Every finding on record at Hatton Prairie Village

Based on record review, review of the Centers for Disease Control and Prevention (CDC) guidelines and recommendations, and staff interview the facility failed to ensure residents were offered the pneumococcal immunization for 1 of 5 sampled residents (Resident #5) reviewed for immunizations. Failure to administer the pneumococcal vaccine to all eligible residents and document the administration has the potential for non-immunized residents to contract pneumonia and spread the infection to other residents, visitors, and staff.Findings include:Review of the CDC: Vaccines and Preventable Diseases webpage (https://www.cdc.gov/vaccines/vpd/pneumo/hcp/recommendations.html), dated October 26, 2024, stated, . CDC recommends pneumococcal vaccination . age [AGE] years or older who have . Not previously received a dose of PCV13, PCV15, PCV20, or PCV21 or whose previous vaccination history is unknown .Review of Resident #5's medical record occurred on all days of survey. A form titled, 2023-2024 Vaccination Season, signed on 09/28/23 by resident, resident representative and facility representative, indicated consent to receive the pneumonia vaccine [pneumococcal vaccine]. The immunization records lacked documentation the resident received the pneumococcal vaccine.During an interview on 09/24/25 at 2:20 p.m., an administrative nurse (#2) verified the facility failed to provide Resident #5's pneumococcal immunization.

Based on observation, review of facility policy, and staff interview the facility failed to follow standards of infection control for 1 of 2 sampled residents (Resident #12) observed during a dressing change. Failure to follow infection control practices during wound care has the potential to spread infection throughout the facility.Findings include: Review of the facility policy titled Dressing Change (Clean) occurred on 09/24/25. This policy, dated June 2024, stated, . Perform hand hygiene . Create clean field with paper towels or towelette dressing . Open dressing pack. Put on first pair of disposable gloves. Remove soiled dressing and discard . Dispose of gloves . Put on second pair of disposable gloves . Cleanse wound . Apply dressings . Review of Resident #12's medical record occurred on all days of survey. The current care plan stated, . Resident has a pressure ulcer present upon admission . Monitor pressure ulcer daily, change dressing daily. A current physician's order stated, Change Mepilex [an absorbent foam dressing] to coccyx [tailbone] daily and PRN [as needed] Observation on 09/23/2025 at 8:30 a.m. showed a nurse (#3) performed Resident #12's dressing change. The nurse applied a gown and gloves and entered the resident's room. With gloved hands, the nurse opened and closed the resident's door to speak to someone in the hall. After the certified nurse aides (CNAs) positioned the resident on his side, the nurse (#3) placed a clean Mepilex dressing and an open saline wipe packet with the tip of the wipe exposed onto the resident's bed. The nurse removed the old Mepilex dressing, discarded it and without changing gloves, measured the wound, cleansed the wound with the saline wipe, and applied a new Mepilex dressing. The nurse (#3) removed the gloves and without performing hand hygiene, applied new gloves, used a pen from the resident's nightstand to write down the wound measurements, touched the resident's phone, and applied a medicated powder to the resident's groin. The nurse removed the gown and gloves and performed hand hygiene before exiting the resident's room. The nurse (#3) failed to establish a clean field on which to set dressing supplies, maintain glove cleanliness by touching the doorknob and other items, apply clean gloves before applying the new dressing, and perform hand hygiene between glove changes. During an interview on 09/24/25 at 4:45 p.m. an administrative staff member (#2) stated she expected staff to establish a clean field for a dressing change, change gloves from dirty to clean, and perform hand hygiene between glove changes.

Based on record review, review of facility policy, review of professional reference, and staff interview, the facility failed to follow professional standards of practice for 1 of 5 sampled residents (Resident #6) reviewed for unnecessary medications. Failure to correctly transcribe physician orders placed residents at risk for medication errors and adverse health events. Findings include:Kozier & Erb's Fundamentals of Nursing, Concepts, Process and Practice, 11th Edition eText, 2021, Pearson, Boston, Massachusetts, page 63, stated, Nurses are expected to analyze procedures and medications ordered by the physician or primary care provider. It is the nurse's responsibility to seek clarification of ambiguous or seemingly erroneous orders from the prescriber. Clarification from any other source is unacceptable and regarded as a departure from competent nursing practice.Review of the facility policy titled Physician Signature occurred on 09/24/25. This policy, dated June 2024, stated, . To establish a consistent process for obtaining physician signatures on all required clinical and administrative documents .Review of Resident #6's medical record occurred on all days of survey. Diagnoses included atrial fibrillation (irregular, rapid heartbeat). A faxed order from the anticoagulation clinic dated 09/23/25 at 3:13 p.m. stated .Warfarin [an anticoagulant] 7.5 milligrams (mg) every Monday and Friday., 5 mg. all other days .An order entry in the resident's electronic medical record (EHR), dated 09/24/25, showed Warfarin 7.5 mg Monday and Tuesday and Warfarin 5 mg the other five days. During an interview on 09/24/25 at 2:30 p.m., an administrative staff member (#2) stated a nurse (#4) incorrectly transcribed the order from the anticoagulation clinic onto a physician's order sheet as 7.5 mg. on Monday and Tuesday instead of Monday and Friday. The administrative staff member (#2) confirmed the nurse (#5) failed to verify the order before changing it in the EHR.

