PRAIRIE ACRES

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Number of residents sampled:<BR/>Number of residents cited:<BR/> Based on observations, interviews, and record review, the facility failed to ensure residents were treated in a respectful manner that maintained or enhanced each resident's dignity for 1 (Resident #21) of 16 residents reviewed for dignity. The facility failed to ensure CNA C did not incite a verbal altercation with facility staff in the presence of Resident #21. This failure could place residents who require assistance from nursing staff at risk of feeling disrespected. Findings included: Record review of Resident 21's face sheet dated 07/29/2025 revealed a [AGE] year-old female with an initial admission date of 08/26/2025 with diagnoses that included: Alzheimer's Disease, unspecified (having trouble remembering, thinking, or making decisions that affect everyday activities), major depressive disorder (mood disorder that causes a persistent feeling of sadness and loss of interest), generalized anxiety disorder (mental health condition that causes fear, a constant feeling of being overwhelmed and excessive worry about everyday things), and delusional disorders (false beliefs based on an incorrect interpretation of reality). Record review of Resident 21's Annual Comprehensive MDS assessment, dated 10/02/2024, revealed a BIMS score of 99, indicating severe cognitive impairment. The MDS Assessment, under Section D Mood, indicated Resident #21 did not respond to the mood assessment. Resident #21's MDS assessment, under Section GG Functional Abilities, indicated the resident was dependent on staff for eating, oral hygiene, toileting, shower/bathing, upper and lower body dressing, and personal hygiene. The MDS assessment, under Section GG Functional Abilities, also indicated the resident was dependent on staff for all transfers. Record review of Resident #21's care plan undated, included a focus area that began on 08/29/2017 which stated, I have impaired cognitive function and impaired thought processes r/t Alzheimer's., with a goal that stated, I will be able to communicate basic needs on a daily basis., with the Interventions that included the following: I need assistance with all decision making. The care plan also has a focus are that began on 07/09/2018 that stated, I have an ADL Self Care Performance Deficit r/t Dementia. with a goal that stated, I will maintain my current level of function in Bed Mobility, and interventions that states, MOBILITY: I use a Geri chair-for positioning and safety. Staff must take me where I need to go.; TRANSFER: I require assistance x 2 with transfers w/Hoyer lift'; BATHING: I am totally dependent on staff to bath me. Hospice comes to facility to bathe me.; Personal care: I require one person assistance to complete my grooming care. I have my own teeth. R/T dementia, I am unable to complete my ADLs. During an observation on 07/29/2025 at 11:07 AM CNA C was observed coming out of a resident's room. CNA A was observed several feet away with Resident #21, near her bedroom. CNA B was observed in the hallway, near Resident #21's bedroom as well. CNA C was heard telling CNA A and CNA B she had not bathed Resident #21 yet. CNA A stated she was told to get Resident #21 up for lunch. CNA C stated she needed Resident #21 to be put back in bed, so she could bathe her. CNA C stated CNA A needed to take Resident #21 back to her room. CNA A stated she would take her to the nurse's station until lunch began, as she was instructed to get Resident #21 ready for lunch. CNA C stated, I still have time. CNA C began to raise her voice and approached Resident #21 and stated loudly, I will do it myself. I always do everything by myself. as she began pushing Resident #21's Geri-chair. RN D approached CNA C and instructed her to stop fussing. RN D instructed CNA C to finish patient care with another resident and instructed CNA A and CNA B to take Resident #21 back to bed to prepare her for her bed bath. CNA C was observed shaking her head and told RN D no. CNA C continued to argue in a loud and aggressive tone. CNA C told RN D, I will just do it myself. I always do everything myself. CNA C stated, She is agency. I always have issues with her (indicating CNA B), every time I work with her. RN D advised CNA C to stop arguing and instructed her to finish patient care. Resident #21 was taken back to her room by CNA A and CNA B. CNA C was observed entering another resident's room. There was no further exchange from CNA C. Resident #21 did not demonstrate any physical or emotional reaction during the verbal altercation. During an observation and an attempted interview on 07/29/2025 at 11:16 AM with Resident #21. Resident #21 was observed laying in her bed. Resident #21 did not respond to greetings and/or questions from the surveyor. Resident #21 did not appear upset or agitated during the attempted interview. During an interview on 07/29/2025 at 12:10 PM CNA A stated CNA C was a Hospice aide that came in to bathe several residents receiving Hospice services, weekly. CNA A stated CNA B was an agency CNA that worked at the facility often. CNA A stated she was instructed by her charge nurse, RN D, to get Resident #21 up and ready for lunch. CNA A stated CNA C became upset because she told CNA B not to get Resident #21 out of bed yet because she still needed to bathe Resident #21. CNA A stated she did not hear CNA C ask CNA B not to get Resident #21 out of bed yet, so she and CNA B transferred Resident #21 to her Geri-chair to prepare her for lunch. CNA A stated CNA C became upset and said she always had problems with CNA B when she worked with her. CNA A stated she had never seen an altercation occur between CNA C and CNA B before. CNA A stated she was going to take Resident #21 to the nurse's station, but CNA C asked her to put her back in bed so she could bathe her. CNA A stated CNA B said they would not put her back in bed since she was instructed to get her ready for lunch. CNA A stated, following the altercation, CNA B assisted her with getting Resident #21 back to bed so CNA C could bathe her, as instructed by her charge nurse, RN D. CNA A stated she did not see any physical or emotional reaction by Resident #21 following the altercation. During an interview on 07/30/2025 at 10:30 AM CNA C stated she was a CNA with BSA Hospice. CNA C stated she worked at the facility several days a week providing bathing services to residents who receive Hospice care. CNA C stated she asked CNA B not to get Resident #21 ready for lunch until CNA C bathed her. CNA C stated she was bathing another resident and when she came out of the room she saw CNA A and CNA B with Resident #21. CNA C stated she asked CNA A and CNA B to take Resident #21 back to bed so she could bathe her, but they told her they were taking Resident #21 for lunch. CNA C stated she told CNA A and CNA B that she still had time to bathe Resident #21 before lunch, and she would take her back to her room herself, if they would not help her. CNA C denied yelling or being confrontational. CNA C denied having a verbal altercation with CNA A or CNA B. CNA C stated she was aware the surveyor was present during the exchange, but she denied yelling or speaking inappropriately in front of the resident. CNA C stated she was aware Resident #21 was present during her interaction with CNA A and CNA B. CNA C stated she had been trained not to engage in confrontations in the presence of residents. CNA C stated it would have been better for her to speak with the charge nurse or facility administrator if she had trouble with the facility staff, to request assistance. CNA C stated having an altercation could have negatively impacted a resident by causing a resident to become upset or worried. During an interview on 07/30/2025 at 04:00 PM CNA B stated she was an agency CNA that worked at the facility off and on over the past two years. CNA B stated CNA C never asked her to wait to get Resident #21 out of bed until she bathed her. CNA B stated she was advised by her charge nurse, RN D to prepare Resident #21 for lunch, so she and CNA A transferred Resident #21 to her Geri*chair. CNA B stated CNA C was providing patient care to another resident, and as she came out of that resident's room she raised her voice and told CNA B, I told you I was going to get her up. CNA B stated CNA C never told her that. CNA B stated CNA C began yelling, I will do it myself. CNA B stated she had worked with CNA C in the past, but she had never had any other altercations occur. CNA B stated she did not witness any emotional or physical reaction from Resident #21 following the verbal altercation. CNA B stated she had received training on not having verbal altercations in front of residents. CNA B stated this could have had a negative impact on residents by causing the resident to be disrespected. During an interview on 07/31/2025 at 11:00 AM RN D stated she was unaware Resident #21 had not received her bed bath yet, and she advised CNA A and CNA B to prepare Resident #21 for lunch. RN D stated she heard CNA C yelling at her nursing staff (CNA A and CNA B), so she intervened. RN D stated she redirected CNA C and instructed her to stop arguing and return to her patient care. RN D stated she had never had a concern with CNA C in the past. RN D stated CNA C works for BSA Hospice and provides bathing assistance to residents who receive Hospice services. RN D stated it was never acceptable for nursing staff to have a verbal altercation in the presence of a resident, regardless of the situation. RN D stated she did not observe any physical or emotional reaction to the altercation from Resident #21. RN D stated all nursing staff have received training pertaining to Resident Rights and how to conduct themselves in front of residents. RN D stated it was her expectation for her nursing staff to request assistance from their charge nurse if they encounter issues with other staff. RN D stated if staff had verbal altercations in front of residents, it could have caused distress to a resident. During an interview on 07/31/2025 at 10:30 AM the DON stated after speaking with staff she determined CNA C became upset with CNA A and CNA B after they got Resident #21 up for lunch because she was going to give her a bed bath. The DON stated CNA A and CNA B were advised to get Resident #21 up by RN D. The DON stated RN D told CNA C the staff would get Resident #21 back to bed for her bed bath, but CNA C still confronted staff about getting her up before she was bathed. The DON stated it was her expectation that nursing staff would have come to her if they had an issue with other staff. The DON stated she had spoken with her staff about ensuring they assist the Hospice aides with their residents, and she had not had any complaints that her staff was not helping. The DON stated she had spoken with CNA C in the past about bringing any concerns to her if the facility staff were not helping her. The DON stated it was never acceptable for a staff to engage in a verbal altercation in the presence of a resident. The DON stated having a verbal altercation in front of the resident could cause the resident to become upset or have anxiety. During an interview on 07/31/2025 at 11:35 AM the ADM stated it was his expectation that nursing staff would have brought any issues within staff to him or the DON for assistance. The ADM stated he expected his staff to provide additional assistance to the Hospice staff as his staff were more familiar with the residents and their needs The ADM stated it was never acceptable to have a verbal altercation in front of a resident. The ADM stated he was not aware of any previous issues with the Hospice aides and his nursing staff. The ADM stated he would address the concerns with BSA Hospice The ADM stated having a verbal altercation in front of a resident could have caused emotional distress or anxiety to the resident. Record review of the facility's policy titled, Quality of Life - Dignity, undated, revealed the following: Policy Statement:Each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect, and individuality.Policy Interpretation and Implementation:l . Residents shall be treated with dignity and respect at all times.2. Treated with dignity means the resident will be assisted in maintaining and enhancing his or her self-esteem and self-worth.