were trained and licensed, so no one suffered from lack of quality of care. The ADMN stated what led to the failure was the weekend RN called in or did not show up and it was hard to locate an RN to work weekends. The ADMN stated the DON and ADMN monitored RN coverage but it ultimately landed on the ADMN. <BR/>Record review of the facility's, undated, policy titled, RN Coverage revealed, The facility will make every effort to assign registered nurse coverage at least eight (8) hours per day, seven (7) days per week.