Based on record review and staff interview, the facility failed to ensure the residents' right to request, refuse, and/or discontinue treatment for 1 of 13 sampled residents (Resident #29) reviewed for advance directives. Failure to ensure the medical record accurately reflected each resident's code status limited the facility's ability to communicate to direct care staff and emergency personnel the residents' choice in the event of a medical emergency.Findings include:Review of Residents #29's medical record occurred all days of survey. The quarterly Minimum Data Set (MDS), dated [DATE], identified intact cognition.A physician's order signed on 05/21/25 stated code level I (All available reasonable technology will be used in the event of cardiac or respiratory arrest). The resident's demographic face sheet and code status form, signed by the resident and facility representative on 08/27/25 showed Code Status: DNR [do not resuscitate]/DNI [do not intubate]. The medical record lacked the current code status for Resident #29.During an interview on 09/24/25 at 11:40 a.m., an administrative staff member (#2) confirmed staff failed to obtain an updated physician's order to reflect Resident #29's code status.

Based on observation, review of professional reference, and staff interview, the facility failed to ensure food is stored in accordance with professional standards and in a sanitary environment in 1 of 1 kitchen (main kitchen). Failure to ensure food is safe from sources of contamination may result in a foodborne illness or adverse effects for residents, visitors, and staff. Findings include: The 2022 Food and Drug Administration (FDA) Food Code, Annex 3-100 stated, . Preventing contamination from the premises . 3-305.11 Food Storage. Pathogens can contaminate and/or grow in food that is not stored properly. Drips of condensate . can be sources of microbial contamination for stored food. Chapter 6-3 Physical Facilities . 6-202.12 Heating, Ventilating, Air Conditioning System Vents. Heating, ventilating, and air conditioning systems shall be designed and installed so that . air intake and exhaust vents do not cause contamination of FOOD, FOOD-CONTACT SURFACES, EQUIPMENT, or UTENSILS. Observation of the kitchen on 09/03/24 at 11:45 a.m. showed the following: - Walk-in Freezer: Two fans with icicles dripping onto an open pail of steak strips. - Kitchen preparation and serving area: Water from an air conditioning unit running down the wall adjacent to the countertop. Dietary staff had taped aluminum foil to the wall to guide water into a plastic collection receptacle. Water splashed outside the receptacle and onto the countertop. During an interview on 09/05/24 at 10:30 a.m., a maintenance staff member (#3) stated unawareness of the issue with the kitchen air conditioner.

Based on record review, review of facility policy, and staff interview, the facility failed to review and revise care plans to reflect residents' current status for 5 of 13 sampled residents (Resident #4, #13, #15, #30 and #32) and 1 supplemental resident (Resident #35). Failure to update care plans limited staffs' ability to communicate needs and ensure continuity of care. Findings include: Review of the facility policy titled Care Plans and Care Plan Team occurred on 09/05/24. This policy, dated 10/28/22, stated, . The Care Plan Team will develop and implement a comprehensive care plan for each resident. The care plan includes the following: Resident's doctor's plan of medical care to attain or maintain the resident's highest practicable physical, mental and psychosocial well-being . Care plans will be individualized to meet the needs of a resident . Each resident will have care plan meetings when moving into the facility, quarterly, annually and if the resident has a significant change in health. The care plan team will review and revise a resident's care plan at each of these times. - Review of Resident #4's medical record occurred on all days of survey. The progress notes identified Resident #4 returned from a hospitalization on [DATE] with a new diagnosis of STEMI (ST-elevation myocardial infarction, a type of severe heart attack). The hospital return medication orders included an antiplatelet (prevents blood clots), diuretics (increases fluid and salt loss from the body), and blood pressure medications. Resident #4's care plan lacked a problem, goal, and interventions related to a change in condition regarding a new diagnosis of STEMI and medication changes post hospitalization . - Review of Resident #13's medical record occurred on all days of survey and included physician's orders for insulin (lowers blood glucose levels) and a blood thinner. Resident #13's care plan lacked a problem, goal, or interventions related to the resident taking insulin and a blood thinner. - Review of Resident #15's medical record occurred on all days of survey. A physician's order, dated 08/19/24, identified the resident wears a wanderguard. A progress note, dated 08/20/24 at 12:12 a.m., indicated the resident attempted to exit the building and entered several rooms within the facility. Resident #15's care plan lacked a problem, goal, and interventions related to wandering/exit seeking behaviors. - Review of Resident #30's medical record occurred on all days of survey and identified the resident admitted to the facility in March 2024 on hospice services with a diagnosis of liver cancer. Resident #30's care plan lacked a problem, goal, or interventions related to hospice and the diagnosis of liver cancer. During an interview on 09/04/24 at 3:15 p.m., an administrative nurse (#1) agreed Resident #30's care plan lacked a specific hospice problem. - Review of Resident #32's medical record occurred on all days of survey. A physician's order, dated 05/11/23, identified the resident receives an antibiotic for ongoing therapy for an eye condition. Resident #32's care plan lacked a problem, goal, and interventions related to long term use of an antibiotic. - Review of Resident #35's medical record occurred on September 3-4, 2024. The progress notes identified Resident #35 elected hospice services and the hospice admission occurred on 07/03/24. Resident #35's care plan lacked a problem, goal, and interventions related to hospice services. During an interview on 09/04/24 at 3:50 p.m., an administrative nurse (#1) stated she expected staff to update the resident care plans following a change in condition. 40488 40489

