MCCAMEY CONVALESCENT CENTER

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to ensure a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for 4 of 5 (Residents # 116, 122, 126, and 127) reviewed for indwelling catheters. <BR/>The facility failed to ensure Resident # 116, 122, 126, and 127's indwelling catheter were secured to prevent pulling or tugging. <BR/>The failure could place residents at risk for discomfort, urethral trauma, and urinary tract infections.<BR/>Findings included:<BR/>Review of Resident #116's admission Record, dated 12/29/24 revealed he was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included benign prostatic hyperplasia with lower urinary tract symptoms (blocked urinary tract due to swollen prostate). <BR/>Review of Resident #116's Significant Change MDS, dated [DATE], revealed:<BR/>He had a mental status score of 9 of 15 with signs of delirium including inattention and altered level of consciousness that fluctuated. (Indicating interview status was difficult to determine due to delirium.) <BR/>He had an indwelling catheter. <BR/>Review of Resident #116's Care Plan, revised on 11/17/24, revealed:<BR/>Focus: The resident has indwelling catheter: Terminal Condition. <BR/>Goal: The resident will be/remain free from catheter-related trauma through review date.<BR/>Interventions: Check tubing for kinks with peri care each shift.<BR/>Monitor for signs/symptoms of discomfort due to catheter. <BR/>Review of Resident #116's Order Summary, dated 12/29/24, revealed orders dated 12/18/24 Change Foley Cather 16 French (size of catheter) every 18th starting on the 18th every month related to Urinary Tract Infection.<BR/>Observation and interview on 12/28/24 at 11:08 a.m. with LVN B revealed Resident #116 in bed with his catheter not secured. In an interview at that time LVN B said it was not secured. <BR/>Review of Resident #122's admission Record, dated 12/29/24, revealed he was an [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included pressure-induced deep tissue damage of the right and left buttocks. <BR/>Review of Resident #122's admission MDS assessment dated [DATE] revealed:<BR/>He had a mental status score of 15 of 15 with no signs of delirium (indicating he was cognitively intact).<BR/>He used an indwelling catheter. <BR/>Review of Resident #122's Care Plan initiated 11/28/24 revealed:<BR/>Focus: The resident has Indwelling Catheter: Pressure Ulcer, Skin Breakdown<BR/>Goal: The resident will be/remain free from catheter-related trauma through review date.<BR/>Interventions: Check tubing for kinks every two hours and as needed each shift.<BR/>Monitor / document for pain/discomfort due to catheter. <BR/>Review of Resident #122's Order Summary Report, dated 12/29/24, revealed orders dated 11/28/24 may place Coude (A Coude catheter is a type of catheter with a curved tip. The bent tip allows the catheter to bypass obstructions and navigate spaces that a straight catheter, which has a completely straight tip, may have trouble with.) 16 f, change every month and as needed for wound healing. <BR/>Observation and interview on 12/28/24 at 11:08 a.m. with LVN B revealed Resident #122 was in bed but his catheter was not secured. In an interview at that time LVN B said it was not secured. <BR/>Review of Resident #126's admission Record, dated 12/29/24 revealed she was an [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included neuromuscular dysfunction of the bladder.<BR/>Review of Resident #126's Quarterly MDS Assessment, dated 10/3/24, revealed:<BR/>She had a mental status score of 3 of 15 (indicating she was severely cognitively impaired). <BR/>She had an indwelling catheter.<BR/>Review of Resident #126's Care Plan, revised 8/17/23, revealed:<BR/>Focus: The resident has an indwelling catheter.<BR/>Goal: The resident will be/ remail free from catheter-related trauma through review date. <BR/>Interventions: Check tubing for kinks each shift. <BR/>Review of Resident #126's Order Summary, dated 12/29/24 revealed orders dated 3/6/24 for Change Foley Catheter (a type of catheter) with 16 French Foley as needed if removed. <BR/>Observation and interview on 12/28/24 at 11:08 a.m. with LVN B revealed Resident #126 in her room in bed with the catheter not secured. In an interview at that time LVN B said it was not secured. <BR/>Review of Resident #127's admission record, dated 12/29/24, revealed she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included fracture of the left femur. Resident #127 was on hospice services. <BR/>Review of Resident #127's Quarterly MDS assessment dated [DATE] revealed:<BR/>She had long and short-term memory loss and severely impaired decision-making abilities with signs of delirium that included inattention. (Indicating she was not interviewable.)<BR/>She was incontinent of bowel and bladder. (The catheter was not inserted yet.)<BR/>Review of Resident #127's Care Plan, initiated 12/16/24 and revised 12/29/24, revealed:<BR/>Focus: The resident has indwelling catheter related to immobility.<BR/>Goal: The resident will be/remail free from catheter-related trauma through review date.<BR/>Interventions: Check tubing for kinks on rounds every shift.<BR/>Monitor/document for pain/discomfort due to catheter.<BR/>Review of Resident #127's Order Summary, dated 12/29/24, revealed orders dated 12/19/24 for 16 French Foley Change every day shift starting on the 18th and ending on the 16th of every month.<BR/>Observation on 12/28/24 at 10:56 a.m. revealed Resident #127 in bed asleep with the bed in the lowest position to the floor. Her catheter was under her low bed and the catheter was not secured.<BR/>Interview on 12/28/24 at 11:08 a.m. LVN B stated Resident #127's catheter was not secured to her leg and the catheter was probably not effective when it was under the bed. <BR/>In an interview at 12/28/24 at 11:08 a.m. LVN B stated the potential outcome to having unsecured catheters were injuries to the urethra causing damage to the inside of the resident. LVN B said the damage would cause bleeding and swelling, urinary tract infections, or impede urine flow. LVN B said she received in-servicing on keeping the catheter secured but she did not remember when the last time was, it had been a while. LVN B said the Infection Control Coordinator was responsible for monitoring that the catheters were secured. LVN B said she could not think of anything else the state surveyor needed to know about the catheter. <BR/>In an interview on 12/28/24 at 4:12 p.m. the DON stated her expectation for catheter care was they be cleaned at least once a shift and drained at the end of the shift and as needed. The DON said the nurses were responsible for changing the catheters per physician orders and monitoring for kinks. The DON said a catheter on the floor, under a bed would not be an effective catheter. The DON said the facility used a device to secure catheters. The DON explained the devices were a leg sticker that went over the catheter on the resident's leg to keep the catheter from moving. The DON said nurses and CNAs were responsible for monitoring that the devices were present. The DON replied the CNAs were supposed to let the nurses know if there was not a device on the resident's leg so the nurses could put one on. The DON said she would have to look when the last time she in-serviced the staff on catheter care. The DON stated the outcome to an unsecured catheter would be trauma, pain, or bleeding.<BR/>Review of the facility's undated RN/LVN Initial/Annual Skills Competency Checklist revealed:<BR/>Foley Catheter care and management per policy/Urinary drainage systems management:<BR/>Securing the catheter: secure the catheter to the patient's thigh or abdomen to prevent movement and urethral traction. <BR/>Maintain Unobstructed Flow: Ensure that the tubing is not kinked, or twisted and that urine flows freely into the drainage bag. <BR/>Review of the facility's undated Initial/Annual Certified Nurse Aide Competency Checklist revealed:<BR/>Foley Catheter Care/Urinary Drainage System Management:<BR/>Foley Catheter Care: Securing the Catheter: Secure the catheter to the patient's thigh or abdomen to prevent movement and urethral traction. <BR/>Maintain Unobstructed Flow: Ensure that the tubing is not kinked, or twisted and that urine flows freely into the drainage bag. <BR/>Review of the facility's in-service for Catheter Care, dated 12/28/24, revealed:<BR/>The catheter should be attached to the patient's leg or abdomen, and it should be secured so that there is no traction or tension on the catheter. The CNA needs to remember that traction or tension on an indwelling urinary catheter can be painful, and it can cause trauma and/or an infection. Securing the catheter will also prevent it from being accidently pulled out. The catheter can be secured using commercially available devices or improvised methods, and it should be secured to either the upper thigh or the abdomen. <BR/>Review of the facility's undated policy and procedure on Catheterization - Foley revealed:<BR/>Objective: To maintain constant urinary drainage.<BR/>Procedure: secure catheter to thigh and attach to drainage bag. <BR/>Review of the facility's undated Stat Lock Stabilization Device Directions revealed:<BR/>Purpose: To stabilize indwelling urinary catheters, reducing Foley catheter movement, and minimizing accident dislodgement. Using Device maximized patient comfort by eliminating circumferential compression and alleviating urethral traction.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record review, the facility failed to ensure that a resident who needed respiratory care was provided such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for two (Residents #12 and #127) of three residents reviewed for Respiratory Care.<BR/>The facility failed to ensure Resident #12's and #127's nasal cannula was properly stored when not in use.<BR/>This failure could place residents at risk for respiratory infection and not having their respiratory needs met.<BR/>Findings included: <BR/>Resident #12<BR/>Review of Resident #12's admission Record, dated 12/30/24, revealed he was an [AGE] year-old male admitted to the facility on [DATE] with diagnoses which included pleural effusion (lungs clogged with mucous).<BR/>Review of Resident #12's Quarterly MDS Assessment, dated 10/26/24, revealed: <BR/>He had a mental status score of 8 of 15 (indicating severe cognitive impairment).<BR/>He had shortness of breath upon exertion.<BR/>Breathing Treatments were not coded on the MDS.<BR/>Review of the facility's Care Plan, updated 9/7/24, revealed no care plan or interventions regarding the breathing treatment.<BR/>Review of the Order Summary Report, dated 12/30/24, revealed orders dated 10/16/24 for Ipratropium-Albuterol Inhalation Solution 0.5-2.5 mg/3mL 1 inhalation inhale orally every 6 hours as needed for shortness of breath.<BR/>During an observation on 12/28/24 at 11:20 a.m. revealed Resident #12's SVN mask was unbagged and open to air on the nightstand table. <BR/>RESIDENT #127<BR/>Review of Resident #127's admission record, dated 12/29/24, revealed she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included fracture of the left femur. Resident #127 was on hospice services. <BR/>Review of Resident #127's Quarterly MDS assessment dated [DATE] revealed:<BR/>She had long and short-term memory loss and severely impaired decision-making abilities with signs of delirium that included inattention. (Indicating she was not interviewable.)<BR/>She had pneumonia.<BR/>MDS did not include breathing treatments. <BR/>Review of Resident #127's Care Plan, initiated 11/8/22 and revised on 10/9/23, revealed:<BR/>Focus: The resident has shortness of breath related to disease process and was on oxygen.