Every finding on record at Prairie Acres

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for dietary services, in that: The facility failed on 07/29/2025 to properly wash hands during food preparation. This failure could place residents at risk for food contamination and foodborne illness. The findings included: The following observation was made on 07/29/2025 during observation of puree at 10:30 AM: [NAME] E placed piece of fish into puree processor bowl and removed gloves. [NAME] E took sheet pan to dirty dish room. [NAME] E returned to prep area and put on gloves and started puree process of fish. [NAME] E add water to fish in puree processor bowl. [NAME] E removed gloves and went to dry storage room. [NAME] E picked up container of thickener off bottom shelf and placed on prep table across from steam table and scooped thickener into Styrofoam cup. [NAME] E went back to puree prep area and put on gloves and poured small amount of thickener into puree processor bowl with fish. [NAME] E removed puree fish from puree processor bowl into bowl and placed in microwave. [NAME] E removed gloves and took puree processor bowl, lid and blade to dirty dish area. [NAME] E washed hands. No observation of [NAME] E washing hands between glove changes or task change. During an interview on 07/30/25 at 01:35 PM with [NAME] E, he stated he should have washed his hands between glove changes and anytime he changed task. He stated he was nervous and forgot. He stated he has been trained. He stated the potential negative outcome could be cross contamination and spreading bacteria to food or someone. During an interview on 07/30/25 at 01:25 PM with the DM, she stated hands should be washed with any glove change and task change. She stated the cook should have washed his hands when he changed gloves and changed task. She stated she was aware the cook did not wash his hands when he went to the dirty dish area. She stated all staff had been trained on hand washing. She stated she was responsible for monitoring and training kitchen staff. She stated the potential negative outcome could be food borne illness and cross contamination of food. During an interview on 07/30/25 at 01:45 AM with ADM, he stated hands should be washed between glove changes and when changing task. He stated [NAME] E had been trained on hand washing. He stated the DM was responsible for training and monitoring staff on handwashing. He stated the facility does mock audits and [NAME] E had passed, so he must have just been nervous. He stated the potential negative outcome could be cross contamination of food and making residents sick. Record review of the facility's policy, titled Handwashing dated January 2024, reflected the following: Policy:Employees are to wash hands: .Between handling of dirty and clean dishes, equipment/utensils, and food.After touching objects that may be a source of contamination in the next contact with the hands is food or food contact surfaces.Procedure: .4. The use of gloves or the use of hand sanitizer does not replace handwashing.

Number of residents sampled: Number of residents cited: Based on interviews, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that included measurable objectives and timeframes to meet a resident's medical, nursing, mental, and psychosocial needs that were identified in the comprehensive assessment for 1 of 8 residents (Resident #5) reviewed for care plans. Resident #5 did not have a care plan for Cognitive Loss/Dementia, Communication, Urinary Incontinence, Pressure Ulcers, and did not include her diagnosis of Alzheimer's Disease with late onset. This failure could place residents at risk of not receiving the care required to meet their individualized needs. Findings included: Record review of the face sheet, dated 07/29/2025, revealed Resident #5 was an [AGE] year-old female who admitted to the facility on [DATE] with diagnoses that included the following: unspecified Dementia, unspecified severity without behavioral disturbance, mood disturbance, anxiety (memory loss that deteriorates over time), psychotic disorder with hallucinations due to known psychological condition (severe mental health disorders that cause abnormal thinking and perceptions), psychotic disorder with delusions due to known psychological condition(), and Major Depressive Disorder (severe mental health disorders that cause abnormal thinking and perceptions). Record review of Resident #5's admission MDS assessment, dated 02/03/2025, revealed in Section C - Cognitive Patterns, Resident #5 had a BIMS score of 08, which indicated moderate cognition impairment. The document also indicated in Section V - Care Area Assessment (CAA) Summary the following Care Planning Revision Areas: 02. Cognitive Loss/Dementia (dated 02/12/2025)04. Communication (dated 02/12/2025)05. ADL Functional/Rehabilitation Potential (dated 02/12/2025)06. Urinary Incontinence and Indwelling Catheter (dated 02/12/2025)11. Falls (dated 02/12/2025)12. Nutritional Status (02/12/2025)16. Pressure Ulcer (dated 02/12/2025)17. Psychotropic Drug Use (dated 02/12/2025)19. Pain (dated 02/12/2025) Record review of the current care plan for Resident #5, undated, included the following focus areas: I have potential for disturbed thought process r/t dx of psychotic disorder with hallucinations and delusions. (Date Initiated 01/28/2025). With an intervention that included: Administer medications as per physician orders. I am on quetiapine Date Initiated: 01/28/2025. I have disturbed thought process related to delusions/hallucinations. (Date Initiated 01/28/2025) with interventions that included: Monitor and record s/sx of non-verbal pain: Changes in breathing (noisy, deep/shallow, labored, fast/slow); Vocalizations (grunting, moans, yelling out, silence); Mood/behavior (changes, more irritable, restless, aggressive, squirmy, constant motion); Eyes (wide open/narrow slits, glazed, tearing, no focus); Face (sad, crying, worried, scared, clenched teeth, grimacing) Body (tense, rigid, rocking, curled up, thrashing). Notify Physician if pain is new, increasing or non relieved. Record review of Resident #5's active physician's order, dated 7/29/2025, included the following diagnoses: unspecified Dementia, unspecified severity without behavioral disturbance, mood disturbance, anxiety (memory loss that deteriorates over time), psychotic disorder with hallucinations due to known psychological condition (severe mental health disorders that cause abnormal thinking and perceptions), psychotic disorder with delusions due to known psychological condition(severe mental health disorders that cause abnormal thinking and perceptions), and Major Depressive Disorder (mood disorder that causes a persistent feeling of sadness and loss of interest). Resident #5's active physician's order included the following medications: Tramadol HCl Oral Tablet 50 MG (Tramadol HCl) (Give 1 tablet by mouth every 8 hours as needed for pain related to CHRONIC PAIN SYNDROME), Tylenol Extra Strength Oral Tablet 500 MG (Acetaminophen) (Give 1000 mg by mouth every 6 hours as needed for Moderate Pain), Quetiapine Fumarate Oral Tablet 25 MG (Quetiapine Fumarate) (Give 1 tablet by mouth at bedtime related to PSYCHOTIC DISORDER WITH HALLUCINATIONS DUE TO KNOWN PHYSIOLOGICAL CONDITION), and Sertraline HCl Oral Capsule 200 MG (Sertraline HCl) (Give 1 capsule by mouth one time a day related to MAJOR DEPRESSIVE DISORDER, RECURRENT SEVERE WITHOUT PSYCHOTIC FEATURES).-- During an interview on 07/31/2025 at 10:00 AM, the MDS nurse stated she was responsible for completing and updating residents' care plans. The MDS nurse stated care plans were completed upon admission and updated immediately as changes arise, as well as reviewed quarterly for accuracy. The MDS nurse stated the DON also helped to review care plans for accuracy. The MDS nurse stated they reviewed a resident's diagnoses, medications, and areas of care to personalize each resident's care plan based on their current needs. The MDS nurse stated she was not aware Resident #5's care plan was not completed fully, to include all CAA areas indicated on Resident #5's MDS. The MDS nurse stated this was overlooked. The MDS nurse stated all CAA areas should have been included on Resident #5's care plan, as they applied to her current care. The MDS nurse stated the facility had a system to review care planning tasks at their IDT meetings as well. The MDS nurse stated she would ensure Resident #1's care plan was updated that day, 07/31/2025. The MDS nurse stated if a care plan was not updated or completed properly, it would not be specific to the resident's current care needs. During an interview on 07/31/2025 at 10:45 AM, the DON stated the MDS nurse was responsible for completing and updating care plans for residents. The DON stated she also assisted with reviewing care plans and ensuring they were updated with any changes that may arise. The DON stated all CAA areas on a resident's MDS assessment should have been included as focus areas on a resident's care plan. The DON stated it was her expectation that all triggered care areas have a focus area on a resident's care plan to ensure the resident is receiving care for all of their identified needs. The DON stated she was not aware Resident #5's care plan was not completed fully. The DON stated if a care plan was not accurate, the resident may not have received the care they needed. During an interview on 07/31/2025 at 11:40 AM, the ADM stated care plans were the responsibility of the MDS nurse. The ADM stated the MDS nurse was responsible for reviewing and completing care plans, and the DON also reviewed care plans to ensure accuracy. The ADM stated care plans were completed upon admission and reviewed quarterly. The ADM stated any changes would have been added as soon as the change of condition was known. The ADM was not sure if all MDS CAA areas should have been listed on Resident #5's care plan. However, he stated he would follow up to ensure it was updated accurately. The ADM stated care planning tasks were also discussed during the facility's IDT meetings, and any changes or updates were added, as needed, by each department head. The ADM stated it was his expectation that all critical areas were addressed on a resident's care plan. The ADM stated if a resident's care plan was not completed accurately, the resident could have been negatively impacted because expectations could be missed if they were not listed in the care plan. Record review of the facility's policy titled, Care Plans, Comprehensive Person-Centered undated, reflected the following:Policy Statement: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.Policy Interpretation and Implementation:1. The Interdisciplinary Team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident.2. The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment.