Based on record review, review of facility policy, and staff interview, the facility failed to provide the resident or the resident's representative a written notice of transfer or a copy of the notice to the State Long Term Care Ombudsman for 1of 1 resident (Resident #4) reviewed for hospital transfer. Failure to provide a written copy of the transfer notice does not allow the resident and/or their representative to make an informed decision regarding their rights and does not allow the ombudsman to be aware of facility practices regarding transfer and discharge or advocate on the resident's behalf. Findings include: Review of the facility policy Transfer and Discharge of Resident occurred on 09/05/24. This policy, dated October 2022, stated, . Notify the resident and resident's representative in writing of the transfer . Give original notice to resident and resident's personal representative by first class mail or personal delivery; . send copies of transfer and discharge notices to the Office of the State Long Term Care Ombudsman . Review of Resident #4's medical record occurred on all days of survey. A hospital transfer occurred on 06/17/24. The medical record lacked evidence the facility provided the resident and/or representative with a written transfer notice or a copy of the transfer to the ombudsman. During an interview on 09/05/24 at 9:20 a.m., an administrative staff member (#1) confirmed the facility failed to provide a written notice of transfer to the resident or their representative, and send the notice to the ombudsman.

Based on record review, review of facility policy, and staff interview, the facility failed to provide the resident or resident's representative a written bed hold notice for 1 of 1 resident (Resident #4) reviewed for hospital transfer. Failure to provide a written copy of the bed hold notice and include the reserve bed amount does not allow the resident and/or their representative to make an informed decision regarding their rights. Findings include: Review of the facility policy Holding A Resident's Bed During Absences occurred on 09/05/24. This policy, dated November 2016, stated, . will inform a resident, legal representative and interested family members of our policy on holding a resident's bed during a resident's absence from our facility. prior to any hospitalization or therapeutic leave, including the amount of the bed-hold charge. Review of Resident #4's medical record occurred on all days of survey. A hospital transfer occurred on 06/17/24. The medical record lacked evidence the facility provided the resident and/or their representative with a written bed hold notice or the reserve bed hold amount. During an interview on 09/05/24 at 9:20 a.m., an administrative staff member (#1) confirmed the facility failed to provide a written bed hold notice or the reserve bed hold amount to the resident and/or their representative.

Based on record review, review of the Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual (Version 1.18.11), and staff interview, the facility failed to ensure accurate coding of the Minimum Data Set (MDS) for 3 of 13 sampled residents (Resident #4, #12, and #32). Failure to accurately complete the MDS does not allow each resident's assessment to reflect their current status/needs and may affect the accurate development of a comprehensive care plan and the care provided to the residents. Findings include: SECTION I: ACTIVE DIAGNOSES The Long-Term Care Facility RAI User's Manual, revised October 2023, pages I-7 to I-8, stated, . Code diseases that have a documented diagnosis in the last 60 days and have a direct relationship to the resident's current functional status, cognitive status, mood or behavior status, medical treatments, nursing monitoring, or risk of death during the 7-day look-back period. Review of Resident #12's medical record occurred on all days of survey. The care plan identified a problem, goals, and interventions related to Post-Traumatic Stress Disorder (PTSD). Review of psychiatry notes, dated 06/11/24 and 08/13/24, identified PTSD as a current diagnosis. Resident #12's annual MDS, dated [DATE], lacked identification of the PTSD diagnosis. SECTION N: MEDICATIONS The Long-Term Care Facility RAI User's Manual, revised October 2023, pages N-6 to N-7, stated, . Code all high-risk drug class medications according to their pharmacological classification . N0415: High-Risk Drug Classes . Coding Instructions . N0415F1. Antibiotic: Check if an antibiotic medication was taken by the resident at any time during the 7-day look-back period. N0415I1. Antiplatelet: Check if an antiplatelet medication (e.g., [example] . clopidogrel) was taken by the resident at any time during the 7-day observation period. - Review of Resident #4's medical record occurred on all days of survey. Physician's orders, dated 06/20/24, included clopidogrel 75 milligrams daily. The significant change in status assessment (SCSA) MDS, dated [DATE], lacked coding of the antiplatelet. During an interview on 09/05/24 at 8:30 a.m., an administrative nurse (#7) confirmed staff failed to code the MDS correctly for Resident #4. - Review of Resident #32's medical record occurred on all days of survey. The record identified the resident received doxycycline (an antibiotic) since 05/11/23. The quarterly MDS, dated [DATE], lacked coding of the antibiotic. During an interview on 09/04/24 at 5:43 p.m., an administrative nurse (#1) confirmed Resident #32 had been taking doxycycline since 05/11/23 and staff failed to code it on the resident's MDS. 40488