<BR/>Goal: The resident will have no complications related to shortness of breath through review date. Interventions did not address the keeping of respiratory equipment. <BR/>Review of Resident #127's Order Summary, dated 12/29/24, revealed orders dated 12/9/24 Ipratropium-Albuterol Inhalation Solution 0.5-2.5 mg/3mL 1 inhalation inhale orally every 4 hours as needed for shortness of breath related to pneumonia while awake during the night. <BR/>During an observation on 12/28/24 at 10:56 a.m. revealed Resident #127 in bed asleep with the bed in the lowest position to the floor. She had a breathing treatment mask on the bedside table unbagged and open to air.<BR/>During an interview on 12/30/24 at 9:42 a.m. the DON stated her expectation for breathing treatment masks was for them to be stored in a bag to keep them from being contaminated from germs. She stated she personally made sure they got rinsed out and put back in a bag. She was informed of the 12/28/24 observation. She stated someone did not put them where they needed to go. The DON said the Infection Control Nurse typically monitored for the breathing treatment masks to be placed in bags, but her hours were Monday through Friday and 12/28/24 was a Saturday. The DON stated she sometimes came into the facility early on Sundays to catch the night shift or mid-day to catch the day shift. <BR/>Record Review of the facility's undated policy and procedure on Small Volume Aerosol Treatment (Breathing treatment masks) revealed: Purpose: To standardize the delivery of inhalation aerosol drug therapy via small volume nebulizer. Facility will provide equipment and therapy for the aerosolization of pharmacological agents per MD orders to maintain airway patency and provide clearance of retained secretions. Procedure: Place equipment in a patient plastic equipment bag or Wiki pouch labeled with the date the equipment was opened.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the infection prevention and control program was maintained to help prevent the development and transmission of infections for 1 of 1 (Resident #7) residents reviewed for infection control. <BR/>1. The facility failed to ensure LVN D performed hand hygiene, changed gloves, and did not contaminate the wound bed during the wound care for Resident #7.<BR/>This failure could affect the residents, by placing them at risk for contamination of their wounds and causing unnecessary infections and worsening of pressure ulcers.<BR/>Findings included:<BR/>Review of Resident #7's admission Record dated 9/21/22 documented she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses including gout, chronic kidney disease, pancreas disease, pain, urinary tract infections, hypertension and arthritis (joint pain) . <BR/>Review of Resident #7's quarterly MDS assessment dated [DATE] documented:<BR/>Resident #7 had long and short-term memory impairment with moderately impaired decision-making skills.<BR/>She showed no signs of delirium. <BR/>She was totally dependent on one or two staff for all ADLs.<BR/>She had lower range of motion impairment on one side and used a wheelchair. <BR/>She was incontinent of bowel and bladder. <BR/>She needed as-needed pain medications one or two days in the assessment time frame. <BR/>She was expected to live for less than 6 months.<BR/>She weighed 154 pounds and experienced non-prescribed weight loss. <BR/>There were no skin issues identified (the stage two on Resident #7's heel was discovered 8/9/22)<BR/>She received an anti-anxiety medication for 7 of 7 days.<BR/>Specialized treatments included hospice and oxygen usage. <BR/>Review of Resident #7's Order Summary Report dated 9/21/22 documented additional diagnosis of Alzheimer's disease and fracture of the left femur. Order dated 8/10/22 documented cleanse stage 2 to left heel with normal saline, pat dry with 4x4 (gauze), apply zinc oxide and cover with dry dressing every other day and as needed until resolved every day shift every other day. (A stage 2 pressure sore is a partial thickness skin wound caused by pressure).<BR/>Observation and interview on 9/21/22 at 1:27 p.m. revealed LVN D got a sheet of wax paper out of the treatment cart and said Resident #7's sore was practically healed. She stated the orders were to clean with normal saline, pat dry, apply zinc oxide and a dressing. She did not disinfect the bed side table she put the wax paper on. She did not don gloves, nor did she gel (she did not ensure supplies were handled in a manner to prevent contamination). She got all supplies out of a box attached to the wall in Resident #7's room. She opened all treatment supplies (gauze, dressing) with her unwashed, ungloved hands. After setting up the wound care, LVN D went into the bathroom and cleaned her hands. She did get gloves out of Resident #7's bathroom. She explained what she was doing to Resident #7. LVN D raised the bed and donned gloves. Then LVN D put her hands in her pocket to check for gloves, when she realized she did not have enough she returned to Resident #7's bathroom and got more. LVN D used double gloves, took off Resident #7's dressing and placed it on the bed. LVN D showed Resident #7's heel was bright pink closed with new skin in a small area on the heel. LVN D placed the heel on the dirty dressing. LVN D put normal saline on the gauze and cleaned the heel with a circular motion twice. She did not change gloves or perform hand hygiene. LVN D then dried the heel with dry gauze with a circular motion twice (instead of patting dry per the orders). She placed Resident #7's cleaned heel on the dirty dressing on the bed. LVN D applied zinc oxide from a tube onto a bandage and placed the bandage on Resident #7's heel. LVN D took off her gloves. LVN D initialed the dressing and threw away her supplies. She then washed her hands and placed the zinc oxide back in the box in Resident #7's room. <BR/>Interview on 9/21/22 at 3:29 p.m. LVN D said she thought the treatment went ok and said she could have been a little more organized on getting her treatment together. She recalled the treatment was she took the treatment cart by Resident #7's hall, grabbed some wax paper and placed it on the bedside table. She said she opened a package of 4x4 gauze and had the zinc oxide in Resident #7's room. She stated she washed her hands and got gloves. She stated she thought she grabbed four gloves. LVN D stated she double gloved. LVN D stated she cleaned Resident #7's wound with normal saline and applied the zinc oxide. When asked what she would do differently, LVN D stated she would have washed her hands prior to getting her supplies. She stated the point to that would be to keep the environment clean and not contaminate the wound care. She said she did not know why she double gloved during the wound care because she normally did not. LVN D said she did not think she needed to change gloves because she did not touch the dirty dressing, she touched the wound with the gauze, and she had gloves on. LVN D said she did not have training in wound care, she just went by the orders. She stated she knew to wash her hands before the treatment and the end of the treatment. <BR/>Interview on 9/21/22 at 3:48 PM the DON stated her expectation for wound care in general was for the nurse to wash hands and don gloves. The DON stated she doubled gloved to go from dirty to clean. She said she expected the nurses to take all the dirty dressings off and remove the top set of gloves and then use gauze to clean the wound and pat the wound dry, then put on ointment and put on the prescribed dressing and initial the dressing. The DON stated she expected hand hygiene before and after the wound care . Surveyor explained the wound care process observed and the DON stated she did not expect wound care set up to be done with bare, unwashed hands. She stated when LVN D put her hands in the pocket she contaminated the gloves. The DON stated when LVN D cleaned and dried the wound in a circular motion she created friction or shear. She stated the expectation was to pat and not rub. The DON stated at that point she would remove her dirty gloves. The DON said she was new to the facility and did not think she had in-serviced the staff on her expectation for wound care. <BR/>Review of the facility's policy and procedure, undated, on Personal Protective Equipment documented: each employee shall be trained to know at least the following: when is PPE necessary, what PPE is necessary, and limitations of the PPE. <BR/>Review of the facility's policy and procedure, undated , on Wound Care Procedure documented: <BR/>General: Supplies need for Dressing. Pack of 4x4 gauze. Prescribed dressing. Prescribed wound cleanser. Normal Saline. Gloves.

Based on interview and record review, the facility failed to use the services of a RN for at least 8 consecutive hours a day, 7 days a week for 1 of 1 facility reviewed for Licensed Nursing coverage for 1 of 3 months reviewed for RN coverage. (April 2023), (May 2023), and (June 2023). <BR/>The facility did not have the required 8 consecutive hours of RN coverage during the month of April 2023 (April 29th). <BR/>This failure could place residents at risk for not having their nursing care and medical needs met. <BR/>Findings included: <BR/>Review of PBJ [Payroll Based Journal] Staffing Data Report, with a run date of 11/01/2023 revealed Failed to have Licensed Nursing Coverage 24 Hours/Day was triggered for the fiscal year Quarter 3 2023 (April 1 - June 30). The infraction dates were 04/01 (SA); 04/07 (FR); 04/09 (SU); 04/16 (SU); 04/23 (SU); 04/29 (SA); 05/06 (SA); 06/03 (SA); 06/17 (SA), 06/25 (SU).<BR/>Record review of the April 2023 schedule/time sheets indicated an RN only worked 4.5 hours on Sunday 04/09/2023. Time sheets indicate 24-hour licensed nursing coverage for Saturday 04/01/2023, Friday 04/07/2023, Sunday 04/16/2023, Sunday 04/23/2023, and Saturday 04/29/2023.<BR/>Record review of the May 2023 schedule/time sheets indicated 24-hour licensed nursing coverage for Saturday 05/06/2023. <BR/>Record review of the June 2023 schedule/time sheets indicated 24-hour licensed nursing coverage on Saturday 06/03/2023, Saturday 06/17/2023, and Sunday 06/25/2023.<BR/>In an interview on 11/09/23 at 09:15 AM, the DON stated that she or the Infection Preventionist nurse are available to work the required 8 consecutive hours each day when there is not a Registered Nurse available to work. The DON could not recall the specific reason there were missing hours of RN coverage on April 9, 2023. The DON stated this was rare as she is always able to cover a shift as is her Infection Preventionist nurse when the need arises. The DON stated the Registered Nurse who worked on April 9, 2023, agreed to work 4.5 hours and normally either she or the Infection Preventionist would make up the remaining hours to equal the eight hours. The DON stated they have Registered Nurses right around the corner in the hospital who could respond in the event of an emergency. She also stated they have telehealth nurses available 7 days a week. The DON stated staffing is not a problem at this facility. She stated there are 3 Registered Nurses positions available with 2 filled, 6 Licensed Vocational Nurses positions available, and all are filled, 2 Medication Aide positions available and all are filled, and 13 Certified Nurse Aid positions available and all filled. The DON stated she did not report licensed nursing hours including Registered Nursing coverage hours to CMS to account for all but 1 day not covered on April 9th, 2023, (missing 3.5 hours of RN coverage), because she was not aware she could do that but would contact another facility to show her how.