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to implement a comprehensive care plan for each resident that includes measurable objectives and timeframes to meet a resident's medical, nursing, mental, and psychosocial needs that are identified in the comprehensive assessment and describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 1 (Resident #27) of 13 Residents reviewed for comprehensive care plans.<BR/>-The facility failed to include care plans for Resident #27's catheter.<BR/>This failure could affect all residents in the facility receiving care per comprehensive person-centered care plans resulting in resident not being able to attain or maintain their highest practicable physical, mental, and psychosocial well-being. <BR/>Finding include:<BR/>Record review of Resident #27's face sheet printed 3-21-2023 revealed he was a [AGE] year-old male resident admitted to the facility originally on 1-31-2022 and readmitted on [DATE] with diagnoses to include dementia (a group of thinking and social symptoms that interferes with daily functioning), chronic kidney disease (longstanding disease of the kidneys that leads to kidney failure), obstructive and reflux uropathy (when your urine cant flow (either partially or completely) through the ureters, bladder, or urethra due to some type of obstruction), and benign prostate hyperplasia (age associated prostate gland enlargement that can cause urination difficulty.<BR/>Record review of Resident #27's clinical record revealed his last MDS assessment was a quarterly completed on 3-8-2023 listing him with a BIMS of 5 indicating he was severely cognitively impaired, he had a functionality of requiring one-person physical assistance with all his activities, and Section H-Bowel and Bladder he was listed as having a indwelling catheter (a catheter which is inserted into the bladder, via the urethra and remains in-situ to drain urine).<BR/>Record review of Resident #27's Order Summary Report with active orders as of 3-22-2023 listed the following orders:<BR/>-Change foley catheter one time a day starting on the 20th and ending on the 20th every month related to BENIGN PROSTATIC HYPERPLASIA WITHOUT LOWER URINARY TRACT SYMPTOMS (N40.0) (a condition in men in which the prostate gland is enlarged and not cancerous)-order dated 1-20-2023, start date 2-20-2023<BR/>-Foley Catheter care two times a day-order dated 1-20-2023, start date 1-20-2023<BR/>Record review of Resident #27's care plan with admission date 2-27-2023 revealed no care plans for catheter care. <BR/>During an interview on 03-22-2023 at 10:42 AM MA B reported that Resident #27 had a catheter and used a leg bag. MA B stated that Resident #27 used to have the large catheter bag but due to Resident #27's dementia he would not leave it alone and that with a leg bag Resident #27 does not see it under his clothing and therefore will not mess with it.<BR/>During an interview on 03-23-2023 at 08:45 AM the MDS Coordinator reviewed Resident #27's clinical record and reported that Resident #27 did not have a care plan for his urinary catheter, that Resident #27 had a history of having a urinary catheter then having the urinary catheter dc'd due to difficulty with his urinary retention (difficulty urinating or completely emptying the bladder) and that Resident #27 has had this catheter since the first of January 2023 which was addressed on his last MDS. The MDS Coordinator reported that the catheter should have been addressed in his care plan. The MDS Coordinator verified that it is her job to complete the comprehensive care plans. The MDS Coordinator reported that she started the MDS position the first of March 2023 (after the last MDS Coordinator resigned) and is currently reviewing all care plans for accuracy. The MDS Coordinator reported that she will update Resident #27's care plan to include his catheter. The MDS Coordinator reported that if a care plan does not have the resident's current information and needs, that a resident could possibly not receive the care they need but Resident #27 has orders for his catheter and has documentation that addresses the use of his catheter in the nursing notes, so she feels Resident #27 has received his needed care. <BR/>During an interview on 03-23-2023 at 09:11 AM the DON reported that a catheter needs to be addressed in the care plan because that is how the CNA's and other staff know how to perform their care on a resident. The DON reported that if a resident's needs are not addressed in their care plans, then they may receive incorrect care or not receive the care they need. <BR/>Record review of facility provided policy titled Care Plans, Comprehensive Person-Centered, undated, revealed the following:<BR/>Policy Interpretation and Implementation-<BR/>8. The comprehensive, person-centered care plan will<BR/>-b. Describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being.<BR/>-g. Incorporate identified problem area<BR/>9. Areas of concern that are identified during the resident assessment will be evaluated before interventions are added to the care plan.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with the professional standards for food service safety for 1 of 1 kitchen reviewed for kitchen sanitation. <BR/>1. <BR/>The facility failed to ensure freezer items were properly stored, labeled, and dated.<BR/>2. <BR/>The facility failed to ensure walk-in refrigerator items were stored, labeled, and dated.<BR/>3. <BR/>The facility failed to ensure pantry foods were properly stored, labeled, and dated.<BR/>These failures could place residents who ate food served by the kitchen at risk of food-borne illness. <BR/>Findings include:<BR/>Observation of the walk-in pantry on 05/28/24 at 9:12 AM revealed the following:<BR/>1. <BR/>(1) Package of opened bread, with no label or date.<BR/>2. <BR/>(1) Tray of brownies, labeled and dated, with plastic wrap covering most of it except sides which were open to air. <BR/>3. <BR/>(1) Box of corn starch, labeled and dated, box top open and inner bag open to air.<BR/>4. <BR/>(1) container of garlic salt with no date or label.<BR/>5. <BR/>(1) container of parsley flakes with no date or label.<BR/>6. <BR/>(1) container of chives with no date or label.<BR/>7. <BR/>(1) container of ground sage with no date or label.<BR/>8. <BR/>(1) container of Italian seasoning with no date or label.<BR/>9. <BR/>(1) container of ground nutmeg with no date or label.<BR/>10.(7) boxes of peanut butter crackers with individualized packages inside, with no dates or labels. <BR/>Observation of the walk-in refrigerator on 05/28/24 at 9:18 AM revealed the following:<BR/>1. <BR/>(2) bags of what appeared to be lettuce with no dates or labels.<BR/>2. <BR/>(1) whole watermelon with no date or label.<BR/>3. <BR/>(2) trays of cups with what appeared to be juice and tea in them, covered in saran wrap, with no dates or labels.<BR/>4. <BR/>(6) individualized yogurts, with no dates or labels.<BR/>5. <BR/>(6) individualized puddings, with no dates or labels.<BR/>Observation of the freezer on 05/28/24 at 9:23 AM revealed the following:<BR/>1. <BR/>(1) open box of what appeared to be frozen bread sticks, with bag inside open to air, with no date or label.<BR/>2. <BR/>(1) large package of what appeared to be ground beef, with no date or label.<BR/>3. <BR/>(1) tray of brownies, with no date or label.<BR/>In an interview on 05/28/24 at 10:56 AM, [NAME] A stated it was everyone's responsibility to make sure that all food in the kitchen was labeled and dated. [NAME] A stated a possible negative outcome for not having labeled and dated food in walk in refrigerator, pantry, and freezers would be that the food would be that they could be giving outdated food to residents and that it would be bad.<BR/>In an interview on 05/29/24 at 8:37 AM, DM stated that it was everyone's responsibility to make sure that food in the kitchen was labeled and dated. DM stated that a possible negative outcome for not having everything in the kitchen labeled and dated would be that they would not know what the open date was if it was not dated/labeled and then they would not know when to throw out the food and bacteria could grow and then that could be bad if it was served.<BR/>In an interview on 05/29/24 at 8:38 AM, [NAME] B stated it was everyone's responsibility to label and date food in the kitchen. [NAME] B stated a possible negative outcome would be that residents could get sick. <BR/>Record review of the facility-provided policy dated January 2024 titled Food Storage - Dry Storage.<BR/> .Food must be stored in a properly covered container with a date and label identifying what is in the container. <BR/>Record review of the facility-provided policy dated January 2024 titled Food Storage - Refrigerated and Frozen Foods.<BR/> .Food must be stored in a properly covered container with a date and label identifying what is in the container. Foods may remain in the [NAME] box as long as content and date are easily visible on the box. Any foods removed from the [NAME] box must be dated and labeled. <BR/>Record review of the facility-provided policy undated titled Refrigerators and Freezers<BR/> .All food shall be appropriately dated to ensure proper rotations by expiration dates. Received dates (dates of delivery) will be marked on cases and on individual items removed from cases for storage. Use by dates will be completed with expiration dates on all prepared food in refrigerators. Expiration dates on unopened food will be observed and use by dates indicated once food is opened.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to implement a comprehensive care plan for each resident that includes measurable objectives and timeframes to meet a resident's medical, nursing, mental, and psychosocial needs that are identified in the comprehensive assessment and describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 1 (Resident #27) of 13 Residents reviewed for comprehensive care plans.<BR/>-The facility failed to include care plans for Resident #27's catheter.<BR/>This failure could affect all residents in the facility receiving care per comprehensive person-centered care plans resulting in resident not being able to attain or maintain their highest practicable physical, mental, and psychosocial well-being. <BR/>Finding include:<BR/>Record review of Resident #27's face sheet printed 3-21-2023 revealed he was a [AGE] year-old male resident admitted to the facility originally on 1-31-2022 and readmitted on [DATE] with diagnoses to include dementia (a group of thinking and social symptoms that interferes with daily functioning), chronic kidney disease (longstanding disease of the kidneys that leads to kidney failure), obstructive and reflux uropathy (when your urine cant flow (either partially or completely) through the ureters, bladder, or urethra due to some type of obstruction), and benign prostate hyperplasia (age associated prostate gland enlargement that can cause urination difficulty.<BR/>Record review of Resident #27's clinical record revealed his last MDS assessment was a quarterly completed on 3-8-2023 listing him with a BIMS of 5 indicating he was severely cognitively impaired, he had a functionality of requiring one-person physical assistance with all his activities, and Section H-Bowel and Bladder he was listed as having a indwelling catheter (a catheter which is inserted into the bladder, via the urethra and remains in-situ to drain urine).