Based on observation, record review, facility policy review, and staff interview, the facility failed to follow standards of infection control for 2 of 5 sampled residents (Resident #4, and #12) and 1 supplemental resident (Resident #35) observed during cares. Failure to follow infection control practices during resident cares related to hand hygiene, glove use, and enhanced barrier precautions (EBP), has the potential to spread infection throughout the facility. Findings include: Review of the facility policy titled Glove Use occurred on 09/05/24. This policy, dated June 2024, stated, . Gloves shall be used for touching excretions, secretions, blood, body fluids, mucous membranes, and non-intact skin. Handwashing is necessary even if gloves are worn. Handwashing should be completed after every removal of gloves. Review of the facility policy titled Enhanced Barrier Precautions (EBP) occurred on 09/05/24. This policy, dated April 2024, stated, . staff will use EBP (gowns and gloves) for residents with any of the following: . Indwelling medical devices, . Indwelling medical device examples include: . urinary catheters, . Employees will use EBP (gowns and gloves) when performing the following high-contact resident care activities: . Transferring . HAND HYGIENE/GLOVE USE: - Observation on 09/03/24 at 4:09 p.m. showed a certified nurse aide (CNA) (#4) donned gloves, removed Resident #35's soiled brief, assisted the resident onto the toilet, removed her gloves and failed to perform hand hygiene. - Observation on 09/04/24 at 1:34 p.m. showed a CNA (#5) completed perineal cares for Resident #4 after an incontinent bowel movement. During the cares, the CNA failed to perform hand hygiene between glove changes. After the cares, the CNA (#5) removed the soiled gloves and without performing hand hygiene applied a clean brief and adjusted the resident's clothing. ENHANCED BARRIER PRECAUTIONS: Review of Resident #12's medical record occurred on all days of survey. The physician's orders included an indwelling urinary catheter. A supply cart located outside the resident's room contained a sign indicating EBP. Observation on 09/03/24 at 5:30 p.m. showed a CNA (#6) entered Resident #12's room with a stand lift. The CNA failed to donn a gown and gloves before utilizing a mechanical stand lift to assist Resident #12 from the wheelchair into the recliner chair, removing the sling from behind the resident, and placing the resident's personal items and call light within reach. During an interview on 09/05/24 at 10:50 a.m., an administrative nurse (#1) confirmed she expected staff to follow the policy and procedures for hand hygiene, glove use, and EBP.

Based on record review, review of facility policy, and staff interview, the facility failed to ensure residents received adequate supervision and/or monitoring for 1 of 1 sampled resident (Resident #28) with an elopement. Failure to identify the resident's risk for elopement and implement, monitor, and modify individualized resident-centered interventions when necessary placed the resident's health and safety at risk when they eloped from the facility. Findings include: Review of the facility policy titled MISSING RESIDENT occurred on 09/05/24. This policy, dated November 2018, stated, . [NAME] Prairie Village assesses residents prior to and upon admission for elopement risk, including all cognitively impaired residents. It also reassesses residents periodically to see if elopement risk is now present, has decreased or increased. Review of Resident #28's medical record occurred on all days of survey and included the diagnoses of dementia and restlessness and agitation. The care plan, dated 07/24/24, stated, . Resident exhibits wandering and a risk for elopement R/T [related to] was outside facility . The medical record showed the facility admitted Resident #28 and her husband in 2022. Resident #28's husband moved to a different facility in October of 2023 and Resident #28 moved to a different room. Resident #28's progress notes included the following: * 10/01/23 at 5:56 p.m. she is confused and wanders throughout the facility up and down the halls . Resident and her spouse tried to go outside for a walk . * 10/21/23 at 7:29 a.m. Resident . stating 'I want to get out of here!' . * 10/21/23 at 10:32 a.m. resident . insisting that she is 'leaving, going somewhere else'. She paced around the facility . * 11/24/23 at 11:31 a.m. Just now again she [Resident #28] brought a folder with photos in it to the nurse's station wondering what to do with them because 'we're leaving tonight' . * 12/12/23 at 4:53 p.m. [Resident #28's name] was putting her belongings out in the hallway. * 07/20/24 at 3:12 p.m. Writer saw [Resident #28's name] through the window walking around the east side of the building, staff was immediately sent to catch up with [Resident #28's name]. She came back inside with staff willingly without issue. [Resident #28's name] was unharmed. Wander guard on [Resident #28's name] wrist to prevent future elopement. During an interview on 09/05/24 at 10:55 a.m., an administrative nurse (#1) verified the facility lacked documentation of an assessment of Resident #28's elopement risk on admission and prior to or after her elopement on 07/20/24. The facility failed to evaluate Resident #28's elopement risk on admission and even though the resident expressed her wishes to leave the facility on several occasions, the facility failed to recognize those behaviors as possible signs of elopement and implement individualized interventions to prevent an elopement.