<BR/>In an interview on 11/09/2023 at 12:36 PM, the ADON stated she makes the schedule and presents the schedule to the DON for approval. She stated there are times they have limited RN coverage. Right now, they have three Registered Nurses to include the Director of Nurses and Infection Control nurse. <BR/>Review of undated facility policy titled Attendance, Scheduling Nursing Services, Staff Guidelines/Restrictions, revealed, in part:<BR/>Procedure:<BR/>Registered Nurse (RN) coverage hours will be at a minimum in person 8 hours per day in conjunction with telehealth RN coverage for the remaining 16 hours per day (24-hour period).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 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 reviewed for kitchen sanitation. <BR/>The facility failed to ensure that expired foods were discarded.<BR/>This failure could affect residents who received meals prepared meals from the kitchen at risk for food borne illness and cross-contamination.<BR/>The findings included:<BR/>Observation on 11/07/23 at 09:15 AM, of the kitchen refrigerator revealed:<BR/>1, 28-ounce bottle of [NAME] Yellow Mustard with a best by date of 7/21/23<BR/>1, 24-ounce bottle of Young Guns Flame Roasted Salsa with a best by date of 1/9/23<BR/>1, 32-ounce bottle of Food Club Lemon Juice from concentrate with a best by date of 7/11/23<BR/>1, 64-ounce bottle of Food Club Prune Juice unsweetened from concentrate with a best by date of 7/11/23<BR/>1, 5-pound container of Mollys California Style Pasta Salad with an expiration date of 10/4/23<BR/>21, 8-ounce cartons of Hormel Nectar Consistency Thickened Dairy beverage with a best by date of 10/26/23.<BR/>Observation on 11/07/23 at 09:45 AM, of the dry storage room revealed:<BR/>2, 14.5-ounce cans of Health Valley Organic Cream of Mushroom Soup (gluten free) with a best by date of 5/3/23.<BR/>5, 3.4-ounce boxes of Jell-O Pistachio flavored Instant Pudding and Pie filling dry mix with an expiration date of 8/14/23<BR/>1, 1.34-ounce Food Club Vanilla flavored sugar-free Instant Pudding and Pie Filling with an expiration date of 5/17/23<BR/>1, 6-ounce box of Cherry flavored Gelatin dessert with an expiration date of 10/4/23<BR/>1, 2.82-ounce bottle of Great Value Salted Carmel flavored Hot Cocoa Topper with a best by date of 6/2/23<BR/>14, 1.1-ounce bags [NAME] Tortilla Style Protein Chips Nacho Cheese flavored with a best by date of 9/8/23<BR/>10, 1.1-ounce bags [NAME] Tortilla Style Protein Chips Ranch flavored with a best by date of 7/19/23<BR/>3, 1.76-ounce Pure Protein Bars Chocolate Deluxe Gluten Free with a best by date of 7/16/23<BR/>4, 1.76-ounce Pure Protein Bars Chocolate Peanut Butter Gluten Free with a best by date of 8/1/23<BR/>1, 1.76-ounce Pure Protein Bars Chocolate Peanut Carmel Gluten Free with a best by date of 8/29/23<BR/>1, 10-ounce bag Food Club Marshmallows with a best by date of 7/3/23<BR/>1, 10-ounce bag Reese's Peanut butter chips with a best by date of 02/2023<BR/>1, 7-ounce box (10 count) Food Club Waffle Bowls with a best by date of 7/30/23<BR/>2, 3.5-ounce (12 count) Chocolate Dipped Ice Cream Cups with a best by date of 03/2023<BR/>1, 7-ounce (12 count) [NAME] Waffle Cones with a best by date of 06/2023<BR/>1, 400-grams bottle of Tajin Con [NAME] Classico Salsa En Polvo spice with a best by date of 06/2020<BR/>2, 8 fluid-ounce bottles of Clover Valley Imitation Vanilla Flavor with a best by date of 09/2023<BR/>1, 22-ounce can Clabber Girl Baking Powder with a best by date of 2/25/23<BR/>1, 0.4-ounce bottle Clover Valley Italian Seasoning with a best by date of 04/2023<BR/>1, 1.75-ounce bottle Clover Valley Poultry Seasoning with a best by date of 5/5/23<BR/>1, 8-ounce bottle [NAME] Chachere's Original Creole Seasoning with a best by date of 10/2023.<BR/>In an interview on 11/07/23 at 10:45 AM, the Dietary Manager was advised of the expired food items found during the initial inspection of the kitchen. The Dietary Manager took the items to discard them. The Dietary Manager stated expired items were typically disposed of during receipt of food delivery weekly. <BR/>During an interview with Staff C on 11/07/23 at 11:15 AM, when asked how she ensured a food product was not expired prior to cooking, she stated there was an expiration date on the product and also a date when it is received from the truck. She stated she knew to look for expired dates on packaging. Staff C stated a truck with new food is received each Wednesday. <BR/>During an interview with the Dietary Manager on 11/09/23 at 10:30 AM, when asked if she had a process in place to check for expiration dates on food, she stated we get food delivered each week on Wednesday. Two staff label and put the food on shelves with the latest items placed in the back and the old items in the front. Expired or out of date food is discarded at that time. The expired items found was just overlooked. The Dietary Manager also stated the Cooks check for expiration dates prior to cooking food. When asked if she had a system of oversight to ensure less often used food such as sprinkles for cakes or items like this do not go out of date, she stated no but she will get a system in place.<BR/>Review of facility policy dated 03/22 titled Food Storage, revealed, in part:<BR/>All stock must be rotated with each new order received. Rotating stock is essential to assure the freshness and highest quality of foods. <BR/>a. Old stock is always used first (first-in first out method). Supervise the person designated to put stock away to make sure it is rotated properly.<BR/>b. Food should be dated as it is placed on the shelves if required by state regulation.<BR/>c. Date marking will be visible on all high-risk food to indicate the date by which a ready-to-eat, TCS food should be consumed, sold, or discarded.<BR/>d. Foods will be stored and handled to maintain the integrity of the packaging until ready for use. Food stored in bins may be removed from its original packaging.<BR/>Refrigerated food storage:<BR/>f. All foods should be covered, labeled, and dated. All foods will be checked to assure that foods (including leftovers) will be consumed by their safe use by dates, or frozen (where applicable), or discarded.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the infection prevention and control program was maintained to help prevent the development and transmission of infections for 1 of 1 (Resident #7) residents reviewed for infection control. <BR/>1. The facility failed to ensure LVN D performed hand hygiene, changed gloves, and did not contaminate the wound bed during the wound care for Resident #7.<BR/>This failure could affect the residents, by placing them at risk for contamination of their wounds and causing unnecessary infections and worsening of pressure ulcers.<BR/>Findings included:<BR/>Review of Resident #7's admission Record dated 9/21/22 documented she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses including gout, chronic kidney disease, pancreas disease, pain, urinary tract infections, hypertension and arthritis (joint pain) . <BR/>Review of Resident #7's quarterly MDS assessment dated [DATE] documented:<BR/>Resident #7 had long and short-term memory impairment with moderately impaired decision-making skills.<BR/>She showed no signs of delirium. <BR/>She was totally dependent on one or two staff for all ADLs.<BR/>She had lower range of motion impairment on one side and used a wheelchair. <BR/>She was incontinent of bowel and bladder. <BR/>She needed as-needed pain medications one or two days in the assessment time frame. <BR/>She was expected to live for less than 6 months.<BR/>She weighed 154 pounds and experienced non-prescribed weight loss. <BR/>There were no skin issues identified (the stage two on Resident #7's heel was discovered 8/9/22)<BR/>She received an anti-anxiety medication for 7 of 7 days.<BR/>Specialized treatments included hospice and oxygen usage. <BR/>Review of Resident #7's Order Summary Report dated 9/21/22 documented additional diagnosis of Alzheimer's disease and fracture of the left femur. Order dated 8/10/22 documented cleanse stage 2 to left heel with normal saline, pat dry with 4x4 (gauze), apply zinc oxide and cover with dry dressing every other day and as needed until resolved every day shift every other day. (A stage 2 pressure sore is a partial thickness skin wound caused by pressure).<BR/>Observation and interview on 9/21/22 at 1:27 p.m. revealed LVN D got a sheet of wax paper out of the treatment cart and said Resident #7's sore was practically healed. She stated the orders were to clean with normal saline, pat dry, apply zinc oxide and a dressing. She did not disinfect the bed side table she put the wax paper on. She did not don gloves, nor did she gel (she did not ensure supplies were handled in a manner to prevent contamination). She got all supplies out of a box attached to the wall in Resident #7's room. She opened all treatment supplies (gauze, dressing) with her unwashed, ungloved hands. After setting up the wound care, LVN D went into the bathroom and cleaned her hands. She did get gloves out of Resident #7's bathroom. She explained what she was doing to Resident #7. LVN D raised the bed and donned gloves. Then LVN D put her hands in her pocket to check for gloves, when she realized she did not have enough she returned to Resident #7's bathroom and got more. LVN D used double gloves, took off Resident #7's dressing and placed it on the bed. LVN D showed Resident #7's heel was bright pink closed with new skin in a small area on the heel. LVN D placed the heel on the dirty dressing. LVN D put normal saline on the gauze and cleaned the heel with a circular motion twice. She did not change gloves or perform hand hygiene. LVN D then dried the heel with dry gauze with a circular motion twice (instead of patting dry per the orders). She placed Resident #7's cleaned heel on the dirty dressing on the bed. LVN D applied zinc oxide from a tube onto a bandage and placed the bandage on Resident #7's heel. LVN D took off her gloves. LVN D initialed the dressing and threw away her supplies. She then washed her hands and placed the zinc oxide back in the box in Resident #7's room. <BR/>Interview on 9/21/22 at 3:29 p.m. LVN D said she thought the treatment went ok and said she could have been a little more organized on getting her treatment together. She recalled the treatment was she took the treatment cart by Resident #7's hall, grabbed some wax paper and placed it on the bedside table. She said she opened a package of 4x4 gauze and had the zinc oxide in Resident #7's room. She stated she washed her hands and got gloves. She stated she thought she grabbed four gloves. LVN D stated she double gloved. LVN D stated she cleaned Resident #7's wound with normal saline and applied the zinc oxide. When asked what she would do differently, LVN D stated she would have washed her hands prior to getting her supplies. She stated the point to that would be to keep the environment clean and not contaminate the wound care. She said she did not know why she double gloved during the wound care because she normally did not. LVN D said she did not think she needed to change gloves because she did not touch the dirty dressing, she touched the wound with the gauze, and she had gloves on. LVN D said she did not have training in wound care, she just went by the orders. She stated she knew to wash her hands before the treatment and the end of the treatment. <BR/>Interview on 9/21/22 at 3:48 PM the DON stated her expectation for wound care in general was for the nurse to wash hands and don gloves. The DON stated she doubled gloved to go from dirty to clean. She said she expected the nurses to take all the dirty dressings off and remove the top set of gloves and then use gauze to clean the wound and pat the wound dry, then put on ointment and put on the prescribed dressing and initial the dressing. The DON stated she expected hand hygiene before and after the wound care . Surveyor explained the wound care process observed and the DON stated she did not expect wound care set up to be done with bare, unwashed hands. She stated when LVN D put her hands in the pocket she contaminated the gloves. The DON stated when LVN D cleaned and dried the wound in a circular motion she created friction or shear. She stated the expectation was to pat and not rub. The DON stated at that point she would remove her dirty gloves. The DON said she was new to the facility and did not think she had in-serviced the staff on her expectation for wound care. <BR/>Review of the facility's policy and procedure, undated, on Personal Protective Equipment documented: each employee shall be trained to know at least the following: when is PPE necessary, what PPE is necessary, and limitations of the PPE. <BR/>Review of the facility's policy and procedure, undated , on Wound Care Procedure documented: <BR/>General: Supplies need for Dressing. Pack of 4x4 gauze. Prescribed dressing. Prescribed wound cleanser. Normal Saline. Gloves.