Number of residents sampled: Number of residents cited: 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.

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. 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. This failure could place residents at risk of injury or harm. Findings Included: 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 admitted [DATE]. 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). Record review of Resident #35's Quarterly MDS completed on 05/17/24 revealed the following: Section C of the MDS revealed a BIMS of 3 which indicated severely impaired cognition. Section GG of the MDS revealed Resident #35 was dependent on staff for walking and needed partial to substantial assistance with other mobility ADLs. Section J of the MDS indicated Resident #35 had had major surgery to repair a fracture as well as another major surgery. Section P of the MDS revealed bed and chair alarms were used daily. 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: 03/18/24 used a mobility monitor on his w/c for safety. 03/14/24 have increased assistance, surveillance, activities involvement, a mobility alarm, and be placed near the nurses' station. 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. Record review of Resident #35's active orders dated 05/30/24 revealed the following: An order for admission to skilled service related to (right) hip fracture dated 03/13/24. An order to monitor left hip for s/s of infection twice a day dated 05/29/24. 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. Record review of Resident #35's Progress Notes revealed the following: 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. 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. 03/15/24 written by RN L revealed Resident #35 attempted to turn himself in his bed without staff assistance. 03/17/24 written by RN M revealed Resident #35 attempted to get up without staff assistance. 03/18/24 written by RN M revealed Resident #35 attempted to get up without staff assistance. 03/19/24 written by RN L revealed Resident #35 attempted to get up without staff assistance. 03/20/24 written by RN L revealed Resident #35 attempted to get up without staff assistance. 03/25/24 01:11 PM written by RN L revealed Resident #35 got up from his bed without assistance. 03/25/24 10:50 PM written by RN M revealed Resident #35 attempted to get out of bed by himself. 04/30/24 written by LVN H revealed Resident #35 had a mobility alarm on his w/c. 05/03/24 written by RN L revealed Resident #35 attempted to get out of bed by himself. 05/12/24 written by RN M revealed Resident #35 got out of bed by himself. 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. 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. 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). 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. 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. 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. 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. 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 . 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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.