Based on record review, review of the Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual (Version 1.18.11), and staff interview, the facility failed to complete a significant change is status assessment (SCSA) for 1 of 1 supplemental resident (Resident #35) who elected hospice services. Failure to complete a SCSA may affect the development of a comprehensive care plan and the care provided to the resident. Findings include: The Long-Term Care Facility RAI User's Manual, revised October 2023, page 2-25 stated, . An SCSA is required to be performed when a terminally ill resident enrolls in a hospice program . The ARD [assessment reference date] must be within 14 days from the effective date of the hospice election. Review of Resident #35's medical record occurred on September 3-4, 2024. A progress note, dated 07/03/24, identified the resident elected hospice services. The facility failed to complete a SCSA when Resident #35 elected hospice services. During an interview on 09/05/24 at 8:30 a.m., an administrative nurse (#7) confirmed the facility failed to complete a SCSA following Resident #35's election to hospice services.

Based on record review, review of facility policy, review of professional reference, and staff interview, the facility failed to provide care in accordance with professional standards for 1 of 13 sampled residents (Resident #13) who experienced an unwitnessed fall. Failure to perform neurological assessments and follow up on a blood pressure identified as out-of-range following a fall may result in delayed identification and treatment of a resident's medical condition. Findings include: Review of the facility policy titled NEUROLOGICAL ASSESSMENT occurred on 10/05/23. This undated policy stated, . All residents experiencing an unwitnessed fall will have a neurological assessment completed by a nurse. The neurological assessment will be done every 12 hours x [for] 3 days . Kozier & Erb's Fundamentals of Nursing, Concepts, Process and Practice, 11th Edition eText, 2021, Pearson, Boston, Massachusetts, pages 535-536, stated, . blood pressure . is an important indicator of the client's condition and is used extensively as a basis for nursing interventions. confirm accuracy of the reading-especially if it falls outside the normal range . Review of Resident #13's medical record occurred on all days of survey. The record identified unwitnessed falls on 07/01/23 and 09/09/23 with only one documented neurological assessment for each fall. The record also identified one documented blood pressure reading of 171/78 for the 09/09/23 fall. This reading flagged as out-of-range. The record lacked evidence of follow-up blood pressure monitoring. During an interview on 10/04/23 at 9:32 a.m., an administrative nurse (#1) confirmed staff failed to continue with neurological assessments for Resident #13's unwitnessed falls and failed follow-up on the blood pressure reading recorded on 09/09/23.

Based on review of the facility reported incident investigation report, review of the facility employee handbook and policies, review of personnel records, review of the contract staffing agency policies, and staff interviews, the facility failed to complete new employee orientation for 1 of 1 contracted staff (Staff #1). Failure to appropriately train all staff, including facility staff, contracted staff, and volunteers has the potential to adversely affect resident safety, care and may increase the risk of adverse events. Findings include: Review of the facility Employee Handbook occurred on 05/15/23. Page 9 of this handbook, revised April 2023, stated . Orientation. Within seven (7) days of employment you will receive training in the following areas . Safe operating procedures . You will also receive a copy of HPV's [[NAME] Prairie Village] Employee Handbook which describes the expectations of employment at HPV, its policies and benefits available to you. Page 57 of the employee handbook included policy 6.30 titled Code of Conduct and Disciplinary Action This policy states . [NAME] Prairie Village may terminate an employee immediately . for certain actions, as follow .Carrying weapons of any kind in HPV's buildings or on its property . Review of facility policy number 8.64 titled Workplace Violence Policy states . Weapons in the Workplace. [NAME] Prairie Village prohibits employees or any person in its buildings .from possessing weapons of any kind. Prohibited weapons include, but are not limited to, hand guns . Review of the New Employee Onboarding Process effective April 26, 2022, showed on Page 2 that an employee is to Review policies/sign forms including Abuse and Neglect and Alcohol and Drug Use. This form is to be initialed by the orientator when complete. Review of contract staff #1's staffing agency's policies and procedures occurred on 05/15/23. This document, signed by contract staff #1 on 02/21/23 acknowledged I have received a copy of the following Policies and Procedures and any applicable supplement for [staffing agency] . Employee Handbook . Page 15 of the [staffing agency] employee handbook states, being under the influence of . alcohol . while on client premises . is strictly prohibited. Page 16 states . [staffing agency] prohibits the possession of weapons . additionally, while on duty, employees may not carry a weapon of any type. The facility's investigation report included the following documentation: On Sunday afternoon, May 7, (Staff #1) . approached (Individual A) . (Staff #1) was staying in HPV's motel room . The motel room is located at the very end of our south hallway. (Individual A) noticed a large hole in the door to the motel room. (Individual A) asked (Staff #1) what happened to the door. (Staff #1) told (Individual A) her gun had gone off accidentally and could he repair the door. (Individual A) asked (Staff #1) why she had a gun in the room and she said she normally keeps it in her car but brought the gun in with her after drinking/partying in a local bar . (Staff #1) main concern wasn't that her gun had discharged in a nursing home, but how to cover up/hide the damage. (Individual A) immediately called (Staff #2). [NAME] County Sheriff's Department was called immediately after this notification. Two deputies arrived timely at HPV and interviewed (Staff #1). HPV prohibits guns/firearm in our facility and on our grounds. We had no knowledge that (Staff #1) had a gun with her. We did do an orientation with (Staff #1) when she arrived for work at HPV which included our alcohol/drug policy. We did not review our gun/firearms prohibition policy with (Staff #1). It has not been a part of our orientation with agency employees. Review of contract staff #1's personnel file showed no documentation of orientation/onboarding/training provided or signed within seven days of employment. During interviews on 05/15/23 at 9:30 a.m. and 11:10 a.m. respectively, an administrative staff member (#2) confirmed the supervising manager did not complete orientation with contracted staff #1. When asked if it is each department supervisors' responsibility to orientate staff to their departments she stated, Yes. Administrative staff (#2) confirmed the facility does not have a contracted employee onboarding policy or checklist. The facility currently utilized their own employee onboarding checklist. During an interview on 05/15/23 at 12:10 p.m., an administrative staff member (#2) confirmed employee orientation should be done with all new staff including contract staff.