**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 adequate supervision and assistance devices to prevent accidents for 4 of 5 residents (Resident #4, #19, #25 and #27) reviewed accident/hazards/supervision, in that:<BR/>a) <BR/>CNA C and CA B transferred Resident #4 with a mechanical lift with only CNA C conducting the transfer and not being assisted by the CA B as indicated in the facility's policy.<BR/>b) <BR/>CNA A and CA B transferred Resident #19 from his wheelchair to the bed by grabbing him from the back of his pants and his under arms without the use of a gait belt.<BR/>c) <BR/>DON and CA B transferred Resident #25 from his wheelchair to a recliner by hooking their arms under the resident's armpits and without the use of a gait belt.<BR/>d) <BR/>DON and ADON transferred Resident #25 from the recliner to his wheelchair by hooking their arms under the resident's armpits and without the use of a gait belt.<BR/>e) <BR/>CNA A and CA B transferred Resident #27 from her wheelchair to the bed by grabbing her from the back of her pants and her under arms, without the use of a gait belt.<BR/>These failures could put residents at risk of accidents and serious injuries which could result in a reduced quality of life.<BR/>Findings included:<BR/>RESIDENT #4<BR/>Review of Resident #4's admission record dated [DATE] revealed she was an [AGE] year-old female admitted to the facility on [DATE] with diagnoses of dementia, Parkinson's disease, major depressive disorder, generalized anxiety disorder, Alzheimer's disease with late onset, delirium, hypokalemia (Low blood potassium) , hyperlipidemia (high fat blood level), hypertension (high blood pressure) and alcohol dependence.<BR/>Review of Resident #4's MDS dated [DATE] revealed, in part, she had minimal difficulty hearing, she had unclear speech, she was rarely/never understood and rarely/ never understood others, she had moderately impaired vision, BIMS not completed due to resident rarely/never understood, she exhibited verbal behaviors 1 to 3 days, she required total assistance on staff for all ADLs, she used a wheelchair for locomotion, she was always incontinent of bowel and bladder, she received antianxiety medication 7 of 7 days, antidepressant medication 7 of 7 days, diuretic medication 7 of 7 days.<BR/>Review of Resident #4's care plan dated [DATE] revealed, in part, (Resident) has an ADL self-care performance deficit related to poor decision making, forgetfulness, weakness. ADL needs will be met through staff intervention. BED MOBILITY: total dependence by 2 staff members for bed mobility. TRANSFER: Resident requires mechanical lift with 1 or 2 staff assistance for transfers or 2 person total assist., (Resident) has limited physical mobility related to osteoarthritis of knees and obesity. (Resident) will be assisted by 1 staff member for locomotion in room and halls. The resident is totally dependent on 1 staff for locomotion in Geri-chair. <BR/>During observation on [DATE] at 3:57 PM with CNA C and CA B, both staff used hand sanitizer before entering room, CNA C brought mechanical lift into Resident' #4's room, both staff put on gloves, secured sling under resident, attached sling to lift hooks, CA B moved to get Geri-chair (a type of wheelchair) and positioned it at the foot of the bed. CA B remained standing behind the Ger-chair while CNA C used the lift control to lift resident from bed. CNA C moved lift and steadied resident in sling while CA B stood behind the Geri-chair. CNA C positioned resident over Geri-chair while CA B moved resident's legs into place. CNA C unhooked sling and removed lift from under Geri-chair then covered resident with blanket<BR/>In an interview on [DATE] 5:18 PM with CA B, she stated she had not taken the CNA certification test yet, she took her CNA class through her high school and was currently waiting to test. She stated she was taught how to operate the mechanical lift during her CNA training. She explained that the procedure was to turn the resident and put sling under them, hook sling to lift, then raise and move the resident and place them in their chair or on a bed. She stated staff is never to operate the mechanical lift alone and it always requires 2 people. She stated that one person moved the lift and resident over the chair, the second person held the sling/resident to make sure they are steady. When what was observed during transfer was described to CA B, she stated there was nothing wrong with how it was done. She stated it could frighten a resident to be dangling from the sling in the lift with only one person operating it and no one steadying them. CA B stated she did not know what the facility policy says regarding lift transfers and did not remember ever seeing the policy. She stated that she was not trained by facility on how to do lift transfer. <BR/>In an interview on [DATE] 03:34 PM CNA C stated that there were supposed to be 2 staff present during a resident transfer with a lift. CNA C stated that during the transfer for Resident #4, CA B was supposed to assist with the transfer by guiding the resident but that the other aide might have become nervous and did not help with guiding the resident after they had the resident up in the lift. <BR/>In an interview on [DATE] 03:30 PM the DON said that two staff must be present to complete a mechanical lift transfer during the entire procedure. She stated when one aide lifted the resident on the lift then the other aide needed to be ready with the chair to lower the resident on it. The DON stated that one aide maneuvered the lift while the other aides guided the resident to the chair. The DON said the staff received annual training regarding the use of lifts . The DON said she believed the failure occurred because the staff probably got nervous and forget the steps. <BR/>RESIDENT #19<BR/>Review of Resident #19's admission record dated [DATE] revealed he was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses of Cerebral Palsy (A congenital disorder of movement, muscle tone, or posture), cognitive communication deficit, contracture of right and left hands, lack of coordination, muscle spasms, visual loss and tachycardia (fast heart rate).<BR/>Review of Resident #19's MDS dated [DATE] revealed, in part, he had minimal difficulty hearing, unclear speech, was usually understood and usually understood others, had impaired vision, BIMS score of 11 indicating moderate cognitive impairment, required extensive or total dependence for all ADLs, used a wheelchair for locomotion, and was always incontinent of bowel and bladder.<BR/>Review of Resident #19's care plan dated [DATE] revealed, in part, The resident has limited physical mobility related to disease process of cerebral palsy. The resident will remain free of complications related to immobility, including contractures, thrombus formation, skin breakdown, fall related injury through the next review date. The resident is NON-WEIGHT BEARING; the resident is totally dependent on staff for locomotion using wheelchair.<BR/>During observation on [DATE] at 3:43 PM with CNA A and CA B, Resident #19 was taken to his room by staff and wheelchair positioned at bedside, CNA A and CA B each placed an arm under Resident #19's arms (chicken winged) and grabbed hold of the back of his pants and lifted him out of the wheelchair without the use of a gait belt, pivoted him from the wheelchair to the bed and placed him on his bed. Incontinent care was provided with no concerns noted. Once resident was redressed, CNA A and CA B sat him up on the side of the bed, chicken winged him and both grabbed the back of his waistband to pick him up and placed him in his wheelchair. No gait belt observed in room. Resident is non-weight bearing and dependent on staff for all care.<BR/>RESIDENT #25<BR/>Record review of Resident #25's admission Record, dated [DATE], revealed he was a an [AGE] year-old male admitted to the facility on [DATE] with diagnoses which included dementia, Parkinson's Disease, pain in right and left knee, low back pain, tremor, hallucinations, and history of falls.<BR/>Record review of Resident #25's Annual MDS Assessment, dated [DATE], revealed:<BR/>He scored a 9 of 15 on his mental status exam - indicating moderate cognitive impairment.<BR/>He needed extensive assistance of two staff for transfers.<BR/>He needed extensive assistance of one staff to walk or for locomotion. <BR/>He used a walker and a wheelchair.<BR/>Diagnoses included: arthritis, dementia, and Parkinson's Disease.<BR/>He required as-needed pain medications. Resident #25 said the pain was occasional and moderate in severity.<BR/>He had more than two falls with no injuries in the three months prior to the assessment.<BR/>Review of Resident #25's Care Plan revealed:<BR/>ADL initiated on [DATE]: The resident has an ADL self-care performance deficit related to tremors. The identified goal was: the resident will maintain current level of function in ADLs through the next review date. Identified interventions included: Transfer: The resident requires extensive assistance to total assistance of 1 - 2 staff to move between surfaces as necessary (revised [DATE])<BR/>Care Plan, initiated on [DATE] and revised on [DATE], identified Resident #25 was high risk for falls related to history of falls and tremors but the care plans interventions did not address his transfer needs. <BR/>Review of Resident #25's Order Summary Report dated [DATE] revealed orders: Beginning [DATE]: Fall Precautions. Beginning [DATE]: Frequent rounding every 2 hours for High Fall Risk. <BR/>During an observation on [DATE] at 12:33 PM, the DON and CA B transferred Resident #25 from his wheelchair to a recliner. Both staff were observed assisting Resident #25 to stand by hooking their arms under Resident #25's arms. Resident #25 was unsteady on his feet but eventually gained his balance and shuffled sideways to the chair. The DON grabbed Resident #25 by the seat of his flannel pants when assisting him to sit. They did not use a gait belt. <BR/>During an observation on [DATE] at 3:27 PM the DON and ADON were observed getting Resident #25 up from the recliner to the wheelchair. Both hooked under Resident #25's arms in assisting him to stand. They did not use a gait belt. <BR/>During an interview on [DATE] at 5:01 PM the DON said she expected the staff to transfer a resident by using a gait belt. She stated she expected the staff to put their arms under the resident's arms and use a gait belt. She stated she had not completed an in-service with the staff this year on how to use a gait belt or compete a transfer other than the skills check off. The DON stated she was not aware of therapy completing an in-service either. She said possible consequences for an under-arm transfer were popping the resident's shoulder out of socket. She stated the consequences of grabbing a resident by the seat of the pants would cause a wedgie leaving the resident uncomfortable. She stated she could see how grabbing a resident by the seat of the pants could cause the pants to slip out of the hand causing the resident to fall. The DON stated she did hook her arms under Resident #25 while transferring him on [DATE] nor did she use a gait belt. The DON explained Resident #25 used staff for stability because he was able to stand and shuffle over. She admitted she had not had a chance to read the facility's policy on transfer because she was still new to the facility. <BR/>RESIDENT #27<BR/>Record review of Resident #27's admission record dated [DATE] indicated she was admitted to the facility on [DATE] with diagnoses of dementia and history of falling. She was [AGE] years of age.