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. 1. The facility failed to ensure freezer items were properly stored, labeled, and dated. 2. The facility failed to ensure walk-in refrigerator items were stored, labeled, and dated. 3. The facility failed to ensure pantry foods were properly stored, labeled, and dated. These failures could place residents who ate food served by the kitchen at risk of food-borne illness. Findings include: Observation of the walk-in pantry on 05/28/24 at 9:12 AM revealed the following: 1. (1) Package of opened bread, with no label or date. 2. (1) Tray of brownies, labeled and dated, with plastic wrap covering most of it except sides which were open to air. 3. (1) Box of corn starch, labeled and dated, box top open and inner bag open to air. 4. (1) container of garlic salt with no date or label. 5. (1) container of parsley flakes with no date or label. 6. (1) container of chives with no date or label. 7. (1) container of ground sage with no date or label. 8. (1) container of Italian seasoning with no date or label. 9. (1) container of ground nutmeg with no date or label. 10.(7) boxes of peanut butter crackers with individualized packages inside, with no dates or labels. Observation of the walk-in refrigerator on 05/28/24 at 9:18 AM revealed the following: 1. (2) bags of what appeared to be lettuce with no dates or labels. 2. (1) whole watermelon with no date or label. 3. (2) trays of cups with what appeared to be juice and tea in them, covered in saran wrap, with no dates or labels. 4. (6) individualized yogurts, with no dates or labels. 5. (6) individualized puddings, with no dates or labels. Observation of the freezer on 05/28/24 at 9:23 AM revealed the following: 1. (1) open box of what appeared to be frozen bread sticks, with bag inside open to air, with no date or label. 2. (1) large package of what appeared to be ground beef, with no date or label. 3. (1) tray of brownies, with no date or label. In an interview on 05/28/24 at 10:56 AM, Cook A stated it was everyone's responsibility to make sure that all food in the kitchen was labeled and dated. Cook 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. 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. In an interview on 05/29/24 at 8:38 AM, Cook B stated it was everyone's responsibility to label and date food in the kitchen. Cook B stated a possible negative outcome would be that residents could get sick. Record review of the facility-provided policy dated January 2024 titled Food Storage - Dry Storage. .Food must be stored in a properly covered container with a date and label identifying what is in the container. Record review of the facility-provided policy dated January 2024 titled Food Storage - Refrigerated and Frozen Foods. .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. Record review of the facility-provided policy undated titled Refrigerators and Freezers .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 4 (LVN C, CNA E, NA G, and CNA F) of 5 staff members in that: -LVN C did not don PPE to administer medication via PEG tube to Resident #91 -LVN C did not perform hand hygiene or change gloves in between dirty and clean portions of wound care for Resident #5. -CNA E did not perform hand hygiene before, during, or after incontinent care of Resident #24. -NA G did not perform hand hygiene before, during, or after incontinent care of Resident #24. -CNA F did not perform hand hygiene in between assisting Resident #17 and Resident #21 with eating at lunch time meal. -LVN C did not perform hand hygiene between assisting Resident #24 and Resident #5 with eating at lunch time meal. These deficient practices have 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, communicable diseases. Findings include: Observation on 05/28/24 at 11:57 AM revealed LVN C did not don PPE for the administration of antibiotic to Resident #91 via his PEG tube. PPE was in the Residents room next to the sink. Observation on 05/28/24 at 12:25 PM revealed LVN C going from table to table touching residents' silverware and then moving on to other residents with no hand hygiene being performed in between residents. Observation on 05/28/24 at 12:28 PM revealed LVN C touched her clothing and then assisted an unidentified resident with the cutting up of her food. No hand hygiene was performed before LVN C assisted resident. Observation on 05/28/24 at 12:29 PM LVN C touched her clothing and then helped Resident # 24. Resident #24 was handed a spoon to better assist with getting food to his mouth. LVN C then went over to assist Resident # 5 with eating. No hand Hygiene was performed in between the 2 different residents. Observation 05/28/24 at 12:32 PM CNA F was assisting Resident # 17 with eating and then turned around to give Resident # 21 a drink from her cup. No hand hygiene was performed in between these two residents. Observation on 05/28/24 at 12:35 PM LVN C assisted Resident #24 with eating, then went to assist Resident #5, no hand hygiene was performed in between these two residents. Observation on 05/28/24 at 02:47 PM revealed CNA E and NA G who performed incontinent care for Resident #24. No HH was performed before the task was started. No HH or glove change was performed in between cleaning BM from Resident #24 and placing a clean brief on Resident #24. CNA E then proceeded to touch resident, residents' blankets, pillow, bed control, and call light with no HH performed and soiled gloves still on that she cleaned BM with. No HH was performed after incontinent care was concluded or before leaving Resident #24's room. Interview on 05/28/24 at 02:59 PM with CNA E revealed that a negative outcome for not performing HH during incontinent care would be there would be a chance of increased risk of cross contamination. Interview on 05/28/24 at AM with CNA F revealed that a negative outcome for not performing HH between assisting residents to eat would be the spread of germs from one resident to another. Observation on 05/29/24 at 9:52 AM revealed LVN C who performed wound care on Resident #5. There was no dressing on the wound when Resident #5 was turned to her right side. LVN C cleaned the wound and the surrounding areas. Once the area was cleaned LVN C proceeded to take the clean foam dressing and placed it on Resident #5's coccyx. LVN C did not perform a glove change or hand hygiene in between the dirty and clean portion of the wound care. Interview on 05/29/24 at 10:02 PM with LVN C revealed that a negative outcome for not performing HH or a glove change during wound care could lead to an increased risk of infection for the resident. Interview on 05/30/24 at 10:03 AM with DON revealed that a negative outcome for not performing HH and glove changes during incontinent care, HH during mealtime assistance, and HH and glove changes during wound care for residents could all lead to the increased risk for the spread of infection. DON revealed that not donning PPE during a PEG tubed medication administration could also lead to the spread of infection. Interview on 05/31/24 at 10:02 AM with LVN C revealed that LVN C was not aware that she needed to don PPE during a PEG tube medication administration. LVN C stated when she was asked what a negative outcome would be for not donning PPE, her response was I was not informed I needed to put PPE on. Record review of facility provided policy titled Handwashing/Hand Hygiene, revised August 2019, revealed the following: .2. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infection to other personnel, resident, and visitors. .7. Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations; . .b. Before and after direct contact with residents; . .D. Before performing any non-surgical invasive procedures; . . H. Before moving from a contaminated body site to a clean body site during resident care; I. After contact with a resident intact skin; J. After contact with blood or bodily fluids . . M. After removing gloves; . .P. Before and after assisting a resident with meals; . . 8. Hand hygiene is the final step after removing and disposing of personal protective equipment Record review of facility provided policy titled, Incontinent Care Procedure, undated, revealed the following: . Wash hands Put on gloves, . .Reposition resident for safety Dispose of all soiled wipes, linens protector and gloves, tie off bag for final disposal, Wash hands and put on clean gloves, Place a clean brief on resident, secure catheter if needed (ensure tubing has no kinks, obstructions, or loops. Ensure that the privacy cover is in place for the catheter bag) Remove gloves and wash hands Reposition resident for comfort Place signaling device within reach . .Sanitize immediately after leaving the resident's room. Record review of facility provided policy titled, Wound Care Procedure, undated, revealed the following: .9. Perform hand hygiene and apply nonsterile gloves. .13. Assess the wound: . .16. Cleanse the wound based on orders, using moistened gauze, commercial cleanser, or sterile irrigant. When using moistened gauze, use one moistened 2X2 sterile gauze per stroke. Work in straight lines, moving away from the wound with each stroke. Strokes should move from a clean area to a dirty area and from top to bottom. .18. Remove gloves, perform hand hygiene, and apply new gloves. .20. Apply outer dressing if required, Secure the dressing tape as needed. 21. Remove gloves and perform hand hygiene. .24. Perform hand hygiene. Record review of CMS policy titled, Enhanced Barrier Precautions in Nursing Homes, dated 03/20/2024, revealed the following: .Infection or colonization with a CDC-targeted MDRO when Contact Precautions do not otherwise apply: or Wounds and/or indwelling medical devices even if the resident is not known to be infected or colonized with a MDRO. Wounds generally include chronic wounds, not shorter-lasting wound, such as skin breaks or skin tears covered with an adhesive bandage (e.g., Band-Aid) or similar dressing. Examples of chronic wounds include, but are not limited to pressure ulcers, diabetic foot ulcers, unhealed surgical wounds, and venous stasis ulcers. Indwelling medical devices examples include central lines, urinary catheters, feeding tubes, and tracheostomies. A peripheral intravenous line (not a peripherally inserted central catheter) is not considered an indwelling medical device for the purpose of EBP.