<BR/>Record review of Resident #27's Order Summary Report with active orders as of 3-22-2023 listed the following orders:<BR/>-Change foley catheter one time a day starting on the 20th and ending on the 20th every month related to BENIGN PROSTATIC HYPERPLASIA WITHOUT LOWER URINARY TRACT SYMPTOMS (N40.0) (a condition in men in which the prostate gland is enlarged and not cancerous)-order dated 1-20-2023, start date 2-20-2023<BR/>-Foley Catheter care two times a day-order dated 1-20-2023, start date 1-20-2023<BR/>Record review of Resident #27's care plan with admission date 2-27-2023 revealed no care plans for catheter care. <BR/>During an interview on 03-22-2023 at 10:42 AM MA B reported that Resident #27 had a catheter and used a leg bag. MA B stated that Resident #27 used to have the large catheter bag but due to Resident #27's dementia he would not leave it alone and that with a leg bag Resident #27 does not see it under his clothing and therefore will not mess with it.<BR/>During an interview on 03-23-2023 at 08:45 AM the MDS Coordinator reviewed Resident #27's clinical record and reported that Resident #27 did not have a care plan for his urinary catheter, that Resident #27 had a history of having a urinary catheter then having the urinary catheter dc'd due to difficulty with his urinary retention (difficulty urinating or completely emptying the bladder) and that Resident #27 has had this catheter since the first of January 2023 which was addressed on his last MDS. The MDS Coordinator reported that the catheter should have been addressed in his care plan. The MDS Coordinator verified that it is her job to complete the comprehensive care plans. The MDS Coordinator reported that she started the MDS position the first of March 2023 (after the last MDS Coordinator resigned) and is currently reviewing all care plans for accuracy. The MDS Coordinator reported that she will update Resident #27's care plan to include his catheter. The MDS Coordinator reported that if a care plan does not have the resident's current information and needs, that a resident could possibly not receive the care they need but Resident #27 has orders for his catheter and has documentation that addresses the use of his catheter in the nursing notes, so she feels Resident #27 has received his needed care. <BR/>During an interview on 03-23-2023 at 09:11 AM the DON reported that a catheter needs to be addressed in the care plan because that is how the CNA's and other staff know how to perform their care on a resident. The DON reported that if a resident's needs are not addressed in their care plans, then they may receive incorrect care or not receive the care they need. <BR/>Record review of facility provided policy titled Care Plans, Comprehensive Person-Centered, undated, revealed the following:<BR/>Policy Interpretation and Implementation-<BR/>8. The comprehensive, person-centered care plan will<BR/>-b. Describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being.<BR/>-g. Incorporate identified problem area<BR/>9. Areas of concern that are identified during the resident assessment will be evaluated before interventions are added to the care plan.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews the facility failed to ensure each resident receives adequate supervision and assistance devices to prevent accidents for 1 (Resident 35) of 12 residents reviewed for accidents.<BR/>On 05/20/24 the facility failed to provide adequate supervision and assistance devices for Resident #35 and he had an unwitnessed fall which resulted in a broken left hip.<BR/>This failure could place residents at risk of injury or harm.<BR/>Findings Included:<BR/>Record review of Resident #35's admission record dated 05/30/24 revealed an [AGE] year-old male originally admitted to the facility 03/29/23 with a most recent admission date of 05/29/24. He had diagnoses that included, but were not limited to, infection following a procedure, fracture of neck of right femur (right hip), dementia (a group of thinking and social symptoms that interferes with daily functioning), impulse disorder (lack of ability to control self), wandering, and Alzheimer's (a progressive disease that destroys memory and other important mental functions).<BR/>Record review of Resident #35's Quarterly MDS completed on 05/17/24 revealed the following:<BR/>Section C of the MDS revealed a BIMS of 3 which indicated severely impaired cognition. <BR/>Section GG of the MDS revealed Resident #35 was dependent on staff for walking and needed partial to substantial assistance with other mobility ADLs. <BR/>Section J of the MDS indicated Resident #35 had had major surgery to repair a fracture as well as another major surgery. <BR/>Section P of the MDS revealed bed and chair alarms were used daily.<BR/>Record review of Resident #35's care plan completed on 05/29/24 revealed a focus area of fall risk due to impaired mobility, cognitive deficits and weakness. Interventions were as follows:<BR/>03/18/24 used a mobility monitor on his w/c for safety. <BR/>03/14/24 have increased assistance, surveillance, activities involvement, a mobility alarm, and be placed near the nurses' station. <BR/>03/14/24 1:1 monitoring, and or activities to maintain (his) safety and to divert (his) attention away from attempting to stand/ambulate without supervision/assistance. <BR/>Record review of Resident #35's active orders dated 05/30/24 revealed the following:<BR/>An order for admission to skilled service related to (right) hip fracture dated 03/13/24.<BR/>An order to monitor left hip for s/s of infection twice a day dated 05/29/24.<BR/>Record review of Resident #35's Fall Risk Assessments front sheet in the EHR revealed he was assessed as a moderate risk for falls prior to his falls on 03/08/24 and 05/20/24. The falls resulted in a broken right hip and a broken left hip respectively. <BR/>Record review of Resident #35's Progress Notes revealed the following:<BR/>03/08/24 written by DON revealed Resident #35 had fallen in his room and was found on the floor on his left side next to his bed. He was sent to the ER via ambulance.<BR/>03/13/24 written by LVN H revealed Resident #35 was returning to facility following surgery on 03/09/24 for a right hip fracture.<BR/>03/15/24 written by RN L revealed Resident #35 attempted to turn himself in his bed without staff assistance.<BR/>03/17/24 written by RN M revealed Resident #35 attempted to get up without staff assistance.<BR/>03/18/24 written by RN M revealed Resident #35 attempted to get up without staff assistance.<BR/>03/19/24 written by RN L revealed Resident #35 attempted to get up without staff assistance.<BR/>03/20/24 written by RN L revealed Resident #35 attempted to get up without staff assistance.<BR/>03/25/24 01:11 PM written by RN L revealed Resident #35 got up from his bed without assistance. <BR/>03/25/24 10:50 PM written by RN M revealed Resident #35 attempted to get out of bed by himself.<BR/>04/30/24 written by LVN H revealed Resident #35 had a mobility alarm on his w/c.<BR/>05/03/24 written by RN L revealed Resident #35 attempted to get out of bed by himself.<BR/>05/12/24 written by RN M revealed Resident #35 got out of bed by himself.<BR/>05/20/24 02:54 PM written by LVN C revealed Resident #35 fell from his w/c and was sent via ambulance to the ER.<BR/>05/20/24 05:51 PM written by DON revealed Resident #35 was being sent from the local hospital to a higher level of care due to a broken left hip.<BR/>Record review of Resident #35's Daily Skilled Nurses Note2 dated 05/20/24 at 10:50 AM and filled out by LVN C revealed services provided for Resident # included Management/Evaluation of Resident Care Plan, Observation/Assessment of Resident's Condition and Therapy (PT, OT, ST).<BR/>Record review of facility investigation into Resident #35's fall on 05/20/24 revealed Resident #35 had just received a haircut and was wheeling himself in his w/c down the hall from the salon and fell near the chapel door. AD heard him saying help and found him lying on the floor. She asked her assistant to notify nursing staff and LVN C assessed Resident #35 and called an ambulance, his family member, the DON, and his doctor.<BR/>During an interview on 05/29/24 at 07:19 AM ADM stated Resident #35 had just been transitioned from a geri chair to a w/c before the fall on 05/20/24 when he broke his left hip.<BR/>During an observation and interview on 05/29/24 at 09:12 AM AD stated she found Resident #35 wheeling himself in his w/c in the lobby on 05/20/24. She said she asked him if he wanted a haircut, and he said yes. At that point she wheeled him back to the salon and cut his hair. She stated he was strolling out (here she made motions with both hands as if she was spinning the wheels of a wheelchair). AD stated Resident #35 was moving along just fine so she started sweeping up in the salon. She said she heard him say help, help and she peeked around the corner of the salon doorway and could not see him, so she walked around the corner into the hallway and saw him on the floor. AD stated she did not see how he fell or what happened just that he was on the floor. She asked her activity aide to get a nurse. <BR/>During an interview on 05/29/24 at 09:41 AM LVN C stated on 05/20/24 she saw therapy working with Resident #35 on walking and later when he was in his w/c she saw him paddling his feet as if he was walking. LVN C stated when she was sitting at the nurses' station facing the lobby, [Resident #35's fall happened at the end of the hall behind LVN C, if she was facing the lobby] she heard someone make a moaning sound twice. She said she turned to a staff member sitting next to her and they discussed the sound but did not know where it came from. LVN C stated a different staff said, [First name of Resident #35]'s on the floor, [First name of Resident #35]'s on the floor! She then got up from the nurses' station and assessed Resident #35. She stated he was lying on his right side on the incision from his prior hip surgery when she found him, and his w/c was next to him. LVN C said Resident #35 complained of pain in his back at the time she was assessing him. She stated when the ambulance arrived and the EMTs were assessing him, he told them his left arm hurt and they removed his shirt and found a skin tear on his left elbow.<BR/>During an interview on 05/30/24 at 09:58 AM Resident #35's family member stated she had some concern that he had fallen twice in three months and broken both of his hips. She stated the first fall she could understand as he walked all the time without the aid of a cane or walker, and he had trouble seeing out of his left eye. She stated she could see how his constant walking and trouble seeing combined with his Alzheimer's diagnosis might have contributed to a fall. She stated when the second fall happened the chair alarm that was to be in use to help prevent another fall was not in use. She stated two staff members, LVN C and DON, told her during two different phone conversations that the chair alarm was not in use because they were too busy to put it in (his w/c). Resident #35's family member stated neither staff member elaborated on what they were busy doing. She said LVN C told her Resident #35 had just been working with therapy and staff did not have time to put the alarm in his w/c before he fell.<BR/>During an interview on 05/30/24 at 10:34 AM DON stated Resident #35 was supposed to have a mobility alarm in his w/c when he fell but therapy had just taken him out of the geri chair to work with him in the w/c and then staff got him for a haircut and were with him. The alarm was in his geri chair and we had not moved it over to the w/c because he was with somebody the whole time.<BR/>During an interview on 05/30/24 at 10:40 AM AD stated she did not remember if any staff person was with Resident #35 when she found him in the lobby and asked him if he wanted a haircut. She stated she did not know Resident #35 needed to have an alarm in his w/c.