<BR/>Record review of Resident #27's MDS dated [DATE] indicated in part: BIMS = 03 indicating resident had severe impairment. Transfer extensive assistance, 2 plus persons physical assist. <BR/>Record review of Resident #27's care plan dated [DATE] indicated in part: Focus: The resident has an ADL self-care performance deficit r/t weakness/cognition. Goal: The resident will maintain current level of function in through the review date. Interventions: The resident requires assist X2 staff assistance for transfers.<BR/>During an observation on [DATE] at 03:02 PM CNA A and CA B transferred Resident #27 from her wheelchair to her bed. Both aides took the resident from her underarms and from the back of her pants without the use of a gait belt. During the transfer the resident partially assisted with weightbearing as her legs were bent during the transfer and the staff had to manually assist her to the bed.<BR/>During an interview on [DATE] at 03:32 PM CA B said she had been working at the facility for about 4 months. CA B said she worked along a CNA because she was a comfort aide and not certified yet. CA B said the CNAs she worked with told her which residents were a one person, two person or mechanical lift for transfers. CA B said she had not received training on the use of a gait belt and had not used one since working at the facility. CA B said CNA A and she normally transferred Resident #27 from the wheelchair to her bed by taking the resident from under her arms and by the back of her pants. CA B said that was the way she was shown to transfer Resident #27 since working at the facility. CA B said it was probably okay to transfer the resident that way but then said that perhaps it was not safe as that could possibly cause an injury to the resident's shoulders. CA B also said that it could be unsafe if the resident's pants tore or slipped from her hands and cause the resident to fall. <BR/>During an interview on [DATE] at 02:26 PM CNA A said she had been working at the facility for about 2 years. CNA A said they had a daily assignment sheet and that's where it indicated which type of transfer each resident was. CNA A said that it was okay to transfer Resident #27 from under her arm and from the back of her pants. CNA A said they should have used a gait belt because that would have been better than taking the resident from the back of her pants and underarms. CNA A said they had received training today on how to use the gait belt. CNA A said they got in a hurry and transferred the resident without the use of a gait belt. CNA A said she was also nervous while being observed by the state surveyor and possibly caused her to forget to use the gait belt. <BR/>During an interview on [DATE] at 03:10 PM the DON said the aides should have used the gait belt to transfer Resident #27. The DON said staff used the gait belts to prevent falls or injuries. The DON said they did the initial check off list and ongoing in-services regarding the use of gait belts, lifts and fall preventions. The DON said the failure probably occurred because the aides got nervous and forgot to use the gait belt. <BR/>Review of the facility's undated policy titled Resident transfer protocol - safety techniques in transfer indicated in part: Resident of this facility who are unable to transfer themselves independently or with minimum assistance shall be transferred following the principles of this policy to allow for maximum safety during resident transfer. Full lift transfers shall always be conducted following the principles of proper body mechanics and resident safety. Transferring residents with an assistive lift device. At least two staff members are needed to transfer a resident when using a lift device. First staff member should position the destination chair next to the bed so that it is one-half foot away from the resident's bed and will not get in the way of the lift. Place the chair even with the headboard. Assistant is to support residents legs as you move the left away from the bed. Position resident with lift remote in a sitting position. The second staff member should support the resident's head as needed. Be sure to lock all brakes.<BR/>Review of the facility's undated document titled Certified Nurse Aide indicated in part: Prevention of employee injuries - Uses proper body mechanics, uses lifting equipment when needed - utilizes gait belts. <BR/>Review of undated facility policy Hoyer Lift - Proper Use revealed, in part, At least two (2) nursing staff are needed to transfer a resident when using a Hoyer Lift. Position wheelchair/shower chair next to the bed .Have wheelchair/shower chair even with the headboard .Assistant is to support resident's legs as you move the lift away from the bed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the infection prevention and control program was maintained to help prevent the development and transmission of infections for 1 of 1 (Resident #7) residents reviewed for infection control. <BR/>1. The facility failed to ensure LVN D performed hand hygiene, changed gloves, and did not contaminate the wound bed during the wound care for Resident #7.<BR/>This failure could affect the residents, by placing them at risk for contamination of their wounds and causing unnecessary infections and worsening of pressure ulcers.<BR/>Findings included:<BR/>Review of Resident #7's admission Record dated 9/21/22 documented she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses including gout, chronic kidney disease, pancreas disease, pain, urinary tract infections, hypertension and arthritis (joint pain) . <BR/>Review of Resident #7's quarterly MDS assessment dated [DATE] documented:<BR/>Resident #7 had long and short-term memory impairment with moderately impaired decision-making skills.<BR/>She showed no signs of delirium. <BR/>She was totally dependent on one or two staff for all ADLs.<BR/>She had lower range of motion impairment on one side and used a wheelchair. <BR/>She was incontinent of bowel and bladder. <BR/>She needed as-needed pain medications one or two days in the assessment time frame. <BR/>She was expected to live for less than 6 months.<BR/>She weighed 154 pounds and experienced non-prescribed weight loss. <BR/>There were no skin issues identified (the stage two on Resident #7's heel was discovered 8/9/22)<BR/>She received an anti-anxiety medication for 7 of 7 days.<BR/>Specialized treatments included hospice and oxygen usage. <BR/>Review of Resident #7's Order Summary Report dated 9/21/22 documented additional diagnosis of Alzheimer's disease and fracture of the left femur. Order dated 8/10/22 documented cleanse stage 2 to left heel with normal saline, pat dry with 4x4 (gauze), apply zinc oxide and cover with dry dressing every other day and as needed until resolved every day shift every other day. (A stage 2 pressure sore is a partial thickness skin wound caused by pressure).<BR/>Observation and interview on 9/21/22 at 1:27 p.m. revealed LVN D got a sheet of wax paper out of the treatment cart and said Resident #7's sore was practically healed. She stated the orders were to clean with normal saline, pat dry, apply zinc oxide and a dressing. She did not disinfect the bed side table she put the wax paper on. She did not don gloves, nor did she gel (she did not ensure supplies were handled in a manner to prevent contamination). She got all supplies out of a box attached to the wall in Resident #7's room. She opened all treatment supplies (gauze, dressing) with her unwashed, ungloved hands. After setting up the wound care, LVN D went into the bathroom and cleaned her hands. She did get gloves out of Resident #7's bathroom. She explained what she was doing to Resident #7. LVN D raised the bed and donned gloves. Then LVN D put her hands in her pocket to check for gloves, when she realized she did not have enough she returned to Resident #7's bathroom and got more. LVN D used double gloves, took off Resident #7's dressing and placed it on the bed. LVN D showed Resident #7's heel was bright pink closed with new skin in a small area on the heel. LVN D placed the heel on the dirty dressing. LVN D put normal saline on the gauze and cleaned the heel with a circular motion twice. She did not change gloves or perform hand hygiene. LVN D then dried the heel with dry gauze with a circular motion twice (instead of patting dry per the orders). She placed Resident #7's cleaned heel on the dirty dressing on the bed. LVN D applied zinc oxide from a tube onto a bandage and placed the bandage on Resident #7's heel. LVN D took off her gloves. LVN D initialed the dressing and threw away her supplies. She then washed her hands and placed the zinc oxide back in the box in Resident #7's room. <BR/>Interview on 9/21/22 at 3:29 p.m. LVN D said she thought the treatment went ok and said she could have been a little more organized on getting her treatment together. She recalled the treatment was she took the treatment cart by Resident #7's hall, grabbed some wax paper and placed it on the bedside table. She said she opened a package of 4x4 gauze and had the zinc oxide in Resident #7's room. She stated she washed her hands and got gloves. She stated she thought she grabbed four gloves. LVN D stated she double gloved. LVN D stated she cleaned Resident #7's wound with normal saline and applied the zinc oxide. When asked what she would do differently, LVN D stated she would have washed her hands prior to getting her supplies. She stated the point to that would be to keep the environment clean and not contaminate the wound care. She said she did not know why she double gloved during the wound care because she normally did not. LVN D said she did not think she needed to change gloves because she did not touch the dirty dressing, she touched the wound with the gauze, and she had gloves on. LVN D said she did not have training in wound care, she just went by the orders. She stated she knew to wash her hands before the treatment and the end of the treatment. <BR/>Interview on 9/21/22 at 3:48 PM the DON stated her expectation for wound care in general was for the nurse to wash hands and don gloves. The DON stated she doubled gloved to go from dirty to clean. She said she expected the nurses to take all the dirty dressings off and remove the top set of gloves and then use gauze to clean the wound and pat the wound dry, then put on ointment and put on the prescribed dressing and initial the dressing. The DON stated she expected hand hygiene before and after the wound care . Surveyor explained the wound care process observed and the DON stated she did not expect wound care set up to be done with bare, unwashed hands. She stated when LVN D put her hands in the pocket she contaminated the gloves. The DON stated when LVN D cleaned and dried the wound in a circular motion she created friction or shear. She stated the expectation was to pat and not rub. The DON stated at that point she would remove her dirty gloves. The DON said she was new to the facility and did not think she had in-serviced the staff on her expectation for wound care. <BR/>Review of the facility's policy and procedure, undated, on Personal Protective Equipment documented: each employee shall be trained to know at least the following: when is PPE necessary, what PPE is necessary, and limitations of the PPE. <BR/>Review of the facility's policy and procedure, undated , on Wound Care Procedure documented: <BR/>General: Supplies need for Dressing. Pack of 4x4 gauze. Prescribed dressing. Prescribed wound cleanser. Normal Saline. Gloves.