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. -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. 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. Findings include: 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. 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. 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. Record review of Resident #20's physician orders, dated [DATE] revealed that Resident #20 has an order for the following insulins: HumaLOG Solution 100 UNIT/ML (Insulin Lispro) Inject as per sliding scale: if 0 - 149 = 0; 150 - 200 = 2; 201 - 250 = 3; 251 - 300 = 4; 301 - 350 = 5; 351 - 400 = 6 If over 400 call MD, subcutaneously before meals and at bedtime related to TYPE 2 DIABETES MELLITUS WITHOUT COMPLICATIONS (E11.9) Lantus Solution 100 UNIT/ML (Insulin Glargine) Inject 30 unit subcutaneously one time a day related to TYPE 2 DIABETES MELLITUS WITHOUT COMPLICATIONS (E11.9) 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. 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. 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. 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. 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. Record review of facility provided policy titled, Adverse Consequences and Medication Errors, undated, revealed the following: .4. The staff and practitioner shall strive to minimize adverse consequences by: a. Following relevant clinical guidelines and manufacturer's specifications for use, dose, administration, duration, and monitoring of the medication; . .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. 6. Examples of medication errors include: . .h. Failure to follow manufacturer instructions and/or accepted professional standards . .9. Facility staff monitor the resident for possible medication -related adverse consequences, including mental status and level of consciousness, when the following conditions occur: . .f. Medication error, e.g., wrong or expired medication. Record review of facility provided policy titled, Labeling of Medication Containers, undated, revealed the following: .3. Labels for individual resident medications include all necessary information, such as: . .h. The expiration date when applicable; . Record review of facility provided policy titled, Administering Medications, undated, revealed the following: .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. Record review of https://humalog.lilly.com, manufacture website for Humalog, website revised ,d+[DATE] revealed the following: After vials have been opened: Store opened vials in the refrigerator or at room temperature up to 86 F (30 C) for up to 28 days. Keep vials away from heat and out of direct light. Throw away all opened vials after 28 days of use, even if there is insulin left in the vial.

Based on observation, interview, and record review the facility failed to ensure a resident who needs respiratory care, is provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 1 (Resident #34) of 12 residents reviewed for respiratory care. Resident #34 had physician's orders for oxygen via nasal cannula at 2-3 lpm and was receiving oxygen at 5 lpm. This failure could place residents at risk for hypercapnia (too much carbon dioxide in the blood), pulmonary oxygen toxicity (damage to the lung lining tissues and air sacs), hypoxemia (low levels of oxygen in the blood, decreasing the oxygen supply to vital organs), and shortness of breath. Findings Included: Record review of Resident #34's admission record dated 05/28/24 revealed a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included, but were not limited to, unspecified dementia (a group of thinking and social symptoms that interferes with daily functioning), lack of coordination, anxiety disorder (mental disorder characterized by significant and uncontrollable feelings of anxiety and fear), muscle weakness, and tremor (Unintentional trembling or shaking movements in one or more parts of the body). Record review of Resident #34's significant change MDS completed on 03/21/24 revealed the following: Section C revealed a BIMS of 2 which indicated severely impaired cognition. Section O of the MDS revealed Resident #34 was receiving O2 therapy while a resident. Record review of Resident #34's care plan completed 05/02/24 revealed I have Oxygen Therapy r/t Ineffective gas exchange. This focus area was initiated on 03/07/2024. One of the interventions listed was Maintain my oxygen settings per physician's orders. Check on liter flow when entering my room. Record review of Resident #34's active orders dated 05/28/24 revealed the following order with a start date of 03/20/24: Oxygen 2-3 L to maintain oxygen levels at or above 90%. Two times a day related to MUSCLE WEAKNESS .CHRONIC PAIN. Record review of Resident #34's O2 saturations for the last 4 months revealed 4 entries for February of 2024 all of which were above 90% and were on room air. Resident #32's O2 saturation was checked 27 times in March of 2024 4 of those times she was on room air, the other 23 times she was receiving O2 via NC. Resident #34's O2 saturation did not drop below 90% during the month of March. Her O2 saturation was checked 62 times in April of 2024, it never dropped below 90% during the month. Resident #34 was on room air for 11 of those times and receiving O2 via nasal cannula the other 51 times. Her O2 saturation was checked 60 times from May 1-28, 2024. It did not fall below 90% for the month and she was on room air 2 of the times and receiving O2 via NC the other 58 times. During an observation on 05/28/24 at 10:38 AM Resident #34 was seated in her w/c near the nurses' station receiving O2 via NC at 5 lpm. During an observation on 05/28/24 at 12:09 PM Resident #34 was seated in her w/c at a table in the dining room receiving O2 via NC at 5 lpm. During an observation on 05/28/24 at 03:23 PM Resident #34 was seated in her w/c near the nurses' station receiving O2 via NC at 5 lpm. During an observation on 05/29/24 at 07:35 AM Resident #34 was seated in her w/c at a table in the dining room receiving O2 via NC at 5 lpm. During an observation on 05/29/24 at 08:50 AM Resident #34 was seated in her w/c near the nurses' station receiving O2 via NC at 5 lpm. During an interview on 05/29/24 at 08:57 AM CNA D stated CNAs do not have anything to do with setting lpm on O2 concentrators. He said he will check the lpm to be sure it was what the nurses tell him it should be. He stated Resident #34's O2 was normally set at 2 lpm unless she gets anxious and then we will turn it up to 3 (lpm). During an interview on 05/29/24 at 11:53 DON stated it was the nurses who were responsible for setting O2 levels for residents. She said they know what lpm to set the O2 by referring to physician orders. She stated she did not know why Resident #34's O2 was set at 5 lpm. She stated a resident receiving O2 at higher levels than ordered could result in the O2 not being effective or could create respiratory issues for the resident. During an interview on 05/29/24 at 12:43 PM LVN C stated she checked lpm for each resident receiving O2 each morning when she documented O2 saturation. She stated receiving O2 at higher concentrations than ordered could be bad for the resident. LVN C said she looked at physician orders to find out what lpm to set the O2. During an interview on 05/30/24 at 03:54 PM LVN H stated a resident could develop issues breathing if they were to receive O2 at a higher lpm than ordered by the physician. She stated she knew what lpm to set O2 concentrators for residents by referring to the physician's orders. Record review of undated facility policy titled Administering Medications revealed the following: . Medications are administered in a safe and timely manner, and as prescribed. 4. Medications are administered in accordance with prescriber orders . Record review of undated facility policy titled Oxygen Administration revealed the following: . 2. Check physician's orders for liter flow and method of administration. 11. Set the flow meter to the rate ordered by the physician. 15. At regular intervals, check liter flow .