<BR/>During an interview and observation on 05/30/24 AD pointed out the door of the salon, the 20 to 30-foot hallway to the corner, and the spot around the corner where she found Resident #35 on the floor after hearing him moaning.<BR/>During an interview on 05/30/24 at 02:02 PM ADM and DON stated 1:1 meant a resident would receive individual attention during a specific time from a staff member. DON stated no residents in the facility required 1:1 monitoring all the time and the facility did not have enough staff to provide that type of monitoring. <BR/>During an interview on 05/30/24 at 03:28 PM MDS RN stated a care plan was instructions on how to care for a resident and if they are not followed that is not gonna be good. MDS RN stated the 1:1 monitoring mentioned in Resident #35's care meant, If he is trying to get up staff will intervene and keep him from getting up and stay with him until he is settled.<BR/>During an interview on 05/30/24 at 03:31 PM ADM and DON stated the 1:1 monitoring mentioned in Resident #35's care plan meant if he was attempting to ambulate or stand we will give the resident assistance and when he was stable and settled, they would stop the 1:1 monitoring.<BR/>During an interview on 05/30/24 at 03:37 PM DON stated if a resident's care plan was not followed it would be detrimental for the resident.<BR/>During an interview on 05/30/24 at 03:39 PM LVN H stated if a resident is care planned for a mobility alarm in their w/c it should be put on immediately. She stated if the alarm was not used the resident could get hurt.<BR/>During an interview on 05/30/24 at 03:50 PM ADM stated there could be a negative outcome if a resident's care plan is not followed. He stated in the case of Resident #35's chair alarm, I don't think the alarm would have helped him from falling, it would have alerted us to the fall.<BR/>Record review of undated facility policy titled Care Plans, Comprehensive Person-Centered revealed the following: . A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. <BR/>Record review of undated facility policy titled Fall and Fall Risk, Managing revealed the following: . Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. 8. Position change alarms will not be used as the primary or sole intervention to prevent falls, but rather will be used to assist the staff in identifying patterns and routines of the resident The use of alarms will be monitored for efficacy and staff will respond to alarms in a timely manner.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure a resident who is fed by enteral means receives the appropriate treatment and services to prevent complications of enteral feeding including but not limited to aspiration pneumonia, diarrhea, vomiting, dehydration, metabolic abnormalities, and nasal-pharyngeal ulcers for 1 (Resident #91) of 1 residents reviewed for tube feeding.<BR/>The facility failed to check for PEG tube placement before administering medication (Cephalexin) via the tube for Resident #91.<BR/>This failure could place resident at risk of aspiration, bleeding, or perforation, pneumonia, and even death.<BR/>Findings Included:<BR/>Record review of Resident #91's admission record dated 05/30/24 revealed a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included but were not limited to cerebral infarction due to embolism (stroke due to blood clot), dysphagia following cerebral infarction (difficulty in swallowing following stroke), epilepsy (disorder that causes seizures or unusual sensations and behaviors), pneumonitis due to inhalation of food and vomit (inflammation of lung tissue), aspiration of fluid (breathing fluid into the lungs), and acquired absence of part of stomach.<BR/>Record review of Resident #91's quarterly MDS completed on 03/26/24 revealed the following:<BR/>Section C revealed a BIMS of 3 which indicated severely impaired cognition. <BR/>Section GG noted eating was not attempted due to medical condition or safety concerns. <BR/>Section K revealed Resident #91 was on a feeding tube while a resident and received 51% or more of his total calories and 500 cc/day or less of fluid through the tube.<BR/>Record review of Resident #91's care plan completed 05/02/24 revealed a focus area of risk for aspiration r/t feeding tube initiated on 02/27/24. One intervention for this focus area was to ensure proper tube placement prior to beginning feeding. A second focus area initiated on 08/10/24 addressed the requirement for tube feeding r/t dysphagia. One intervention for this focus area was to ensure placement of the tube by marking the length of the tube. A second intervention for this focus area addressed Resident #91's medications being crushed and administered through his PEG tube. A third intervention for this focus area referred the reader to the previous risk for aspiration focus area.<BR/>Record review of Resident #91's active order summary dated 05/29/24 revealed the following:<BR/>An order for Cephalexin to be given via PEG tube four times a day related to aspiration of fluid with a start date of 05/24/24.<BR/>During an observation on 05/28/24 at 11:57 AM LVN C administered Cephalexin to Resident #91 via his PEG tube without first checking the tube for placement.<BR/>During an interview on 05/29/24 at 12:18 PM DON stated administering medication through a PEG tube without first checking the tube for placement could create issues in the abdomen of the resident and medications/food could go in the wrong place. She stated nurses were responsible to provide proper care to Resident #91's PEG tube.<BR/>During and interview on 05/29/24 at 12:42 PM LVN C stated she has worked for the facility for several years part time. She stated she did not check the placement of Resident #91's tube before administering his medication on 05/28/24. She said, I know, I know I didn't. I went back and looked at it. I did it wrong and I understand. She explained the proper procedure that she should have done was to fill a syringe with a little air, attach it to the tube and listen with her stethoscope at the base of the tube for a whoosh sound as she pushed the air into the tube. LVN C said not checking for placement of the tube could result in an infection for the resident.<BR/>Record review of undated facility policy titled Enteral Feedings-Safety Precautions revealed the following: . Preventing aspiration 1. Check enteral tube placement every 4 hours and prior to feeding or administration of medication. <BR/>Record review of undated facility policy titled Enteral Nutrition revealed the following: . 16. Risk of aspiration is assessed by the nurse and provider and addressed in the individual care plan. [NAME] of aspiration may be affected by: . d. failure to confirm placement of the feeding tube prior to initiating the feeding.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure that residents who needed respiratory care, including tracheostomy care and tracheal suctioning, were provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents' goals, and preferences for one (Resident #147) of 13 residents assessed for respiratory care. <BR/>Resident #147 was wearing/receiving oxygen but did not have an order for oxygen.<BR/>This failure could place residents requiring oxygen at risk for receiving the wrong amount of oxygen, which could lead to shortness of breath, hypoxemia (below normal levels of oxygen in blood), or oxygen toxicity (condition resulting from the harmful effects of breathing molecular oxygen at increased partial pressures).<BR/>Findings include <BR/>Record review of Resident #147's face sheet, dated 03/21/23, revealed a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included, but were not limited to, chronic obstructive pulmonary disease (inflammation of lung tissue due to non-infectious causes, which results in cough without mucus or phlegm, shortness of breath and fatigue), chronic diastolic congestive heart failure (a condition in which the heart can no longer pump enough blood to the rest of the body), Alzheimer's disease, and a history of falling.<BR/>Record review of Resident #147's admission MDS, dated [DATE], revealed a BIMS score of 1 out of 15 which indicated his cognition was severely impaired. Section G revealed he required limited one-person assistance with bed mobility, transferring, dressing and toilet use, and personal hygiene and extensive one-person assistance with eating. Section O indicated that Resident #147 required oxygen therapy while not a resident and while a resident. <BR/>Record review of Resident #147's care plan, dated 03/14/23, revealed, in part, I have oxygen therapy r/t CHF, Ineffective gas exchange Date Initiated: 03/16/2023 . OXYGEN SETTINGS: Maintain my oxygen settings per physician orders. Check on liter flow when entering my room. Date Initiated: 03/16/2023<BR/>Record review of Resident #147's physician's orders dated 03/21/23 revealed no orders for oxygen administration. <BR/>Record review of Resident #147's physician's orders dated 03/22/23 revealed an order for oxygen administration dated 03/22/23 at 04:23 PM.<BR/>Record review of Resident #147's Weights and Vitals Summary dated 03/22/23 revealed the following oxygen saturation [The percentage of oxygen in the blood; normal oxygen saturation level for healthy adults is between 95% and 100%.] recordings while Resident #147 was receiving oxygen via nasal cannula: <BR/>03/09/23 at 10:36 PM 94% <BR/>03/10/23 at 02:42 PM 95%<BR/>03/10/23 at 10:17 PM 98%<BR/>03/13/23 at 01:56 PM 99%<BR/>03/13/23 at 09:26 PM 96%<BR/>03/14/23 at 08:33 AM 96%<BR/>03/14/23 at 11:10 PM 94%<BR/>03/15/23 at 10:10 AM 92%<BR/>03/15/23 at 10:44 PM 92%<BR/>03/16/23 at 11:00 AM 94%<BR/>03/16/23 at 11:35 PM 92%<BR/>03/17/23 at 02:31 PM 92%<BR/>03/18/23 at 03:32 PM 95%<BR/>03/18/23 at 10:23 PM 90%<BR/>03/19/23 at 03:32 PM 95%<BR/>03/19/23 at 10:32 PM 92%<BR/>03/20/23 at 11:54 PM 91%<BR/>03/21/23 at 02:45 PM 95%<BR/>03/22/23 at 10:40 PM 98%<BR/>During an observation and interview on 03/21/23 at 02:17 PM, Resident #147 was sitting in a recliner in his room receiving oxygen by nasal cannula at 3 liters per minute. Two of Resident #147's family members were in his room with him. They stated he had not been in the facility long and seemed to be doing well.<BR/>During an observation on 03/22/23 at 08:26 AM Resident #147 was lying in bed on his back asleep receiving oxygen by nasal cannula at 2.5 liters per minute.<BR/>During an observation on 03/22/23 at 09:03 AM Resident #147 was lying in bed on his back asleep, receiving oxygen by nasal cannula at 2.5 liters per minute.<BR/>During an observation on 03/22/23 at 09:54 AM Resident #147 was lying in bed on his back asleep, receiving oxygen by nasal cannula at 3 liters per minute.<BR/>During an observation and interview on 03/22/23 at 11:00 AM Resident #147 was lying in bed on his back asleep, receiving oxygen by nasal cannula at 3 liters per minute. Resident #147's family member was sitting in his room and stated he had been on oxygen for several years now, 24/7.<BR/>During an observation and interview on 03/23/23 at 08:58 AM Resident #147 was sitting in his recliner receiving oxygen by nasal cannula at 3 liters per minute. Resident #147's family member was sitting in his room with him and stated he was doing well.<BR/>During an interview on 03/23/23 at 09:17 AM LVN C stated she had worked for the facility for a year. She stated nurses and CNAs were responsible for checking oxygen saturation levels for residents and ensuring those receiving oxygen were receiving it at the correct liters per minute. She said the physician's orders determined what liters per minute a resident's oxygen was set to. She said if the order information was not available a resident could be negatively affected. She stated, They would be hypoxic [low blood oxygen], their O2 [oxygen] would drop and they would be lethargic, confused, pale, sweaty, anxious.