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident for 4 of 5 (Resident #4, #19, #25 and #27) residents reviewed for competent nursing staff, in that:<BR/>a) <BR/>CNA C and CA B transferred Resident #4 with a mechanical lift with only one conducting the transfer alone. <BR/>b) <BR/>CNA A and CA B transferred Resident #19 from his wheelchair to the bed by grabbing him from the back of his pants and his under arms without the use of a gaitbelt.<BR/>c) <BR/>DON and CA B transferred Resident #25 from his wheelchair to a recliner by hooking their arms under the resident's armpits without the use of a gaitbelt.<BR/>d) <BR/>DON and ADON transferred Resident #25 from the recliner to his wheelchair by hooking their arms under the resident's armpits without the use of a gaitbelt.<BR/>e) <BR/>CNA A and CA B transferred Resident #27 from her wheelchair to the bed by grabbing her from the back of her pants and her under arms without the use of a gaitbelt.<BR/>This failure has the potential to affect residents by placing them at an increased and unnecessary risk of discomfort, pain and injury.<BR/>Finding included:<BR/>RESIDENT #4<BR/>Review of Resident #4's admission record dated [DATE] revealed she was an [AGE] year-old female admitted to the facility on [DATE] with diagnoses of dementia, Parkinson's disease, major depressive disorder, generalized anxiety disorder, Alzheimer's disease with late onset, delirium, hypokalemia, hyperlipidemia (high fat blood level), hypertension (high blood pressure) and alcohol dependence.<BR/>Review of Resident #4's MDS dated [DATE] revealed, in part, she had minimal difficulty hearing, she had unclear speech, she was rarely/never understood and rarely/ never understood others, she had moderately impaired vision, BIMS not completed due to resident rarely/never understood, she exhibited verbal behaviors 1 to 3 days, she required total assistance on staff for all ADLs, she used a wheelchair for locomotion, she was always incontinent of bowel and bladder, she received antianxiety medication 7 of 7 days, antidepressant medication 7 of 7 days, diuretic medication 7 of 7 days.<BR/>Review of Resident #4's care plan dated [DATE] revealed, in part, (Resident) has an ADL self-care performance deficit related to poor decision making, forgetfulness, weakness. ADL needs will be met through staff intervention. BED MOBILITY: total dependence by 2 staff members for bed mobility. TRANSFER: Resident requires mechanical lift with 1 or 2 staff assistance for transfers or 2 person total assist., (Resident) has limited physical mobility related to osteoarthritis of knees and obesity. (Resident) will be assisted by 1 staff member for locomotion in room and halls. The resident is totally dependent on 1 staff for locomotion in Geri-chair. <BR/>During observation on [DATE] at 3:57 PM with CNA C and CA B, both staff used hand sanitizer before entering room, CNA C brought mechanical lift into Resident' #4's room, both staff donned gloves, secured sling under resident, attached sling to lift hooks, CA B moved to get Geri-chair(a type of wheelchair) and positioned it at the foot of the bed. CA B remained standing behind the Geri-chair while CNA C used lift control to lift resident from bed. CNA C moved lift and steadied resident in sling while CA B stood behind the Geri-chair. CNA C positioned resident over Geri-chair while CA B moved resident's legs into place . CNA C unhooked sling and removed lift from under Geri-chair then covered resident with blanket.<BR/>In an interview on [DATE] 03:34 PM CNA C stated that there were supposed to be 2 staff present during a resident transfer with a lift. CNA C stated that during the transfer for Resident #4 the other CA B was supposed to assist with the transfer by guiding the resident but that the other aide might have become nervous and did not help with guiding the resident after they had the resident up in the lift. CNA C said she received training on using the lift when she started working at the facility. She said they received gait belt training today, but it was not necessarily done on a regular basis. <BR/>In an interview on [DATE] 03:30 PM the DON said that two staff must be present to complete a mechanical lift transfer during the entire procedure. She stated when one aide lifted the resident on the lift then the other aide needed to be ready with the chair to lower the resident on it. DON stated that one aide maneuvered the lift while the other aides guided the resident to the chair. DON said the staff received annual training regarding the use of lifts. The DON said she believed the failure occurred because the staff probably got nervous and forget the steps. <BR/>RESIDENT #19<BR/>Review of Resident #19's admission record dated [DATE] revealed he was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses of Cerebral Palsy (A congenital disorder of movement, muscle tone, or posture), cognitive communication deficit, contracture of right and left hands, lack of coordination, muscle spasms, visual loss and tachycardia (fast heart rate).<BR/>Review of Resident #19's MDS dated [DATE] revealed, in part, he had minimal difficulty hearing, unclear speech, was usually understood and usually understood others, had impaired vision, BIMS score of 11 indicating moderate cognitive impairment, required extensive or total dependence for all ADLs, used a wheelchair for locomotion, and was always incontinent of bowel and bladder.<BR/>Review of Resident #19's care plan dated [DATE] revealed, in part, The resident has limited physical mobility related to disease process of cerebral palsy. The resident will remain free of complications related to immobility, including contractures, thrombus formation, skin breakdown, fall related injury through the next review date. The resident is NON-WEIGHT BEARING; the resident is totally dependent on staff for locomotion using wheelchair.<BR/>During observation on [DATE] at 3:43 PM with CNA A and CA B, Resident #19 was taken to his room by staff and wheelchair positioned at bedside, CNA A and CA B each placed an arm under Resident #19's arms (chicken winged) and grabbed hold of the back of his pants and lifted him out of wheelchair without the use of a gaitbelt, pivoted him from the wheelchair to the bed and placed him on his bed. Incontinent care was provided with no concerns noted. Once resident was redressed, CNA A and CA B sat him up on the side of the bed, chicken winged him and both grabbed the back of his waistband to pick him up without the use of a gaitbelt and placed him in his wheelchair. No gait belt observed in room. Resident is non-weight bearing and dependent on staff for all care.<BR/>In an interview on [DATE] 5:18 PM with CA B, she stated she had not taken the CNA certification test yet, she took her CNA class through her high school and was currently waiting to test. She stated she was taught how to operate the mechanical lift during her CNA training. She explained that the procedure was to turn the resident and put sling under them, hook sling to lift, then raise and move the resident and place them in their chair or on a bed. She stated staff is never to operate the mechanical lift alone and it always requires 2 people. She stated that one person moved the lift and resident over the chair, the second person held the sling/resident to make sure they are steady. When what was observed during transfer was described to CA B , she stated there was nothing wrong with how it was done. She stated it could frighten a resident to be dangling from the sling in the lift with only one person operating it and no one steadying them. CA B stated she did not know what facility policy says regarding lift transfers and did not remember ever seeing the policy. She stated that she was not trained by facility on how to do lift transfer.<BR/>RESIDENT #25<BR/>Record review of Resident #25's admission Record, dated [DATE], revealed he was a an [AGE] year-old male admitted to the facility on [DATE] with diagnoses which included dementia, Parkinson's Disease, pain in right and left knee, low back pain, tremor, hallucinations, and history of falls.<BR/>Record review of Resident #25's Annual MDS Assessment, dated [DATE], revealed:<BR/>He scored a 9 of 15 on his mental status exam - indicating moderate cognitive impairment.<BR/>He needed extensive assistance of two staff for transfers.<BR/>He needed extensive assistance of one staff to walk or for locomotion. <BR/>He used a walker and a wheelchair.<BR/>Diagnoses included: arthritis, dementia, and Parkinson's Disease.<BR/>He required as-needed pain medications. Resident #25 said the pain was occasional and moderate in severity.<BR/>He had more than two falls with no injuries in the three months prior to the assessment.<BR/>Review of Resident #25's Care Plan revealed:<BR/>ADL initiated on [DATE]: The resident has an ADL self-care performance deficit related to tremors. The identified goal was: the resident will maintain current level of function in ADLs through the next review date. Identified interventions included: Transfer: The resident requires extensive assistance to total assistance of 1 - 2 staff to move between surfaces as necessary (revised [DATE])<BR/>Care Plan, initiated on [DATE] and revised on [DATE], identified Resident #25 was high risk for falls related to history of falls and tremors but the care plans interventions did not address his transfer needs. <BR/>Review of Resident #25's Order Summary Report dated [DATE] revealed orders: Beginning [DATE]: Fall Precautions. Beginning [DATE]: Frequent rounding every 2 hours for High Fall Risk.<BR/>During an observation on [DATE] at 12:33 PM DON and CA B transferred Resident #25 from his wheelchair to a recliner. Both staff were observed assisting Resident #25 to stand by hooking their arms under Resident #25's arms. Resident #25 was unsteady on his feet but eventually gained his balance and shuffled sideways to the chair. The DON grabbed Resident #25 by the seat of his flannel pants when assisting him to sit. They did not use a gait belt. <BR/>During an observation on [DATE] at 3:27 PM the DON and ADON were observed getting Resident #25 up from the recliner to the wheelchair. Both hooked under Resident #25's arms in assisting him to stand. They did not use a gait belt. <BR/>During an interview on [DATE] at 5:01 PM the DON said she expected the staff to transfer a resident by using a gait belt. She stated she expected the staff to put their arms under the resident's arms and use a gait belt. She stated she had not completed an in-service with the staff this year on how to use a gait belt or compete a transfer other than the skills check off. The DON stated she was not aware of therapy completing an in-service either . She said possible consequences for an under-arm transfer were popping the resident's shoulder out of socket. She stated the consequences of grabbing a resident by the seat of the pants would cause a wedgie leaving the resident uncomfortable. She stated she could see how grabbing a resident by the seat of the pants could cause the pants to slip out of the hand causing the resident to fall. The DON stated she did hook her arms under Resident #25 while transferring him on [DATE] nor did she use a gait belt. The DON explained Resident #25 used staff for stability because he was able to stand and shuffle over. She admitted she had not had a chance to read the facility's policy on transfer because she was still new to the facility .<BR/>RESIDENT #27<BR/>Record review of Resident #27's admission record dated [DATE] indicated she was admitted to the facility on [DATE] with diagnoses of dementia and history of falling. She was [AGE] years of age.