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. -1 insulin medications were found in Hall Emerald and [NAME] medication cart with no date of when medication vial was opened. -Medication refrigerator in medication room was logged at 30 degrees 4 out of the last 28 days. -LVN C left treatment cart unlocked and unattended. 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. Findings include: 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. 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. 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. 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. 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. Record review of facility provided policy titled, Refrigerators and Freezers, undated, revealed the following: Policy Interpretation and Implementation 1. Acceptable temperature ranges are 35 degrees F to 40 degrees F for refrigerators and less then 0 degrees F for freezers. .3. Monthly tracking sheets will include date, temperature, and initials. If temperatures are not within range, staff must notify supervisor immediately. Record review of facility provided policy titled, Labeling of Medication Containers, undated, revealed the following: .3. Labels for individual resident medications include all necessary information, such as: . .h. The expiration date when applicable; . Record review of facility provided policy titled, Administering Medications, undated, revealed the following: .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. Record review of https://humalog.lilly.com, manufacture website for Humalog, website revised ,d+[DATE] revealed the following: After vials have been opened: Store opened vials in the refrigerator or at room temperature up to 86 F (30 C) for up to 28 days. Keep vials away from heat and out of direct light. Throw away all opened vials after 28 days of use, even if there is insulin left in the vial. Record review of Drug label information for Lorazepam concentrate on DailyMed - LORAZEPAM concentrate (nih.gov), updated [DATE] revealed the following: Store at Cold Temperature-Refrigerate 2 -8 C (36 -46 F) Dispense only in the bottle and only with the calibrated dropper provided. Discard opened bottle after 90 days. Record review of facility provided policy titled, Security of Medication Cart, undated revealed the following: 1. The nurse must secure the medication cart during the medication pass to prevent unauthorized entry. .4. Medication carts must be securely locked at all times when out of the nurse's view. 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.

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. 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. The faciltiy failed to train CNA J on dementia management. These failures could place residents at risk of injury or harm due to being cared for by untrained staff. Findings included: 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. 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 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. 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. Record review of facility provided New Hire Instructions page revealed the following: .New Hire MUST complete the following BEFORE floor work: - [Name of Electronic Program] Training And after all training is complete - then they are added to the schedule for orientation. Record Review of the facility provided policy titled Abuse, Neglect and Exploitation Prevention Program not dated, revealed the following: 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. 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 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. The facility failed to check for PEG tube placement before administering medication (Cephalexin) via the tube for Resident #91. This failure could place resident at risk of aspiration, bleeding, or perforation, pneumonia, and even death. Findings Included: 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. Record review of Resident #91's quarterly MDS completed on 03/26/24 revealed the following: Section C revealed a BIMS of 3 which indicated severely impaired cognition. Section GG noted eating was not attempted due to medical condition or safety concerns. 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. 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. Record review of Resident #91's active order summary dated 05/29/24 revealed the following: 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. 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. 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. 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. 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. 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.

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. The facility did not implement the training /orientation of CNA I related to abuse, neglect, and exploitation per facility policy. This failure could place residents in the facility at risk of Abuse, Neglect, or Exploitation. Findings included: 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. 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. 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. Record review of the facility provided New Hire Instructions page included the following: .New Hire MUST complete the following BEFORE floor work: - [Brand name of electronic program] Training And after all training is complete - then they are added to the schedule for orientation. Record Review of the facility provided policy titled Abuse, Neglect and Exploitation Prevention Program not dated, revealed the following: 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 observations, interviews, and record reviews the facility failed to develop and implement a comprehensive person-centered care plan for 1 (Resident #35) of 12 residents reviewed for care plans. The facility failed to implement Resident #35's care plan for a chair alarm in his w/c and 1:1 monitoring, and he had an unwitnessed fall which resulted in a broken left hip. This failure could place residents at risk of injury due to falls. Findings Included: 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 admitted [DATE]. 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). Record review of Resident #35's Quarterly MDS completed on 05/17/24 revealed the following: Section C of the MDS revealed a BIMS of 3 which indicated severely impaired cognition. Section GG of the MDS revealed Resident #35 was dependent on staff for walking and needed partial to substantial assistance with other mobility ADLs. Section J of the MDS indicated Resident #35 had had major surgery to repair a fracture as well as another major surgery. Section P of the MDS revealed bed and chair alarms were used daily. 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: 03/18/24 used a mobility monitor on his w/c for safety. 03/14/24 have increased assistance, surveillance, activities involvement, a mobility alarm, and be placed near the nurses' station. 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. Record review of Resident #35's active orders dated 05/30/24 revealed the following: An order for admission to skilled service related to hip fracture dated 03/13/24. An order to monitor left hip for s/s of infection twice a day dated 05/29/24. 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 which resulted in a broken right hip and a broken left hip. Record review of Resident #35's Progress Notes revealed the following: 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. 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. 03/15/24 written by RN L revealed Resident #35 attempted to turn himself in his bed without staff assistance. 03/17/24 written by RN M revealed Resident #35 attempted to get up without staff assistance. 03/18/24 written by RN M revealed Resident #35 attempted to get up without staff assistance. 03/19/24 written by RN L revealed Resident #35 attempted to get up without staff assistance. 03/20/24 written by RN L revealed Resident #35 attempted to get up without staff assistance. 03/25/24 01:11 PM written by RN L revealed Resident #35 got up from his bed without assistance. 03/25/24 10:50 PM written by RN M revealed Resident #35 attempted to get out of bed by himself. 04/30/24 written by LVN H revealed Resident #35 had a mobility alarm on his w/c. 05/03/24 written by RN L revealed Resident #35 attempted to get out of bed by himself. 05/12/24 written by RN M revealed Resident #35 got out of bed by himself. 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. 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 for a broken left hip. 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). 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. 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. 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. 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, she heard someone make a moaning sound twice. She said she turned to someone sitting next to her and they discussed the sound but did not know where it came from. LVN C stated 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. 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 . 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. 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. 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. 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. 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. During an interview on 05/30/24 at 03:28 PM, MDS RN stated she was responsible for writing care plans. She said 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. 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. 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. 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. 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. 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.