<BR/>During an interview on 03/23/23 at 09:22 AM the DON stated nurses were responsible for setting oxygen levels for residents receiving oxygen. She stated the nurses knew what levels to set the oxygen to for residents because it is in their orders. When asked what could happen if the information was not in the orders she stated, They [nurses] could set it too high or not high enough. She stated the nurses were responsible for ensuring orders are in the chart when a resident is admitted to the facility. She stated she did not know why Resident #147 was receiving oxygen since his admission on [DATE] without physician's orders for oxygen until an order dated 03/22/23. She stated a possible negative outcome of administering oxygen to a resident without physician's orders was the resident could have Chronic Obstructive Pulmonary Disease (a chronic inflammatory lung disease that causes obstructed airflow from the lungs) and not be a candidate to receive O2 on the level they put it on.<BR/>Record review of an undated facility policy titled Admission revealed the following:<BR/> . 5. Prior to or at the time of admission, the resident's Attending Physician provides the facility with information needed for the immediate care of the resident, including orders covering at least: . b. Medication orders .<BR/>Record review of an undated facility policy titled Medication and Treatment Orders revealed the following:<BR/>1. Medications shall be administered only upon the written order of a person duly licensed and authorized to prescribe such medications .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, the interview and record review, the facility failed to ensure residents were free of any significant medication errors for one of 1 (Resident #20) 12 residents reviewed for medication administration. <BR/>-LVN C was attempting to administer Resident #20's expired insulin. Resident #20's insulin did not have an open date on the vial; therefore it could not be determined if insulin was expired. <BR/>This failure could place residents who receive insulin medications at an increased risk for complications such as increased blood glucose levels, change in cognition, and an exacerbation of symptoms and disease process.<BR/>Findings include:<BR/>Record review of Resident #20's face sheet, dated [DATE], revealed Resident #20 as a [AGE] year-old female who was admitted into the facility on [DATE]. Resident #20 had the following diagnosis: Cerebral infarction due to unspecified occlusion or stenosis of left middle cerebral artery. Type 2 diabetes mellitus without complication, Essential (Primary)Hypertension, cognitive communication deficit, muscle weakness (Generalized), major depressive disorder, recurrent, unspecified. <BR/>Record review of Resident #20's current MDS, dated [DATE], revealed Resident #20 had a BIMS of 07, which indicates that Resident 20 is severely impaired when it comes to cognitive function. Resident #20's functional ability revealed that Resident #20 is dependent upon staff for most ADLs except for eating. <BR/>Record review of Resident #20's care plan dated [DATE] revealed Resident #20 was care planned for her Diabetes mellitus. Interventions read that Diabetes medication as ordered by doctor. Monitor/document side effects and effectiveness.<BR/>Record review of Resident #20's physician orders, dated [DATE] revealed that Resident #20 has an order for the following insulins:<BR/>HumaLOG Solution 100 UNIT/ML (Insulin Lispro)<BR/>Inject as per sliding scale: if 0 - 149 = 0; 150 - 200 =<BR/>2; 201 - 250 = 3; 251 - 300 = 4; 301 - 350 = 5; 351 -<BR/>400 = 6 If over 400 call MD, subcutaneously before<BR/>meals and at bedtime related to TYPE 2 DIABETES<BR/>MELLITUS WITHOUT COMPLICATIONS (E11.9)<BR/>Lantus Solution 100 UNIT/ML (Insulin Glargine) Inject<BR/>30 unit subcutaneously one time a day related to<BR/>TYPE 2 DIABETES MELLITUS WITHOUT<BR/>COMPLICATIONS (E11.9)<BR/>Record review of Resident #20's MARs, dated for the month of [DATE] revealed that Resident #20 received Humalog sliding scale every day for the last 30 days of May except on [DATE], [DATE], and [DATE]. These 3 days Resident #20 did not need her Humalog sliding scale. <BR/>Record review of Resident #20's blood glucose logs, dated [DATE] revealed that resident did not have any dangerously high blood sugars for the month of May. The highest Resident #20's blood glucose got was 300mg/dL (milligrams/deciliter) on [DATE] and that was covered by 4 units of her Humalog sliding scale. <BR/>Observation/Interview on [DATE] at 09:46 AM revealed LVN C getting insulin from the facility's treatment cart. Insulin for Resident #20 was drawn up in an insulin syringe by LVN C. LVN C went into the room of Resident #20 proceeded to give 2 units of medication to resident in her right arm. LVN C was stopped by surveyor before medication was administered. LVN C was asked to review the expiration and open date on the insulin. LVN C stated that she could not find the open date on the insulin. LVN C was asked if the medication should be given since the open date is nowhere to be found. LVN C stated she would go and take it to the DON. LVN C was asked if the insulin had been given today, LVN C stated that it had been given. <BR/>Interview on [DATE] at 11:49 AM with LVN C stated that giving a medication that is expired would not be effective for the resident. <BR/>Interview on [DATE] at 10:05 AM with DON stated that the negative outcome of giving an expired insulin would be that the medication is not as effective. <BR/>Record review of facility provided policy titled, Adverse Consequences and Medication Errors, undated, revealed the following: <BR/> .4. The staff and practitioner shall strive to minimize adverse consequences by:<BR/>a. <BR/>Following relevant clinical guidelines and manufacturer's specifications for use, dose, administration, duration, and monitoring of the medication; .<BR/> .5. A medication error is defined as the preparation or administration of drugs or biological which is not in accordance with physician's orders, manufacturer specifications, or accepted professional standards and principles of the professional(s) providing services. <BR/>6. Examples of medication errors include: .<BR/> .h. Failure to follow manufacturer instructions and/or accepted professional standards .<BR/> .9. Facility staff monitor the resident for possible medication -related adverse consequences, including mental status and level of consciousness, when the following conditions occur: .<BR/> .f. Medication error, e.g., wrong or expired medication.<BR/>Record review of facility provided policy titled, Labeling of Medication Containers, undated, revealed the following:<BR/> .3. Labels for individual resident medications include all necessary information, such as: .<BR/> .h. The expiration date when applicable; .<BR/>Record review of facility provided policy titled, Administering Medications, undated, revealed the following: <BR/> .12. The expiration/beyond use date on the medication label is checked prior to administering. When opening a multi-dose container, the date opened is recorded on the container.<BR/>Record review of https://humalog.lilly.com, manufacture website for Humalog, website revised 08/2023 revealed the following: <BR/>After vials have been opened:<BR/>Store opened vials in the refrigerator or at room temperature up to 86&deg;F (30&deg;C) for up to 28 days.<BR/>Keep vials away from heat and out of direct light.<BR/>Throw away all opened vials after 28 days of use, even if there is insulin left in the vial.

**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 the professional standards for food service safety for 1 of 1 kitchen reviewed for kitchen sanitation. <BR/>1. <BR/>The facility failed to ensure freezer items were properly stored, labeled, and dated.<BR/>2. <BR/>The facility failed to ensure walk-in refrigerator items were stored, labeled, and dated.<BR/>3. <BR/>The facility failed to ensure pantry foods were properly stored, labeled, and dated.<BR/>These failures could place residents who ate food served by the kitchen at risk of food-borne illness. <BR/>Findings include:<BR/>Observation of the walk-in pantry on 05/28/24 at 9:12 AM revealed the following:<BR/>1. <BR/>(1) Package of opened bread, with no label or date.<BR/>2. <BR/>(1) Tray of brownies, labeled and dated, with plastic wrap covering most of it except sides which were open to air. <BR/>3. <BR/>(1) Box of corn starch, labeled and dated, box top open and inner bag open to air.<BR/>4. <BR/>(1) container of garlic salt with no date or label.<BR/>5. <BR/>(1) container of parsley flakes with no date or label.<BR/>6. <BR/>(1) container of chives with no date or label.<BR/>7. <BR/>(1) container of ground sage with no date or label.<BR/>8. <BR/>(1) container of Italian seasoning with no date or label.<BR/>9. <BR/>(1) container of ground nutmeg with no date or label.<BR/>10.(7) boxes of peanut butter crackers with individualized packages inside, with no dates or labels. <BR/>Observation of the walk-in refrigerator on 05/28/24 at 9:18 AM revealed the following:<BR/>1. <BR/>(2) bags of what appeared to be lettuce with no dates or labels.<BR/>2. <BR/>(1) whole watermelon with no date or label.<BR/>3. <BR/>(2) trays of cups with what appeared to be juice and tea in them, covered in saran wrap, with no dates or labels.<BR/>4. <BR/>(6) individualized yogurts, with no dates or labels.<BR/>5. <BR/>(6) individualized puddings, with no dates or labels.<BR/>Observation of the freezer on 05/28/24 at 9:23 AM revealed the following:<BR/>1. <BR/>(1) open box of what appeared to be frozen bread sticks, with bag inside open to air, with no date or label.<BR/>2. <BR/>(1) large package of what appeared to be ground beef, with no date or label.<BR/>3. <BR/>(1) tray of brownies, with no date or label.<BR/>In an interview on 05/28/24 at 10:56 AM, [NAME] A stated it was everyone's responsibility to make sure that all food in the kitchen was labeled and dated. [NAME] A stated a possible negative outcome for not having labeled and dated food in walk in refrigerator, pantry, and freezers would be that the food would be that they could be giving outdated food to residents and that it would be bad.<BR/>In an interview on 05/29/24 at 8:37 AM, DM stated that it was everyone's responsibility to make sure that food in the kitchen was labeled and dated. DM stated that a possible negative outcome for not having everything in the kitchen labeled and dated would be that they would not know what the open date was if it was not dated/labeled and then they would not know when to throw out the food and bacteria could grow and then that could be bad if it was served.<BR/>In an interview on 05/29/24 at 8:38 AM, [NAME] B stated it was everyone's responsibility to label and date food in the kitchen. [NAME] B stated a possible negative outcome would be that residents could get sick. <BR/>Record review of the facility-provided policy dated January 2024 titled Food Storage - Dry Storage.<BR/> .Food must be stored in a properly covered container with a date and label identifying what is in the container. <BR/>Record review of the facility-provided policy dated January 2024 titled Food Storage - Refrigerated and Frozen Foods.<BR/> .Food must be stored in a properly covered container with a date and label identifying what is in the container. Foods may remain in the [NAME] box as long as content and date are easily visible on the box. Any foods removed from the [NAME] box must be dated and labeled. <BR/>Record review of the facility-provided policy undated titled Refrigerators and Freezers<BR/> .All food shall be appropriately dated to ensure proper rotations by expiration dates. Received dates (dates of delivery) will be marked on cases and on individual items removed from cases for storage. Use by dates will be completed with expiration dates on all prepared food in refrigerators. Expiration dates on unopened food will be observed and use by dates indicated once food is opened.

Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 (CNA A) of 4 staff observed for resident care. <BR/>-CNA A failed to perform hand hygiene or glove changes during incontinent care. <BR/>This deficient practice has the potential to affect all residents in the facility by exposing them to care that could lead to the spread of viral infections, secondary infections, tissue breakdown, communicable diseases, and feelings of isolation related to poor hygiene. <BR/>Findings include: <BR/>During an observation on 03-22-2023 09:44 AM CNA A performed incontinent care for Resident #4, CNA A was noted to wash his hands upon entering the room, CNA A then placed gloves, adjusted the residents curtains, placed a transfer belt on the resident, transferred the resident to bed, pulled the resident pants down, checked the front of the resident brief with his gloved hand to determine if the resident was wet, rolled the resident to his side, opened the new brief and placed it at the foot of the bed, removed multiple wipes from the wipe package and placed them on the opened new brief. CNA A then started to remove the used brief the resident was wearing and rolled it under the resident. CNA A used several wipes from on top of the new brief to clean the resident's rectal area, CNA A then placed the new brief under the resident, rolled the resident to his other side, finished removing the used brief, then removed a wipe from the wipe package to clean the penis and groin area (area in the body where the upper thighs meet the lowest pare of the lowest part of the abdomen). CNA A finished placing the new brief, pulled up the resident's cover, placed the resident in a position of comfort, and used the bed controls to lower the bed. CNA A then removed his gloves and placed them in the trash. CNA A then placed the residents fall mat, removed the used supplies and walked down the hallway to the last room on the right where he placed the used supplies in a trash container, then washed his hands. CNA A did not wash his hands, use ABHR, or change his gloves while providing incontinent care. <BR/>During an observation on 03-22-2023 at 01:08 PM CNA A performed incontinent care for Resident #11, CNA A was noted to wash his hands upon entering the room,, placed gloves, lowered the residents bed with the electronic control, transferred the resident from her wheelchair with his hands under her armpits to the bed, placed his hands under her back and knees and laid her in the bed, rolled her to her side and lowered her pants, rolled her to her other side and lowered her pants to her knees, then rolled her to her back, placed her new brief next to her right shoulder, removed multiple wipes from the wipe container and placed them on top of the wipe container with several falling off on the bed sheets, CNA A then used several wipes to clean the residents vaginal area, rolled the resident to her left side, cleaned her rectal area, removed her used brief, placed her new brief, rolled her to her right side, finished placing the brief, rolled her to her back, pulled her new brief up and secured the brief, CNA A then pulled the residents pants back up, CNA A then removed and disposed of his gloves, CNA A pulled the residents cover back up, placed the residents call light next to the resident, adjusted the bed with the electric controls, removed the used supplies, exited the room, walked to the last room on the hallway on the right, disposed of the used supplies in a trash container, and washed his hands. CNA A did not wash his hands, use ABHR, or change his gloves while providing incontinent care.<BR/>During an interview on 03-22-2023 at 01:16 PM CNA A reported that if he notices that a hand becomes soiled with BM or other substance then he will switch to his other hand and if that hand becomes soiled then he will change his gloves and wash his hands, this was how he was taught 17 years ago when he received his CNA license. CNA A verified that he had been trained by this facility and has watched several training videos but stated, I often go back to my original training. CNA A reported that if handwashing and glove changes are not done correctly then resident could be at risk for the spread of yeast or infection. <BR/>During an interview on 03-23-2023 at 09:22 AM the DON reported that during incontinent care hand hygiene should be performed before the care is started, after care is completed, and after the dirty portion of the care/before starting the clean portion/placing the new brief. The DON reported that this same process should be used with handwashing during incontinent care. The DON reported that if either of these processes are not followed then the resident receiving care can be placed at risk for infection or cross-contamination. The DON reported that a staff members glove can become contaminated at any time when dealing with a resident during incontinent care especially when cleaning the resident or when removing the residents dirty brief. The DON reported that she is the person responsible for training all staff on incontinent care and handwashing and she completed all staff training last October 2022. <BR/>Record review of the facility provided policy titled Handwashing/Hand Hygiene undated revealed the following:<BR/>Policy Interpretation and Implementation:<BR/>1. <BR/>All personnel shall be trained and regularly in-serviced on the importance do hand hygiene in preventing the transmission of healthcare-associated infections. <BR/>2. <BR/>All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infection to other personnel, residents, and visitors. <BR/>7. Use of alcohol-based hand rub containing at least 62% alcohol, or, alternatively, soap and water for the following situations<BR/>b. Before and after direct contact with residents.<BR/>h. Before moving from a contaminated body site to a clean body site during resident care. <BR/>9. The use of gloves does not replace hand washing/hand hygiene, integration of glove use along with routine hand hygiene is recognized as the best practice for preventing healthcare-associated infections. <BR/>Record review of the facility provided training Peri Care Skills Checklist undated revealed the following:<BR/>-Wash hands<BR/>-Gather supplies<BR/>-Set supplies on a clean field or surface<BR/>-Wash hands, Put on gloves<BR/>-Remove soiled brief<BR/>-Using clean wipes, clean the genital area<BR/>-Dispose of soiled wipes, linen protectors, and gloves<BR/>-Wash hands and put on clean gloves<BR/>-Place a clean brief<BR/>-Remove gloves and wash hands<BR/>-Reposition the resident in bed for comfort<BR/>-Place call light<BR/>-Sanitize immediately after leaving the resident room.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure that residents who needed respiratory care, including tracheostomy care and tracheal suctioning, were provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents' goals, and preferences for one (Resident #147) of 13 residents assessed for respiratory care. <BR/>Resident #147 was wearing/receiving oxygen but did not have an order for oxygen.<BR/>This failure could place residents requiring oxygen at risk for receiving the wrong amount of oxygen, which could lead to shortness of breath, hypoxemia (below normal levels of oxygen in blood), or oxygen toxicity (condition resulting from the harmful effects of breathing molecular oxygen at increased partial pressures).<BR/>Findings include <BR/>Record review of Resident #147's face sheet, dated 03/21/23, revealed a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included, but were not limited to, chronic obstructive pulmonary disease (inflammation of lung tissue due to non-infectious causes, which results in cough without mucus or phlegm, shortness of breath and fatigue), chronic diastolic congestive heart failure (a condition in which the heart can no longer pump enough blood to the rest of the body), Alzheimer's disease, and a history of falling.<BR/>Record review of Resident #147's admission MDS, dated [DATE], revealed a BIMS score of 1 out of 15 which indicated his cognition was severely impaired. Section G revealed he required limited one-person assistance with bed mobility, transferring, dressing and toilet use, and personal hygiene and extensive one-person assistance with eating. Section O indicated that Resident #147 required oxygen therapy while not a resident and while a resident. <BR/>Record review of Resident #147's care plan, dated 03/14/23, revealed, in part, I have oxygen therapy r/t CHF, Ineffective gas exchange Date Initiated: 03/16/2023 . OXYGEN SETTINGS: Maintain my oxygen settings per physician orders. Check on liter flow when entering my room. Date Initiated: 03/16/2023<BR/>Record review of Resident #147's physician's orders dated 03/21/23 revealed no orders for oxygen administration. <BR/>Record review of Resident #147's physician's orders dated 03/22/23 revealed an order for oxygen administration dated 03/22/23 at 04:23 PM.<BR/>Record review of Resident #147's Weights and Vitals Summary dated 03/22/23 revealed the following oxygen saturation [The percentage of oxygen in the blood; normal oxygen saturation level for healthy adults is between 95% and 100%.] recordings while Resident #147 was receiving oxygen via nasal cannula: <BR/>03/09/23 at 10:36 PM 94% <BR/>03/10/23 at 02:42 PM 95%<BR/>03/10/23 at 10:17 PM 98%<BR/>03/13/23 at 01:56 PM 99%<BR/>03/13/23 at 09:26 PM 96%<BR/>03/14/23 at 08:33 AM 96%<BR/>03/14/23 at 11:10 PM 94%<BR/>03/15/23 at 10:10 AM 92%<BR/>03/15/23 at 10:44 PM 92%<BR/>03/16/23 at 11:00 AM 94%<BR/>03/16/23 at 11:35 PM 92%<BR/>03/17/23 at 02:31 PM 92%<BR/>03/18/23 at 03:32 PM 95%<BR/>03/18/23 at 10:23 PM 90%<BR/>03/19/23 at 03:32 PM 95%<BR/>03/19/23 at 10:32 PM 92%<BR/>03/20/23 at 11:54 PM 91%<BR/>03/21/23 at 02:45 PM 95%<BR/>03/22/23 at 10:40 PM 98%<BR/>During an observation and interview on 03/21/23 at 02:17 PM, Resident #147 was sitting in a recliner in his room receiving oxygen by nasal cannula at 3 liters per minute. Two of Resident #147's family members were in his room with him. They stated he had not been in the facility long and seemed to be doing well.<BR/>During an observation on 03/22/23 at 08:26 AM Resident #147 was lying in bed on his back asleep receiving oxygen by nasal cannula at 2.5 liters per minute.<BR/>During an observation on 03/22/23 at 09:03 AM Resident #147 was lying in bed on his back asleep, receiving oxygen by nasal cannula at 2.5 liters per minute.<BR/>During an observation on 03/22/23 at 09:54 AM Resident #147 was lying in bed on his back asleep, receiving oxygen by nasal cannula at 3 liters per minute.<BR/>During an observation and interview on 03/22/23 at 11:00 AM Resident #147 was lying in bed on his back asleep, receiving oxygen by nasal cannula at 3 liters per minute. Resident #147's family member was sitting in his room and stated he had been on oxygen for several years now, 24/7.<BR/>During an observation and interview on 03/23/23 at 08:58 AM Resident #147 was sitting in his recliner receiving oxygen by nasal cannula at 3 liters per minute. Resident #147's family member was sitting in his room with him and stated he was doing well.<BR/>During an interview on 03/23/23 at 09:17 AM LVN C stated she had worked for the facility for a year. She stated nurses and CNAs were responsible for checking oxygen saturation levels for residents and ensuring those receiving oxygen were receiving it at the correct liters per minute. She said the physician's orders determined what liters per minute a resident's oxygen was set to. She said if the order information was not available a resident could be negatively affected. She stated, They would be hypoxic [low blood oxygen], their O2 [oxygen] would drop and they would be lethargic, confused, pale, sweaty, anxious.<BR/>During an interview on 03/23/23 at 09:22 AM the DON stated nurses were responsible for setting oxygen levels for residents receiving oxygen. She stated the nurses knew what levels to set the oxygen to for residents because it is in their orders. When asked what could happen if the information was not in the orders she stated, They [nurses] could set it too high or not high enough. She stated the nurses were responsible for ensuring orders are in the chart when a resident is admitted to the facility. She stated she did not know why Resident #147 was receiving oxygen since his admission on [DATE] without physician's orders for oxygen until an order dated 03/22/23. She stated a possible negative outcome of administering oxygen to a resident without physician's orders was the resident could have Chronic Obstructive Pulmonary Disease (a chronic inflammatory lung disease that causes obstructed airflow from the lungs) and not be a candidate to receive O2 on the level they put it on.<BR/>Record review of an undated facility policy titled Admission revealed the following:<BR/> . 5. Prior to or at the time of admission, the resident's Attending Physician provides the facility with information needed for the immediate care of the resident, including orders covering at least: . b. Medication orders .<BR/>Record review of an undated facility policy titled Medication and Treatment Orders revealed the following:<BR/>1. Medications shall be administered only upon the written order of a person duly licensed and authorized to prescribe such medications .

Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 (CNA A) of 4 staff observed for resident care. <BR/>-CNA A failed to perform hand hygiene or glove changes during incontinent care. <BR/>This deficient practice has the potential to affect all residents in the facility by exposing them to care that could lead to the spread of viral infections, secondary infections, tissue breakdown, communicable diseases, and feelings of isolation related to poor hygiene. <BR/>Findings include: <BR/>During an observation on 03-22-2023 09:44 AM CNA A performed incontinent care for Resident #4, CNA A was noted to wash his hands upon entering the room, CNA A then placed gloves, adjusted the residents curtains, placed a transfer belt on the resident, transferred the resident to bed, pulled the resident pants down, checked the front of the resident brief with his gloved hand to determine if the resident was wet, rolled the resident to his side, opened the new brief and placed it at the foot of the bed, removed multiple wipes from the wipe package and placed them on the opened new brief. CNA A then started to remove the used brief the resident was wearing and rolled it under the resident. CNA A used several wipes from on top of the new brief to clean the resident's rectal area, CNA A then placed the new brief under the resident, rolled the resident to his other side, finished removing the used brief, then removed a wipe from the wipe package to clean the penis and groin area (area in the body where the upper thighs meet the lowest pare of the lowest part of the abdomen). CNA A finished placing the new brief, pulled up the resident's cover, placed the resident in a position of comfort, and used the bed controls to lower the bed. CNA A then removed his gloves and placed them in the trash. CNA A then placed the residents fall mat, removed the used supplies and walked down the hallway to the last room on the right where he placed the used supplies in a trash container, then washed his hands. CNA A did not wash his hands, use ABHR, or change his gloves while providing incontinent care. <BR/>During an observation on 03-22-2023 at 01:08 PM CNA A performed incontinent care for Resident #11, CNA A was noted to wash his hands upon entering the room,, placed gloves, lowered the residents bed with the electronic control, transferred the resident from her wheelchair with his hands under her armpits to the bed, placed his hands under her back and knees and laid her in the bed, rolled her to her side and lowered her pants, rolled her to her other side and lowered her pants to her knees, then rolled her to her back, placed her new brief next to her right shoulder, removed multiple wipes from the wipe container and placed them on top of the wipe container with several falling off on the bed sheets, CNA A then used several wipes to clean the residents vaginal area, rolled the resident to her left side, cleaned her rectal area, removed her used brief, placed her new brief, rolled her to her right side, finished placing the brief, rolled her to her back, pulled her new brief up and secured the brief, CNA A then pulled the residents pants back up, CNA A then removed and disposed of his gloves, CNA A pulled the residents cover back up, placed the residents call light next to the resident, adjusted the bed with the electric controls, removed the used supplies, exited the room, walked to the last room on the hallway on the right, disposed of the used supplies in a trash container, and washed his hands. CNA A did not wash his hands, use ABHR, or change his gloves while providing incontinent care.<BR/>During an interview on 03-22-2023 at 01:16 PM CNA A reported that if he notices that a hand becomes soiled with BM or other substance then he will switch to his other hand and if that hand becomes soiled then he will change his gloves and wash his hands, this was how he was taught 17 years ago when he received his CNA license. CNA A verified that he had been trained by this facility and has watched several training videos but stated, I often go back to my original training. CNA A reported that if handwashing and glove changes are not done correctly then resident could be at risk for the spread of yeast or infection. <BR/>During an interview on 03-23-2023 at 09:22 AM the DON reported that during incontinent care hand hygiene should be performed before the care is started, after care is completed, and after the dirty portion of the care/before starting the clean portion/placing the new brief. The DON reported that this same process should be used with handwashing during incontinent care. The DON reported that if either of these processes are not followed then the resident receiving care can be placed at risk for infection or cross-contamination. The DON reported that a staff members glove can become contaminated at any time when dealing with a resident during incontinent care especially when cleaning the resident or when removing the residents dirty brief. The DON reported that she is the person responsible for training all staff on incontinent care and handwashing and she completed all staff training last October 2022. <BR/>Record review of the facility provided policy titled Handwashing/Hand Hygiene undated revealed the following:<BR/>Policy Interpretation and Implementation:<BR/>1. <BR/>All personnel shall be trained and regularly in-serviced on the importance do hand hygiene in preventing the transmission of healthcare-associated infections. <BR/>2. <BR/>All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infection to other personnel, residents, and visitors. <BR/>7. Use of alcohol-based hand rub containing at least 62% alcohol, or, alternatively, soap and water for the following situations<BR/>b. Before and after direct contact with residents.<BR/>h. Before moving from a contaminated body site to a clean body site during resident care. <BR/>9. The use of gloves does not replace hand washing/hand hygiene, integration of glove use along with routine hand hygiene is recognized as the best practice for preventing healthcare-associated infections. <BR/>Record review of the facility provided training Peri Care Skills Checklist undated revealed the following:<BR/>-Wash hands<BR/>-Gather supplies<BR/>-Set supplies on a clean field or surface<BR/>-Wash hands, Put on gloves<BR/>-Remove soiled brief<BR/>-Using clean wipes, clean the genital area<BR/>-Dispose of soiled wipes, linen protectors, and gloves<BR/>-Wash hands and put on clean gloves<BR/>-Place a clean brief<BR/>-Remove gloves and wash hands<BR/>-Reposition the resident in bed for comfort<BR/>-Place call light<BR/>-Sanitize immediately after leaving the resident room.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, it was determined the facility failed to ensure drugs and biologicals were stored in locked compartments and labeled in accordance with currently accepted professional principles and include the appropriate accessory and cautionary instructions, and the expiration date when applicable for 2 of 2 (Halls Emerald and [NAME], and Halls Topaz and Sapphire) medication carts and 1 of 1 medication room, and 1 of 1 treatment cart reviewed for medication storage. <BR/>-1 insulin medications were found in Hall Emerald and [NAME] medication cart with no date of when medication vial was opened. <BR/>-Medication refrigerator in medication room was logged at 30 degrees 4 out of the last 28 days. <BR/>-LVN C left treatment cart unlocked and unattended. <BR/>The facility's failure to ensure drugs and biologicals were stored at appropriate temperatures, in locked compartments, and labeled in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable could place residents at risk. <BR/>Findings include:<BR/>Observation on [DATE] at 09:44 AM revealed medication room for facility and the medication refrigerator was out of temperature range 4 ([DATE]th, [DATE]th, [DATE]th, and [DATE]th) out of the last 28 days with a temp of 30 degrees. E-kit in fridge was full of insulins and narcotic box had Lorazepam oral concentrate for Resident #11, Resident #23, and Resident #16. <BR/>Observation of the treatment cart with LVN C [DATE] at 09:46 AM revealed Resident #20's Humalog insulin did not have an open date on the vial. <BR/>Observation on [DATE] at 11:07 AM revealed LVN C left treatment cart unattended while letting DON that insulin for Resident #20 did not have an open date on it. The treatment cart was left unattended until 11:11am. An agitated resident was in hallway next to treatment cart being redirected by other staff away from the unlocked cart. <BR/>Interview on [DATE] at 11:49 AM LVN C stated if she had administered the expired insulin to Resident #20 a negative outcome would be that the medication would not be effective for the resident. <BR/>Interview on [DATE] at 10:05 AM with DON stated the negative outcome of giving an expired insulin would be that the medication was not as effective. DON stated the negative outcome for leaving an unlocked medication cart unattended would be that another resident could get into it. DON stated the negative outcome for frozen medications would be the effectiveness of the medication could be compromised. <BR/>Record review of facility provided policy titled, Refrigerators and Freezers, undated, revealed the following:<BR/>Policy Interpretation and Implementation<BR/>1. <BR/>Acceptable temperature ranges are 35 degrees F to 40 degrees F for refrigerators and less then 0 degrees F for freezers.<BR/> .3. Monthly tracking sheets will include date, temperature, and initials. If temperatures are not within range, staff must notify supervisor immediately. <BR/>Record review of facility provided policy titled, Labeling of Medication Containers, undated, revealed the following:<BR/> .3. Labels for individual resident medications include all necessary information, such as: .<BR/> .h. The expiration date when applicable; .<BR/>Record review of facility provided policy titled, Administering Medications, undated, revealed the following: <BR/> .12. The expiration/beyond use date on the medication label is checked prior to administering. When opening a multi-dose container, the date opened is recorded on the container.<BR/>Record review of https://humalog.lilly.com, manufacture website for Humalog, website revised 08/2023 revealed the following: <BR/>After vials have been opened:<BR/>Store opened vials in the refrigerator or at room temperature up to 86&deg;F (30&deg;C) for up to 28 days.