<BR/>Record review of Resident #27's MDS dated [DATE] indicated in part: BIMS = 03 indicating resident had severe impairment. Transfer extensive assistance, 2 plus persons physical assist. <BR/>Record review of Resident #27's care plan dated [DATE] indicated in part: Focus: The resident has an ADL self-care performance deficit r/t weakness/cognition. Goal: The resident will maintain current level of function in through the review date. Interventions: The resident requires assist X2 staff assistance for transfers.<BR/>During an observation on [DATE] at 03:02 PM CNA A and CA B transferred Resident #27 from her wheelchair to her bed. Both aides took the resident from her underarms and from the back of her pants without the use of a gaitbelt. During the transfer the resident partially assisted with weightbearing as her legs were bent during the transfer and the staff had to manually assist her to the bed.<BR/>During an interview on [DATE] at 03:32 PM CA B said she had been working at the facility for about 4 months. CA B said she worked along a CNA because she was a comfort aide and not certified yet. CA B said the CNAs she worked with told her which residents were a one person, two person or mechanical lift for transfers. CA B said she had not received training on the use of a gait belt and had not used one since working at the facility. CA B said CNA A and she normally transferred Resident #27 from the wheelchair to her bed by taking the resident from under her arms and by the back of her pants. Cab B said that was the way she was shown to transfer Resident #27 since working at the facility. CA B said it was probably okay to transfer the resident that way but then said that perhaps it was not safe as that could possibly cause an injury to the resident's shoulders. CA B also said that it could be unsafe if the resident's pants tore or slipped from her hands and cause the resident to fall. <BR/>During an interview on [DATE] at 02:26 PM CNA A said she had been working at the facility for about 2 years. CNA A said they had a daily assignment sheet and that's where it indicated which type of transfer each resident was. CNA A said that it was okay to transfer Resident #27 from under her arm and from the back of her pants. CNA A said they should have used a gait belt because that would have been better than taking the resident from the back of her pants and underarms. CNA A said they had received training today on how to use the gait belt. CNA A said they got in a hurry and transferred the resident without the use of a gait belt. CNA A said she was also nervous while being observed by the state surveyor and possibly caused her to forget to use the gait belt. <BR/>During an interview on [DATE] at 03:10 PM the DON said the aides should have used the gait belt to transfer Resident #27. The DON said staff used the gait belts to prevent falls or injuries. The DON said they did the initial check off list and ongoing in-services regarding the use of gait belts, lifts and fall preventions. The DON said the failure probably occurred because the aides got nervous and forgot to use the gait belt. <BR/>Review of the facility's document dated [DATE] titled Job description - Certified Nursing Assistant indicated in part: Job summary - under general supervision of licensed personnel monitors and response to patient needs. Observes instructions of the nursing staff in line with established routines. Provides maximum resident/patient care services to assure well-being of the residents. Acquires necessary equipment for procedures and explains procedures to patients and families. Essential duties and responsibilities - assists residents in the activities of daily living in accordance with the plan of care and the is established policies and procedures of the unit - assists in maintaining a clean, safe environment for residents, finding and correcting situations that have a high probability of causing accidents or injuries to residents.<BR/>Review of the facility's undated document titled Certified Nurse Aide indicated in part: Prevention of employee injuries - Uses proper body mechanics, uses lifting equipment when needed - utilizes gait belts. <BR/>Review of the facility's undated document titled Certified Nurse Aide indicated in part: Prevention of employee injuries - Uses proper body mechanics, uses lifting equipment when needed utilizes gait belts.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to ensure residents had the right to personal privacy and confidentiality of his or her personal and medical records for 3 of 13 residents (#4, #5, #6) reviewed for privacy. <BR/>1. <BR/>CMA F failed to protect Resident #4's record by not locking the screen of her laptop, while CMA F was in a resident's room administering medication. <BR/>2. <BR/>CMA G failed to protect Resident #5's record by not locking the screen of her laptop when going to the restroom.<BR/>3. <BR/>CMA G failed to protect Resident #6's record by not locking the screen of her laptop while in a room checking vital signs.<BR/>These deficient practices could place residents at-risk of loss of dignity due to lack of privacy.<BR/>The findings included: <BR/>1. <BR/>An observation 12/29/24 at 9:20 a.m. revealed an open laptop on the facility's medication cart, outside of room [ROOM NUMBER]. The screen was not locked and displayed Resident #4's information. CMA F was in a resident's room administering medication. <BR/>During an interview with CMA F on 12/29/2024 at 12:26 p.m., she verbally confirmed her laptop's screen should have been locked when she was not using it to protect the privacy of information of the residents. <BR/>2. <BR/>An observation 12/30/24 at 9:30 a.m. revealed an open laptop on the facility's medication cart. The screen was not locked and displayed resident #5's information. CMA G had stepped away to the restroom.<BR/>3. <BR/>An observation 12/30/24 at 9:35 a.m. revealed after vital signs were taken, this state surveyor walked out of the room and noticed CMA G's laptop screen was not locked and was showing Resident #6's medication information. <BR/>During an interview with CMA G on 12/30/2024 at 9:50 a.m., she verbally confirmed her laptop's screen should have been locked when she was not using it to protect the privacy of information of the residents. <BR/>During an interview with the DON on 12/30/24 at 4:31 p.m., the DON stated privacy must be provided during care. She confirmed laptop screens should always be locked when not in use to protect residents' information. She stated the staff had received training when hired and annually on HIPPA, keeping medical records private, not giving out paper copies of resident's records, and to keep screens locked. The training was provided by the DON. The DON states she did spot checks for unlocked screens during walk throughs. <BR/>Record review of the facility's policy titled Access Control with Scope: HIPAA, EPHI, Security, dated 11/2021, revealed the following in part: .Workforce members are responsible for complying with this policy, including protecting ePHI by logging off system/application or workstation/electronic device before leaving a workstation unattended.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** <BR/>Based on observation, interview and record review the facility failed to develop and implement a comprehensive, person-centered care plan for each resident that included measurable objectives and time frames to meet, attain, and/or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 7 of 16 Residents (Residents # 7, 10, 13, 14, 15, 19, 21) for care plans.<BR/>a) Resident #7's did not have a care plan for her stage 2 pressure ulcer to the heel (partial thickness skin wound caused by pressure).<BR/>b) <BR/>Resident #10 did not have a care plan for dentures.<BR/>c) <BR/>Residents #13 did not have a care plan for diabetic care. <BR/>d) <BR/>Resident #14 did not have a care plan for diabetic care, anticoagulant use, seizures, or pain.<BR/>e) <BR/>Resident #15 did not have a care plan for oxygen and hospice.<BR/>f) <BR/>Resident #19's transfer was inaccurately care planned. <BR/>g) <BR/>Resident #21 did not have a care plan for weight loss, hospice, or pain management.<BR/>These failures placed residents at risk of weaknesses or needs from being identified to assist residents to attain or maintain their highest practicable well-being and prevent avoidable decline.<BR/>Findings included:<BR/>Resident #7<BR/>Review of Resident #7's admission Record dated 9/21/22 documented she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses including gout, chronic kidney disease, pancreas disease, pain, urinary tract infections, hypertension and arthritis (joint pain). <BR/>Review of Resident #7's quarterly MDS assessment dated [DATE] documented:<BR/>Resident #7 Had long and short-term memory impairment with moderately impaired decision-making skills.<BR/>She was totally dependent on one or two staff for all ADLs.<BR/>She had lower range of motion impairment on one side and used a wheelchair. <BR/>She weighed 154 pounds and experienced non-prescribed weight loss. <BR/>There were no skin issues identified (the stage two on Resident #7's heel was discovered 8/9/22)<BR/>Specialized treatments included hospice and oxygen usage. <BR/>Review of Resident #7's Order Summary Report dated 9/21/22 documented additional diagnosis of Alzheimer's disease and fracture of the left femur. Order dated 8/10/22 documented cleanse stage 2 to left heel with normal saline, pat dry with 4x4 (gauze), apply zinc oxide and cover with dry dressing every other day and as needed until resolved every day shift every other day. <BR/>Review of Resident #7's care plan, last revised 8/22/22, revealed there was no care plan for Resident #7's stage 2 pressure ulcer to her heel. <BR/>Interview on 9/21/22 at 3:48 p.m. the DON stated she thought Resident #7 had a care plan addressing her pressure ulcer and acknowledged she needed one. She stated, I guess it slipped through the cracks. The DON stated she was responsible for doing care plans. <BR/>Interview on 9/21/22 at 5:00 p.m. the DON stated Resident #7's wound was found 8/12/22. <BR/>Resident #10<BR/>Review of Resident #10's admission Record dated 9/22/22 documented he was an [AGE] year-old male admitted to the facility on [DATE] with diagnoses which included Dementia with Behavioral Disturbance, Vitamin D deficiency, Covid-19, hypothyroidism (low thyroid), depression, intermittent explosive disorder (looses temper without warning), benign prostatic hyperplasia (enlarged prostate), repeated falls, and wedge compression fracture (vertebrae fracture). <BR/>Review of Resident #10's annual MDS assessment dated [DATE] documented:<BR/>He scored a 15 of 15 on his mental status exam (indicating he was cognitively intact)<BR/>He needed supervision of one staff to completed ADLs.<BR/>He had no range of motion impairment and used a walker or a wheelchair. <BR/>He was on antidepressant medication for 7 of 7 days.<BR/>Review of Resident #10's care plan, last revised 8/22/22, revealed no care plan for his dentures or other dental needs. <BR/>Interview on 9/20/22 at 11:56 a.m. Resident #10 stated he got sick and went to the facility's attached hospital and then was transferred to a hospital in the closest city. He stated somewhere he lost his dentures . Resident #10 said the staff said it was his fault that they were lost and did not believe the staff would help him get a new pair. <BR/>Resident #13<BR/>Review of Resident #13's admission Record dated 9/21/22 documented he was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses including stroke, repeated falls, paraplegic (legs are fully or partially paralyzed), diabetes, dementia with behavioral disturbance, and presence of a cardiac pacemaker.