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. -CNA A failed to perform hand hygiene or glove changes during incontinent care. 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. Findings include: 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. 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. 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 [AGE] 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. 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. Record review of the facility provided policy titled Handwashing/Hand Hygiene undated revealed the following: Policy Interpretation and Implementation: 1. All personnel shall be trained and regularly in-serviced on the importance do hand hygiene in preventing the transmission of healthcare-associated infections. 2. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infection to other personnel, residents, and visitors. 7. Use of alcohol-based hand rub containing at least 62% alcohol, or, alternatively, soap and water for the following situations b. Before and after direct contact with residents. h. Before moving from a contaminated body site to a clean body site during resident care. 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. Record review of the facility provided training Peri Care Skills Checklist undated revealed the following: -Wash hands -Gather supplies -Set supplies on a clean field or surface -Wash hands, Put on gloves -Remove soiled brief -Using clean wipes, clean the genital area -Dispose of soiled wipes, linen protectors, and gloves -Wash hands and put on clean gloves -Place a clean brief -Remove gloves and wash hands -Reposition the resident in bed for comfort -Place call light -Sanitize immediately after leaving the resident room.

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. -The facility failed to include care plans for Resident #27's catheter. 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. Finding include: 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. 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). Record review of Resident #27's Order Summary Report with active orders as of 3-22-2023 listed the following orders: -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 -Foley Catheter care two times a day-order dated 1-20-2023, start date 1-20-2023 Record review of Resident #27's care plan with admitted [DATE] revealed no care plans for catheter care. 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. 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. 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. Record review of facility provided policy titled Care Plans, Comprehensive Person-Centered, undated, revealed the following: Policy Interpretation and Implementation- 8. The comprehensive, person-centered care plan will -b. Describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. -g. Incorporate identified problem area 9. Areas of concern that are identified during the resident assessment will be evaluated before interventions are added to the care plan.

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. Resident #147 was wearing/receiving oxygen but did not have an order for oxygen. 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). Findings include 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. 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. 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 Record review of Resident #147's physician's orders dated 03/21/23 revealed no orders for oxygen administration. 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. 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: 03/09/23 at 10:36 PM 94% 03/10/23 at 02:42 PM 95% 03/10/23 at 10:17 PM 98% 03/13/23 at 01:56 PM 99% 03/13/23 at 09:26 PM 96% 03/14/23 at 08:33 AM 96% 03/14/23 at 11:10 PM 94% 03/15/23 at 10:10 AM 92% 03/15/23 at 10:44 PM 92% 03/16/23 at 11:00 AM 94% 03/16/23 at 11:35 PM 92% 03/17/23 at 02:31 PM 92% 03/18/23 at 03:32 PM 95% 03/18/23 at 10:23 PM 90% 03/19/23 at 03:32 PM 95% 03/19/23 at 10:32 PM 92% 03/20/23 at 11:54 PM 91% 03/21/23 at 02:45 PM 95% 03/22/23 at 10:40 PM 98% 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. 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. 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. 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. 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. 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. 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. 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 03/09/23 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. Record review of an undated facility policy titled Admission revealed the following: . 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 . Record review of an undated facility policy titled Medication and Treatment Orders revealed the following: 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 store, prepare, and serve food under sanitary conditions in one of one kitchen when they failed to: A. Ensure foods were stored, prepared and served under sanitary conditions. B. Failed to ensure expired foods were discarded. These failures may increase the resident's risk for foodborne illness. Findings include: In an observation on [DATE] at 09:57 AM, on initial kitchen rounds in the refrigerator, the following: 1.A large container labeled double strength fortified milk dated [DATE]. In an observation on [DATE] at 03:02 PM, the following issues in the large pantry were observed: 1. 2 boxes of pullman wheat bread labeled keep frozen by manufacturer on box was sitting at room temperature 2. 4 bags of classic lays potato chips use by date [DATE] 3. 7 bags of Tostitos use by date [DATE] In an observation on [DATE] at 03:02 PM, the following issues in the small pantry were observed: 1. One of two boxes of crackers not sealed shut In an observation on [DATE] at 03:16 PM, the following issues in the kitchen were observed: 1. Two of two water filters on ice machine not dated In an observation on [DATE] at 03:18 PM, the following issues in the refrigerator were observed and unchanged: 1. A large container labeled fortified double strength milk dated [DATE] In an interview and a walk through with the Corporate Dietary Manager on [DATE] at 03:24 PM, the CDM stated that the fortified double strength milk had the created date of [DATE]. CDM stated the discard date would have been 7 days after creation date and affirmed it should have been on the label. The CDM stated that the wheat bread, classic lays potato chips, Tostitos and box of crackers would not be suitable for consumption and said he would deal with discarding the items. He stated the consequences of this action were that unsanitary conditions in the kitchen could cause germs to the food when using preparing foods that were expired or unsanitary which would cause the residents to get sick from food poisoning. He stated he has provided training to the dietary staff on cleanliness in the kitchen. In an interview with the Maintenance Supervisor on [DATE] at 03:39 PM, the MS stated he did not have records on changing the water filters for the ice machine. The MS said he did not have a logbook, but it was part of his routine to change the filters every 30 days. The MS stated if he were missing from work, it would not be done until he returned to work. Record review of the USDA Food Code, dated 2017, revealed: ,d+[DATE].11 Frozen Food. Stored frozen FOODS shall be maintained frozen. Record review of the USDA Food Code, dated 2017, revealed: ,d+[DATE].17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking. (A) Except when PACKAGING FOOD using a REDUCED OXYGEN PACKAGING method as specified under § ,d+[DATE].12, and except as specified in (E) and (F) of this section, refrigerated, READY-TOEAT, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and held in a FOOD ESTABLISHMENT for more than 24 hours shall be clearly marked to indicate the date or day by which the FOOD shall be consumed on the PREMISES, sold, or discarded when held at a temperature of 5ºC (41ºF) or less for a maximum of 7 days. The day of preparation shall be counted as Day 1. Record review of the USDA Food Code, dated 2017, revealed: ,d+[DATE].15 Package Integrity. FOOD packages shall be in good condition and protect the integrity of the contents so that the FOOD is not exposed to ADULTERATION or potential contaminants. Record review of the facility policy titled 'Sanitation of Equipment' dated [DATE], documented equipment will be cleaned daily.