<BR/>Keep vials away from heat and out of direct light.<BR/>Throw away all opened vials after 28 days of use, even if there is insulin left in the vial.<BR/>Record review of Drug label information for Lorazepam concentrate on DailyMed - LORAZEPAM concentrate (nih.gov), updated [DATE] revealed the following: <BR/>Store at Cold Temperature-Refrigerate 2&deg;-8&deg;C (36&deg;-46&deg;F)<BR/>Dispense only in the bottle and only with the calibrated dropper provided.<BR/>Discard opened bottle after 90 days.<BR/>Record review of facility provided policy titled, Security of Medication Cart, undated revealed the following: <BR/>1. The nurse must secure the medication cart during the medication pass to prevent unauthorized entry.<BR/> .4. Medication carts must be securely locked at all times when out of the nurse's view. <BR/>5. When the medication cart is not being used, it must be locked and parked at the nurses' station or inside of the medication room.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to implement a comprehensive care plan for each resident that includes measurable objectives and timeframes to meet a resident's medical, nursing, mental, and psychosocial needs that are identified in the comprehensive assessment and describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 1 (Resident #27) of 13 Residents reviewed for comprehensive care plans.<BR/>-The facility failed to include care plans for Resident #27's catheter.<BR/>This failure could affect all residents in the facility receiving care per comprehensive person-centered care plans resulting in resident not being able to attain or maintain their highest practicable physical, mental, and psychosocial well-being. <BR/>Finding include:<BR/>Record review of Resident #27's face sheet printed 3-21-2023 revealed he was a [AGE] year-old male resident admitted to the facility originally on 1-31-2022 and readmitted on [DATE] with diagnoses to include dementia (a group of thinking and social symptoms that interferes with daily functioning), chronic kidney disease (longstanding disease of the kidneys that leads to kidney failure), obstructive and reflux uropathy (when your urine cant flow (either partially or completely) through the ureters, bladder, or urethra due to some type of obstruction), and benign prostate hyperplasia (age associated prostate gland enlargement that can cause urination difficulty.<BR/>Record review of Resident #27's clinical record revealed his last MDS assessment was a quarterly completed on 3-8-2023 listing him with a BIMS of 5 indicating he was severely cognitively impaired, he had a functionality of requiring one-person physical assistance with all his activities, and Section H-Bowel and Bladder he was listed as having a indwelling catheter (a catheter which is inserted into the bladder, via the urethra and remains in-situ to drain urine).<BR/>Record review of Resident #27's Order Summary Report with active orders as of 3-22-2023 listed the following orders:<BR/>-Change foley catheter one time a day starting on the 20th and ending on the 20th every month related to BENIGN PROSTATIC HYPERPLASIA WITHOUT LOWER URINARY TRACT SYMPTOMS (N40.0) (a condition in men in which the prostate gland is enlarged and not cancerous)-order dated 1-20-2023, start date 2-20-2023<BR/>-Foley Catheter care two times a day-order dated 1-20-2023, start date 1-20-2023<BR/>Record review of Resident #27's care plan with admission date 2-27-2023 revealed no care plans for catheter care. <BR/>During an interview on 03-22-2023 at 10:42 AM MA B reported that Resident #27 had a catheter and used a leg bag. MA B stated that Resident #27 used to have the large catheter bag but due to Resident #27's dementia he would not leave it alone and that with a leg bag Resident #27 does not see it under his clothing and therefore will not mess with it.<BR/>During an interview on 03-23-2023 at 08:45 AM the MDS Coordinator reviewed Resident #27's clinical record and reported that Resident #27 did not have a care plan for his urinary catheter, that Resident #27 had a history of having a urinary catheter then having the urinary catheter dc'd due to difficulty with his urinary retention (difficulty urinating or completely emptying the bladder) and that Resident #27 has had this catheter since the first of January 2023 which was addressed on his last MDS. The MDS Coordinator reported that the catheter should have been addressed in his care plan. The MDS Coordinator verified that it is her job to complete the comprehensive care plans. The MDS Coordinator reported that she started the MDS position the first of March 2023 (after the last MDS Coordinator resigned) and is currently reviewing all care plans for accuracy. The MDS Coordinator reported that she will update Resident #27's care plan to include his catheter. The MDS Coordinator reported that if a care plan does not have the resident's current information and needs, that a resident could possibly not receive the care they need but Resident #27 has orders for his catheter and has documentation that addresses the use of his catheter in the nursing notes, so she feels Resident #27 has received his needed care. <BR/>During an interview on 03-23-2023 at 09:11 AM the DON reported that a catheter needs to be addressed in the care plan because that is how the CNA's and other staff know how to perform their care on a resident. The DON reported that if a resident's needs are not addressed in their care plans, then they may receive incorrect care or not receive the care they need. <BR/>Record review of facility provided policy titled Care Plans, Comprehensive Person-Centered, undated, revealed the following:<BR/>Policy Interpretation and Implementation-<BR/>8. The comprehensive, person-centered care plan will<BR/>-b. Describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being.<BR/>-g. Incorporate identified problem area<BR/>9. Areas of concern that are identified during the resident assessment will be evaluated before interventions are added to the care plan.

Based on interviews and record review, the facility failed to implement written policies and procedures that prohibit and prevent abuse, neglect, and exploitation of residents for 1 (CNA I) of 12 staff reviewed for abuse policies.<BR/>The facility did not implement the training /orientation of CNA I related to abuse, neglect, and exploitation per facility policy.<BR/>This failure could place residents in the facility at risk of Abuse, Neglect, or Exploitation.<BR/>Findings included:<BR/>Record Review of CNA I's employee file revealed she was hired on 03/01/24 and her Abuse, Neglect, or Exploitation Training took place on 03/28/24.<BR/>During an interview on 05/30/24 at 3:11 PM, ADM stated he hired this CNA after she had worked for the facility as agency staff. ADM stated he needed CNAs so badly that he allowed her to work and do trainings after she was hired. <BR/>During an interview on 05/30/24 at 3:37 PM, ADM stated that a possible negative outcome for not having staff trained about Abuse and Neglect would be that they would not be prepared for issues that could arise. He stated he made a judgment call to hire this CNA without proper training, and it was his mistake.<BR/>Record review of the facility provided New Hire Instructions page included the following:<BR/> .New Hire MUST complete the following BEFORE floor work:<BR/>- <BR/>[Brand name of electronic program] Training<BR/>And after all training is complete - then they are added to the schedule for orientation.<BR/>Record Review of the facility provided policy titled Abuse, Neglect and Exploitation Prevention Program not dated, revealed the following:<BR/>4. Require staff training/orientation programs that include such topics as abuse prevention, identification, and reporting of abuse, stress management, and handling verbally or physically aggressive resident behavior.

Based on interview and record review the facility failed to provide training to their staff that at a minimum educates staff on activities that constitute abuse, neglect, exploitation, and misappropriation of resident property and procedures for reporting incidents of abuse, neglect, exploitation, or the misappropriation of resident property and dementia management for 2 (CNA I and CNA J) of 12 employees reviewed for staff training.<BR/>The facility failed to train CNA I on what constitutes abuse, neglect, exploitation, misappropriation of resident property and how to report the above. The facility failed to train CNA I on dementia management.<BR/>The faciltiy failed to train CNA J on dementia management.<BR/>These failures could place residents at risk of injury or harm due to being cared for by untrained staff.<BR/>Findings included:<BR/>Record review of CNA I's employee file revealed a hire date of 03/01/24. The file did not contain any record of training on abuse, neglect, exploitation, misappropriation of resident property or dementia.<BR/>Record review of CNA J's employee file revealed a hire date of 08/07/23. The file did not contain any record of dementia training<BR/>During an interview on 05/30/24 at 3:11 PM, ADM stated a couple of the CNAs were agency staff before they came over to officially work for the facility and he needed CNA's so badly, that he let them work and do trainings after hire. <BR/>During an interview on 05/30/24 at 3:37 PM, ADM stated a possible negative outcome for not having staff trained about HIV would be that they would not be prepared for issues that arise and that it was a judgment call that he made to hire those 2 employees without proper training, and it was his mistake.<BR/>Record review of facility provided New Hire Instructions page revealed the following:<BR/> .New Hire MUST complete the following BEFORE floor work:<BR/>- <BR/>[Name of Electronic Program] Training<BR/>And after all training is complete - then they are added to the schedule for orientation.<BR/>Record Review of the facility provided policy titled Abuse, Neglect and Exploitation Prevention Program not dated, revealed the following:<BR/>Policy Statement: Our residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual, or physical abuse, and physical or chemical restraint not required to treat the resident's symptoms.<BR/>4. Require staff training/orientation programs that include such topics as abuse prevention, identification, and reporting of abuse, stress management, and handling verbally or physically aggressive resident behavior.