<BR/>Review of Resident #13's quarterly MDS Assessment, dated 8/3/22, revealed he:<BR/>He scored a 9 of 15 on his mental status exam (indicating moderate cognitive impairment).<BR/>He was independent with ADLs.<BR/>He had range of motion impairment of the upper and lower extremities on one side.<BR/>He used a cane, a walker, and a wheelchair.<BR/>He received insulin injections for 7 of 7 days in the assessment time frame. <BR/>Review of Resident #13's Order Summary Report dated 9/21/22 documented orders for Order start date: 10/7/16 a no concentrated sweets diet <BR/>Order start date 5/21/22: Insulin Regular Human Solution 100 unit/ml Inject per sliding scale. <BR/>Order Start Date 6/14/22 Insulin Degludec Solution 100 unit/ml Inject 5 units subcutaneously (under the skin, a shallow injection) two times a day.<BR/>Review of Resident #13's care plan, last revised on 8/22/22, revealed no care plan for diabetes and/or insulin. <BR/>Resident #14<BR/>Review of Resident #14's admission record dated 09/22/22 revealed he was a [AGE] year-old male admitted to the facility on [DATE] with admitting diagnoses of Type 1 Diabetes Mellitus, epilepsy (seizures), dementia (loss of cognitive function), degeneration of nervous system (nerve damage) , and hypertension.<BR/>Review of Resident #14's MDS dated [DATE] revealed, in part, he had minimal difficulty hearing, clear speech, was able to make himself understood and usually understood others, had impaired vision, BIMS score 7 of 15 (indicating he was severely cognitively impaired), was independent for all ADLs requiring only supervision for some tasks, used a walker and a wheelchair for ambulation/mobility, was always continent of bowel and bladder, had frequent pain rated at 6 of 10 and requiring pain medication, received insulin injections 7 of 7 days, and anticoagulant 7 of 7 days. <BR/>Review of Resident #14's care plan dated 09/21/22 revealed no care plan in place for diabetic monitoring including the use of insulin, no care plan in place for anticoagulant use monitoring, no care plan in place for seizure precautions or monitoring with use of medication, and no care plan in place for pain with use of PRN pain medication.<BR/>Review of Resident #14's order summary dated 09/22/22 revealed the following orders:<BR/>Apixaban tablet 5mg - give 1 tablet by mouth two times a day for pelvic DVT start date 03/24/22<BR/>Leviteracetam tablet 1000mg - give 1 tablet by mouth two times a day related to epilepsy start date 05/03/22<BR/>Metformin HCL ER tablet - give 1000mg by mouth two times a day for diabetes mellitus start date 06/14/22<BR/>Insulin aspart Solution100 units/mL - inject as per sliding scale: if 140-180 = 4 units; 181-240 = 6 units; 241-300 = 8 units; 301-350 = 10 units; 351-400 = 12 units; 401+ = 12 units recheck CBG in 30 minutes and notify healthcare provider if still over 400., subcutaneously before meals and at bedtime related to Type 1 Diabetes Mellitus start date 05/16/22<BR/>Tramadol HCL tablet 50mg - give 1 tablet by mouth every 6 hours as needed for pain start date 01/12/22<BR/>Insulin Degludec Solution 100 unit/ml - inject 20 units subcutaneously in the morning related to Type 1 Diabetes Mellitus start date 08/04/22<BR/>Acetaminophen Tablet 325mg - give 2 tablets by mouth at bedtime for pain start date 03/24/22<BR/>Resident #15<BR/>Review of Resident #15's admission record dated 09/22/22 revealed she was a [AGE] year-old female admitted to the facility 05/16/16 with diagnoses of dementia (cognitive disfunction), delusional disorder, major depressive disorder, Alzheimer's disease with late onset, psychotic disorder with delusion (believes things that are not true), Chronic Obstructive Pulmonary Disease (difficulty breathing), adjustment disorder, anxiety disorder, shortness of breath, hypertension, and chronic fatigue. <BR/>Review of Resident #15's MDS dated [DATE] revealed, in part, she had moderate difficulty hearing, unclear speech, she sometimes made herself understood and sometimes understood others, she had highly impaired vision and wore glasses, BIMS not completed due to resident not understanding questions (not interviewable), she had total dependence on staff for all ADLs and used a wheelchair for locomotion, she was always incontinent of bowel and bladder, she was on a scheduled pain medication regimen with nonverbal indications of pain observed 3 to 4 out of 5 days, she received an antipsychotic medication 7 of 7 days and an antidepressant medication 7 of 7 days.<BR/>Review of Resident #15's care plan dated 07/21/22 revealed no care plan in place for oxygen use, no care plan for hospice services including use of medications ordered by hospice.<BR/>Review of Resident #15's order summary dated 09/22/22 revealed the following orders:<BR/>Admit to Hospice order date 03/16/22<BR/>May use oxygen via nasal canula to keep oxygen 92% or above as needed start date 09/18/21<BR/>Lorazepam Intensol Concentrate 2mg/ml - give 0.5ml orally every 6 hours as needed for anxiety start date 03/23/22<BR/>Morphine Sulfate Solution 20mg/ml - give 0.25ml by mouth one time a day every Tuesday, Thursday start date 08/31/22<BR/>Morphine Sulfate Solution 20mg/ml - give 0.25ml by sublingually every 6 hours as needed for pain/shortness of breath start date 08/31/22<BR/>Interview and observation on 09/20/22 at 03:31 PM revealed Resident #15 resting quietly in bed, oxygen at 2LPM via nasal canula (no date on tubing or humidifier bottle), when asked how she was doing she responded, pretty good and then did not answer any further questions. <BR/>Resident #19<BR/>Review of Resident #19's admission record dated 09/21/22 revealed he was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses of Cerebral Palsy (cannot maintain posture), cognitive communication deficit, contracture of right and left hands (loss of function due to joints locking up), lack of coordination, muscle spasms, visual loss and tachycardia (heart beats too fast). <BR/>Review of Resident #19's MDS dated [DATE] revealed, in part, he had minimal difficulty hearing, unclear speech, was usually understood and usually understood others, had impaired vision, BIMS score of 11 indicating moderate cognitive impairment, required extensive or total dependence for all ADLs, used a wheelchair for locomotion, and was always incontinent of bowel and bladder.<BR/>Review of staff daily assignment/mobility assistance list dated 09/14/22 revealed Resident #19 was a 2-person assist or mechanical lift transfer.<BR/>Review of Resident #19's care plan dated 09/21/22 revealed, in part, The resident has limited physical mobility related to disease process of cerebral palsy. The resident will remain free of complications related to immobility, including contractures, thrombus formation, skin breakdown, fall related injury through the next review date. The resident is NON-WEIGHT BEARING; the resident is totally dependent on staff for locomotion using wheelchair. Resident #19 did not have a care plan addressing mechanical lift transfer.<BR/>Resident #21<BR/>Review of Resident #21's admission record dated 09/22/22 revealed she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses of dementia, gastro-esophageal reflux disease (acid reflux), partial intestinal obstruction, hypothyroidism, iron deficiency, hypertension, cardiomyopathy (heart has difficulty pumping blood), atrial fibrillation (irregular heart rate) , muscle weakness, and abnormalities of gait and mobility.<BR/>Review of Resident #21's MDS dated [DATE] revealed, in part, she had moderate difficulty hearing, clear speech, was able to make herself understood and understand others, had impaired vision, BIMS of 14 out of 15 (indicating she was cognitively intact), required extensive assistance or total dependance on staff for all ADLs, used a wheelchair for locomotion, was always incontinent of bowel and bladder, had frequent pain rated at a 6 of 10 that made it difficult to sleep and limiting her day to day activities and requiring PRN pain medication, weight loss of 5% or more in the last month or loss of 10% or more in the last 6 months while not on physician-prescribed weight-loss regimen.<BR/>Review of Resident #21's order summary dated 09/22/22 revealed the following orders:<BR/>Admit to Hospice Care - metastatic breast cancer order date 09/08/22<BR/>House Shake as needed if resident eats less than 50% start date 04/20/22<BR/>House Shake three times a day for weight loss start date 01/19/22<BR/>Morphine Sulfate Solution 100mg/5ml - give 0.25ml by mouth every 2 hours as needed for breakthrough pain start date 09/08/22<BR/>Morphine Sulfate Solution 100mg/5ml - give 0.25ml by mouth every 4 hours for metastatic breast cancer/pain start date 09/09/22<BR/>Review of Resident #21's care plan dated 09/21/22 revealed no care plan in place for pain, hospice or weight loss. <BR/>Interview on 9/22/22 at 11:36 a.m. the DON stated when a resident was first admitted she looked at the resident's medications and needs. She stated care plans were reviewed by dietary, social work, and activities and they were altered as needed. The DON said she tried to look at the care plans monthly. She stated she did not have a process for determining what got care planned. She said she expected to see medications, use of special equipment, any individualized care, and wounds. The DON stated the expectation was to follow the facility's policy on care plans but admitted she had not had a chance to look at it yet. She stated she did not know Resident #10 had dentures but she never saw a care plan on dentures for any resident, including Resident #10. The DON confirmed Residents #13 and #14 were on insulin and admitted she did not know if there should be a care plan for insulin. She stated she would add them if it was required. The DON stated she believed she care planned pain medications especially if they were at end of life. The DON sated pressure ulcer risk for residents was determined by Braden Scale and she had only looked at the residents who were admitted since January 2022 . The DON said Resident #21's cancer got aggressive and Resident #21 had a sudden decline. She said Resident #21 needed end of life services and was high risk for developing pressure ulcers; the DON said she did not have care plans ready for Resident #22. The DON stated Resident #15 just recently went on oxygen. <BR/>Review of the facility's policy and procedure on Comprehensive Care Plans, undated, documented:<BR/>The facility shall provide an individualize, interdisciplinary plan of care for all residents that shall be appropriate to the resident's needs, strengths, results of diagnostic testing limitations and goals.<BR/>Results of assessments shall be used to develop, review and revise the resident's comprehensive plan of care.<BR/>Care, treatment and services shall be planned to ensure that they are individualized to the resident's needs. <BR/>The care plan shall describe the following: the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental and psychosocial well-being as required. <BR/>The plan of care shall be individualized, based on the diagnosis, resident assessment and personal goals of the resident and his/her family.<BR/>The planning for care, treatment and services shall include the following: care planning is based on data collected from resident assessments with integration of those assessment findings in the care planning process; the frequency of care, services and treatment, team members responsible for care, services and treatment; the needs of the resident, goals, time frames, required services and the service settings are critical considerations in determining the plan of care; documenting pain assessment and management; monitoring the effectiveness of care planning and the provision of care, treatment and services; the plan of care shall be individualized to the needs of the resident.