Based on observation, review of facility policy, and manufacturer's guidelines, the facility failed to follow professional standards of practice for 2 of 7 residents (Resident #7 and #26) observed during medication pass. Failure to properly store medications and refer to the Medication Administration Record [REDACTED]. Findings include: Review of the facility policy titled Medication Administration occurred on 06/06/19. This undated policy stated, . Identify and compare medication supply with Medication Administration Record [REDACTED]. Review of the facility policy titled Injection (Subcutaneous) occurred on 06/06/19. This undated policy stated, . Please follow these recommendations when administering insulin: [MEDICATION NAME] 5 -10 minutes before a meal. Patient package insert information for Humalog KwikPen insulin, found at www.humalog.com., stated, . Humalog starts acting fast, so inject it up to 15 minutes before or right after you eat a meal . Humalog may cause serious side effects, including low blood sugar ([DIAGNOSES REDACTED]) . - Observation of medication pass occurred on 06/04/19 at 3:57 p.m. A licensed nurse (#1) retrieved Resident #7's eye drops from her uniform pocket, located the Resident in his room and administered the eye drops. The nurse stored Resident #7 and another resident's eye drops in her uniform pocket and failed to check Resident #7's MAR before administering the eye drops. - Observation on 06/04/19 at 4:58 p.m., showed a licensed nurse (#1) administered six units of Humalog insulin to Resident #26. Observation showed Resident #26 received his meal tray at 5:18 p.m., 24 minutes after receiving a fast-acting insulin.

Based on observation, review of manufacturer's instructions, and staff interview, the facility failed to prepare and serve food in a sanitary manner in 1 of 1 facility kitchen. Failure to ensure the concentration of quaternary (quat) solution is within manufacturer's guidelines may result in an incorrect solution concentration and inadequate sanitization of kitchen surfaces. Findings include: Review of manufacturer's instructions for Ecolab Oasis 146 Multi-Quat Sanitizer identified a concentration of 150 parts per million (ppm) - 400 ppm active quat for effective sanitizing. Observation in the kitchen on 06/11/18 at 12:23 p.m. showed a bucket of Oasis 146 quat on the counter. Observation showed the test strips available to test the solution were specific to testing chlorine-based solutions. Two dietary staff members (#1 and #2) confirmed they use the strips to test the quat solution. Review of the (MONTH) log for testing the quat solution showed staff did not record any measurements, except 06/06/18 which identified a concentration of 10 ppm. When dipped in the quat solution, the chlorine strips failed to produce a color change (identifying the concentration of the quat solution). During an interview on 06/12/18 at 8:09 a.m., a dietary supervisor (#3) stated the facility did not have a policy, but she expected staff to change the quat solution every two hours, and record the concentration on the log sheet. The staff member identified she has quat testing strips available for use.

Based on record review and staff interview, the facility failed to ensure residents who use [MEDICAL CONDITION] drugs receive gradual dose reductions (GDRs), unless clinically contraindicated, in an effort to discontinue the drugs for 1 of 2 sampled residents (Resident #5) reviewed for anti-anxiety medication use. Failure to attempt a GDR placed residents at risk for receiving unnecessary medications and experiencing adverse consequences related to their use. Findings include: Review of Resident #5's medical record occurred on all days of survey. [DIAGNOSES REDACTED]. The record identified the initiation of [MEDICATION NAME] (an anti-anxiety medication) on 08/17/17. The record lacked evidence of an attempted GDR (or contraindications for one) since 08/17/17. On the morning of 06/14/18, a supervisory nurse (#4) identified she contacted the physician that morning regarding a GDR, but the physician did not want to reduce the medication at that time. The facility failed to ensure Resident #5 received a GDR twice during the first year in two separate quarters, with at least a month between attempts, unless contraindicated.