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 five of 16 Residents (Resident #25, #26, #27, #33, and #34) reviewed for infection control. -LVN B failed to use proper technique when providing blood sugar monitoring for Residents #25, #26, #27, and #34. -LVN B provided care to Resident #33 who was positive for COVID-19 without wearing proper PPE. These failures have the potential to affect all residents receiving care by exposing them to infections resulting in poor healing, exacerbation of conditions, and deterioration in their health often resulting in the need for increased care, therapy, and even hospitalization . Findings include: Resident #25 Record review of Resident #25's face sheet, dated 1/5/2022, revealed a [AGE] year-old female resident admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #25's quarterly MDS, dated [DATE], revealed she had a BIMS of 6 which indicated she was severely cognitively impaired, and she had a functionality of requiring one to two-person assistance with activities. Resident #26 Record review of Resident #26's face sheet, dated 1/5/2022, revealed she was a [AGE] year-old female resident admitted to the facility originally on 2/7/2019 and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #26's admission MDS, dated [DATE], revealed a BIMS of 13 which indicated she was cognitively intact, and she had a functionality of requiring one to two-person assistance with all activities. Section H of the MDS revealed, Bladder and Bowel, H0100 Appliances, A. Indwelling Catheter . The answer was marked yes. Resident #27 Record review of Resident #27's face sheet, dated 1/5/2022, revealed a [AGE] year-old female resident admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #27's annual MDS, dated [DATE], revealed she had a BIMS of 1 which indicated she was severely cognitively impaired, and she had a functionality of requiring one to two-person assistance with activities. Resident #34 Record review of Resident #34's face sheet, dated 1/5/2022, revealed a [AGE] year-old male resident admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #34's admission MDS, dated [DATE], revealed he had a BIMS of 5 which indicated he was severely cognitively impaired, and he had a functionality of requiring one-person assistance with activities. During an observation on 01/04/22 at 11:08 AM, LVN B tested the blood sugar of Resident #34 using a glucometer and did not wipe or clean the glucometer upon completion During an observation on 01/04/22 at 11:15 AM, LVN B tested the blood sugar of Resident #26 (currently quarantined for [CONDITION(S)]) using the same glucometer she used on Resident #34. LVN B did not wipe or clean the glucometer prior to testing and then wiped the glucometer with Sani-Wipe-Plus (EPA# 9480-6 - not listed on the EPA for treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . During an observation on 01/04/22 at 11:23 AM, LVN B tested the blood sugar of Resident #27 using the glucometer she used on Resident #34 and #26. LVN B used the glucometer without cleaning it before or after the procedure. During an observation on 01/04/22 at 11:29 AM, LVN B tested the blood sugar of Resident #25 using the glucometer she used on Resident #34, #26, and #27. She did not clean the glucometer before testing resident #25's blood sugar. During an interview on 01/04/22 at 11:33 AM, when asked if the facility had a policy on cleaning blood sugar equipment between resident use, LVN B stated, Yes. I'm supposed to do that. I missed that. I usually do that. Y'all just made me nervous. When questioned what she was supposed to clean the blood sugar equipment with, LVN B pulled a prepackaged Sani-Cloth from the cart and wiped the machine. When asked how often she should have cleaned the blood sugar machine, LVN B stated, After every use. When questioned as to the possible consequences of not cleaning the blood sugar equipment between uses, LVN B stated, It can cause cross-contamination especially since there is blood involved. During an interview and observation on 01/04/22 at 11:54 AM, when in the presence of the PPE station in front of Resident #26's room the administrator verified that Resident #26 currently had [CONDITION(S)], verified that he could not find were the current Sani-Wipes Plus addressed the [CONDITION(S)] and reported he would pull the sheet to find out what this product treated. During an interview on 01/04/22 at 12:12 PM, ADM reported that he pulled the SDS sheet and the only thing he found was that the product kills VRE. ADM stated, I don't see anything about it killing [CONDITION(S)]. He provided this surveyor with the products SDS sheet which had no information on the disinfection against [CONDITION(S)]. During an interview on 01/04/22 at 12:23 PM, when questioned concerning the use of the Sani-Wipes-Plus, DON stated, We don't use those wipes for anything. They are part of a kit we pull for isolation. Residents are supposed to have their own equipment. Nothing comes out of their room, especially when they have [CONDITION(S)]. They have their own B/P cuff, pulse ox, thermometer, and anything they need of that nature. Nothing is supposed to come out of the room that could be used on anyone else. When questioned if she had any knowledge if Sani-Wipes Plus killed [CONDITION(S)], DON stated, Nothing kills [CONDITION(S)]. That's why nothing is removed from the resident's environment. When asked again, DON stated, No, the wipes do not kill [CONDITION(S)]. When presented with the issue of staff removing a glucometer used on a previous resident and then using the same glucometer on two other residents after cleaning with the Sani-Wipes-Plus, DON stated, That resident is supposed to have her own glucometer. When asked as to what the possible consequences were of not cleaning the glucometer with the proper cleaner to kill [CONDITION(S)], DON stated, There could be cross-contamination and we could pass on the [CONDITION(S)]. DON went on to report she would make sure that Resident #26 immediately received her own glucometer that would not be removed from the room. DON reported that all employees had been trained on proper infection control with [CONDITION(S)]. When questioned as to the facility policy on cleaning glucometer equipment between resident use, DON stated, The machine should be wiped down after each use, When asked what the consequences were if equipment, such as glucometers, were not cleaned between resident uses, DON stated, It could cause cross contamination and residents could develop illnesses. Record review of facility provided policy titled Cleaning and Disinfection of Resident-Care Items and Equipment undated, revealed the following: Policy Interpretation and Imp mentation: d. Reusable items - are cleaned and disinfected or sterilized between residents. (e.g., stethoscopes, durable medical equipment). 3, Durable medical equipment (DME) must be cleaned and disinfected before reuse by another resident. Resident #33 Record review of Resident #33's face sheet, dated 01/06/22, revealed a [AGE] year-old female admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #33's Admission MDS, dated [DATE], revealed a BIMS score of 3 out of 15 which indicated her cognition was severely impaired. She required extensive one-person assistance with bed mobility, transferring, and toilet use, extensive two-person assistance with dressing and limited one-person assistance with personal hygiene. Record review of Resident #33's progress notes revealed, in part: 1/5/2022 15:24 CNA called for nurse, resident was crawling out of her bedroom, resident at this time is on covid monitoring d/t recent positive results . 1/5/2022 17:04 Late Entry: Note Text: Spoke with husband concerning residents positive covid During an interview on 01/05/22 at 9:30 AM, DON stated Resident #33 tested positive for COVID-19 that morning during outbreak testing of all staff and residents. During an observation on 01/05/22 at 12:05 PM, a sign on Resident #33's room door read: DROPLET PRECAUTIONS To prevent the spread of infection, ANYONE ENTERING THIS ROOM MUST Hand Hygiene Surgical Mask Gloves Gown During an observation on 01/05/22 at 12:08 PM, LVN B was in Resident #33's room wearing an N95 respirator only. Resident #33 was not wearing any type of mask. LVN B was observed handling Resident #33's blanket that was lying across Resident #33 as she was sitting in her wheelchair. LVN B was then observed sitting on Resident #33's bed, talking to Resident #33 face-to-face while Resident #33 was sitting in her wheelchair. Container containing PPE observed outside of Resident #33's room. The only other COVID-19 positive resident was in the room next door to Resident #33 and there was not staff dedicated to caring for the COVID-19 positive residents only. During an interview on 01/05/22 at 12:12 PM, LVN B stated she should have been wearing a gown and gloves, in addition to her mask, every time she was in Resident #33's room. LVN B stated Resident #33 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . LVN B stated she just ran into Resident #33's room to make sure she didn't fall. LVN B stated not wearing proper PPE in a COVID-19 positive resident's room could have resulted in the spread of infection. During an interview on 01/06/22 at 11:22 AM, DON, who was also the Infection Control Preventionist, stated she expected staff to wear a gown, gloves, face shield, and mask when in a COVID-19 positive resident's room. DON stated if not wearing the proper PPE, staff could have obtained COVID-19 and could have spread it to the other residents. DON stated staff have been in-serviced and trained and they were aware what PPE to wear in a COVID-19 positive room. Record review of facility policy titled, Isolation-Initiating Transmission-Based Precautions, not dated, revealed, in part: Policy Statement Transmission-Based Precautions are initiated when a resident develops signs and symptoms of a transmissible infection; .or has a laboratory confirmed infection; and is at risk of transmitting the infection to other residents. Transmission-Based Precautions may include Contact Precautions, Droplet Precautions, or Airborne Precautions. .Policy Interpretation and Implementation .3. When Transmission-Based Precautions are implemented, the Infection Preventionist (or designee): .d. Determines the appropriate notification on the room entrance door so that personnel and visitors are aware of the need for and type of precautions: (1) The signage informs the staff of the type of CDC precautions(s), instructions for use of PPE, .