Based on observation, review of facility menus, and staff interview, the facility failed to meet the nutritional needs of residents receiving modified diets by serving incorrect portions of puree foods during 1 of 2 observed meals (04/25/17 noon meal). Failure to follow the recommended portion sizes as outlined on menus may result in weight changes and/or inadequate nutritional intake for residents on a modified (puree) diet. Findings include: The facility failed to provide a policy regarding portion sizes of menu items per request. Observation of tray line occurred on 04/25/17 at 11:45 a.m. during the noon meal. Observation showed the following inconsistencies between portion sizes listed on the facility's menus and the actual amount served to residents: * Puree cranberry glazed chicken served with a 2 2/3 ounce (oz) scoop. The menu identified a 4 oz scoop. * Puree boiled potatoes served with a 2 2/3 ounce (oz) scoop. The menu identified a 4 oz scoop. * Puree green beans served with a 2 2/3 ounce (oz) scoop. The menu identified a 4 oz scoop. During an interview on the morning of 04/26/17, a managerial dietary staff member (#8) confirmed staff should follow the recommended portion sizes identified on the menus.

Based on observation and staff interview, the facility failed to properly maintain the walk-in freezer in 1 of 1 (main) kitchen during 2 of 2 observations. Failure to ensure staff properly maintained a walk-in freezer has the potential to affect the quality of the food consumed by residents. Findings include: The facility failed to provide a policy regarding sanitation of the walk-in freezer per request. During the initial kitchen tour on 04/24/17 at 12:30 p.m., observation showed a pipe coming from the box fan located on the ceiling of the walk in freezer. Water condensation leaked from the pipe and froze onto the food items located underneath; a covered pail of soup on the top shelf, a closed box of mozzarella cheese on the second shelf, and a closed box of dessert bars on the third shelf. The managerial dietary staff member (#8) removed the ice-covered pail of soup from the freezer. During the kitchen tour on 04/25/17 at 11:45 a.m., observation showed a pipe coming from the box fan located on the ceiling of the walk in freezer. Water condensation leaked from the pipe and froze onto the food items located underneath; a closed box of mozzarella cheese on the second shelf, a closed box of dessert bars on the third shelf, a closed box of whole wheat rolls on the fourth shelf, a zip-lock baggie lying on top of a closed box of cinnamon rolls on the fifth shelf, and on the floor. During an interview on the afternoon of 04/25/17, a managerial dietary staff member (#8) stated, We used to have a bucket under there. I don't know why someone removed it. I've had to throw other items away before. She confirmed the pipe connected to the box fan in the walk-in freezer did leak and the facility needed to have it repaired.

Based on observation, record review, and staff interview, the facility failed to provide supervision and assistive devices necessary to prevent accidents for 2 of 7 sampled residents (Resident #4 and #8) dependent on staff for transfers and/or transport utilizing gait belts and wheelchairs. Failure to utilize a gait belt appropriately during transfer (Resident #8), utilize a wheelchair as a safety precaution as care planned (Resident #4), and/or provide wheelchair foot pedals during transport (Resident #8), may result in injury and/or falls. Findings include: The facility failed to provide a policy regarding transfers/transport per request. - Review of Resident # 8's medical record occurred on all days of survey. Medical [DIAGNOSES REDACTED]. The significant change Minimum Data Set (MDS), dated [DATE], identified extensive assist of one or more persons with transfers and locomotion on/off the unit. The current care plan identified, . (Resident #8) is unable to complete ADL's (activities of daily living) independently. Extensive assist of two with transfers, pivot transfer . No leg rests on w/c (wheelchair), resident propels self and (is) able to lift feet when being propelled by staff (undated, handwritten entry). A Therapy Standing Lift Screen, dated 12/22/16, identified, During screen, resident demonstrated full weight resting on sling during transfer. Resident unable to pull self up to stand despite verbal and tactile cues. Recommend discontinued use of E-Z stand and use of 2 person, stand pivot transfer to complete for the safety of the resident. Observations showed the following: * During the initial tour at 12:30 p.m. on 04/24/17, a nurse (#6) transported Resident #8 down the hallway in her wheelchair. Resident #8's shoes could be heard brushing the floor as the staff member transported her to the lounge. The staff member (#6) failed to cue Resident #8 to lift her feet and/or apply foot pedals during transport. * 04/24/17 at 4:00 p.m., two certified nursing assistants (CNAs) (#1 and #2) transferred Resident #8 from the recliner to her wheelchair. The CNAs (#1 and #2) placed both hands under Resident #8's axillas (armpits) and lifted her to a standing position. The CNA (#1) turned around and saw this surveyor observing the transfer and told the CNA (#2) to sit the resident back down. After the CNAs (#1 and #2) sat the resident back into the recliner, the CNA (#1) placed a gait belt around Resident #8's waist. Both CNAs (#1 and #2) then grabbed under Resident #8's axilla with both hands, lifted the resident to a standing position, and pivoted the resident into her wheelchair. The CNAs failed to appropriately utilize a gait belt. * 04/26/17 at 8:57 a.m., two CNA's (#3 and #4) transferred Resident #8 from her wheelchair to a recliner in the lounge. The CNAs (#3 and #4) placed a gait belt around Resident #8's waist and lifted her out of her wheelchair by placing one hand on the gaitbelt and the other under her axillas. The CNAs (#3 and #4) held onto the gait belt, supporting Resident #8's weight throughout the transfer. Her heels did not touch the ground and the toes of her shoes drug on the floor as they lowered her into the recliner. The CNAs (#3 and #4) then lifted Resident #8 further back into the recliner by placing one hand on the gait belt and the other under the her axillas. The CNAs failed to cue Resident #8 to stand (bear her own weight) and placed pressure on her arms when they lifted her under the axillas. * On 04/26/17 at 10:17 a.m., two CNA's (#4 and #5) transferred Resident #8 from the recliner in the lounge back into her wheelchair. The CNAs (#4 and #5) placed a gait belt around Resident #8's waist and lifted her out of the recliner. The CNAs (#4 and #5) held onto the gait belt, supporting Resident #8's weight throughout the transfer. Her shoes drug on the floor as they lowered her into the recliner. The CNAs failed to cue Resident #8 to stand (bear her own weight). * On 04/26/17 at 10:50 a.m., two CNA's (#4 and #6) transferred Resident #8 from her wheelchair onto the commode in her room. The CNAs (#4 and #6) placed a gait belt around Resident #8's waist and lifted her out of her wheelchair. One of the CNAs (#6) held onto the gait belt while the other CNA (#4) placed one hand on the gait belt and one hand under the resident's right axilla. The CNAs (#4 and #6) also lifted Resident #8 further back onto the commode by placing one hand on the gait belt and the other under the her axillas. One of the CNAs (#4) commented, I like three (staff members). It is too hard for just two (staff members) to stand her and clean her up. The CNA (#4) then transported Resident #8 down the hallway. Resident #8 dropped her feet twice allowing them to brush along the floor before lifting them again. The CNAs failed to cue Resident #8 to stand (bear her own weight), placed pressure on her arms when they lifted her under her axillas, and failed to cue Resident #8 to lift her feet and/or apply foot pedals during transport. During an interview on the afternoon of 04/26/17, an adminstrative nurse (#7) confirmed staff should utilize the gaitbelt for transfers, versus lifting under the resident's axillas. - Review of Resident # 4's medical record occurred on all days of survey. Medical [DIAGNOSES REDACTED]. The quarterly Minimum Data Set (MDS), dated [DATE], identified extensive assist of one person with bed mobility, transfers, walking in room and corridor, dressing, personal hygiene, and toileting. The current care plan stated, . Problem . ADL functional/Rehabilitation Potential . is unable to perform ADL's independently R/T (related to): Dementia, pain, osteoarthritis, h/o (history of) hip fractures, and weakness. Approach . Extensive assist of one with locomotion on and off unit as needed. W/C (wheel chair) is primary means of locomotion. Problem . Urinary Incontinence . Occasional Incontinence of bowel and bladder. Extensive assist in toileting. Requests to go to toilet frequently. At times she requests to sit on toilet for long periods of time. Approach . Extensive assist of one in toileting . IDT (interdisciplinary team) and family discussed frequent toileting and agreed resident may be left to toilet with call light within reach, sign posted reminding resident to use call light, w/c next to toilet at times when resident wants to sit for a long period of time. Observation on 04/24/17 at 4:24 p.m., showed a CNA (#2) transferred Resident #4 into the bathroom with a front wheel walker utilizing a gait belt. The CNA (#2) assisted Resident #4 onto the toilet, placed the front wheeled walker next to Resident #4, washed his hands, left the bathroom, and shut the bathroom door. The CNA (#2) failed to place the wheelchair in the bathroom as stated in the care plan if the resident is to be alone in the bathroom. Observation on 04/25/17 at 9:47 a.m., showed a CNA (#3) transferred Resident #4 to the bathroom utilizing a front wheeled walker with a gait belt. The CNA (#3) assisted Resident #4 onto the toilet, placed the front wheeled walker next to Resident #4, left the bathroom, and shut the bathroom door. The CNA (#3) failed to place the wheelchair in the bathroom as stated in the care plan if the resident is to be alone in the bathroom. During an interview on 04/26/17 at 12:45 p.m., an administrative staff (#4) stated Resident #4's care plan states to allow Resident #4 to be left alone in the bathroom. The nurse stated she expected staff to utilize Resident #4's wheelchair in the bathroom if she is left alone.