Based on observation, interview and record review, the facility failed to ensure assessments accurately reflected resident's status for 3 of 16 residents (Resident #9, #13, and #26) reviewed for accuracy of MDS assessments. -The facility mis-marked Resident #9 as having a trunk restraint on his MDS. -The facility did not address the use of an anticoagulants on the MDS for Resident #13 and #26. This failure to ensure accurate assessments could affect residents by placing them at risk for inaccurate and incomplete MDS assessments which could result residents not receiving correct care and services. Finding include: Resident #9 Record review of Resident #9's face sheet, dated 01/06/22, revealed a [AGE] year-old male admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #9's Quarterly MDS, dated [DATE], revealed a BIMS score of 14 out of 15 which indicated his cognition was intact. He required extensive two-person assistance with bed mobility, transferring, dressing and toilet use. Section P of the MDS indicated a trunk restraint was used less than daily during the look-back period. Record review of Resident #9's care plan, dated 12/17/21, revealed no care planning for a trunk restraint or any other type of restraint. Record review of Resident #9's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . During an observation and interview on 01/04/22 at 10:12 AM, Resident #9 was lying in his bed, on his back. There were no restraints observed on the resident. Resident #9 stated he had never been restrained. During an interview on 01/06/22 at 9:10 AM, DON stated that Resident #9 had not had any history of needing restraints that she was aware of. During a telephone interview on 01/06/22 at 9:30 AM, MDS Coordinator A stated she was not sure why Resident #9's MDS indicated a trunk restraint. She stated, I'm not sure about that, it must be a typing error. There isn't anything in his orders [about restraints]. I don't see anything that would remotely reflect any type of restraint. MDS Coordinator A stated there would be no negative resident outcome related to Resident #9's MDS being documented inaccurately. She stated there would be no restraint being put on Resident #9. MDS Coordinator A stated there was no restraint being reviewed, the MDS was reflecting incorrect information. MDS Coordinator A stated she followed the RAI manual when completing an MDS. She stated the company she used to work for sent her for training when MDS 3.0 came out, but other than that, she was required to keep up with any additional trainings, such as webinars, on her own. Resident #13 Record review of Resident #13's face sheet, dated 1-5-2022, revealed she was a [AGE] year-old female resident admitted to the facility originally on 9-11-2020 and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #13's annual MDS, dated [DATE], revealed she had a BIMS of 4 which indicated she was severely cognitively impaired, and she had a functionality of requiring set-up assistance with occasional one-person assistance with activities. Section N revealed, Medication-N0410 Medications Received. Indicate the number of days the resident received the following medication by pharmacological classification, not how it is used, during the last 7 days . E. Anticoagulant . the answer was 0. Record review of Resident #13's MAR, dated 11/1/2021 through 11/30/2021, indicated she received [MEDICATION(S)] 5mg po qd 11/1/2021 through 11/5/2021, and record review of Resident #3's MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #26 Record review of Resident #26's face sheet, dated 1/5/2022, revealed she was a [AGE] year-old female resident admitted to the facility originally on 2/7/2019 and readmitted on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #26's admission MDS, dated [DATE], revealed a BIMS of 13 which indicated she was cognitively intact, and she had a functionality of requiring one to two-person assistance with all activities. Section N of the MDS revealed, Medication-N0410 Medications Received. Indicate the number of days the resident received the following medication by pharmacological classification, not how it is used, during the last 7 days . E. Anticoagulant . The answer was 0. Record review of Resident #26's MAR, dated 12/1/2021 through 12/31/2021, indicated she received [MEDICATION(S)] 5mg po qd 12/1/2021 through 12/6/2021 and record review of Resident #26's MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 01/06/22 at 08:57 AM, ADM reported that all MDS information for the residents was currently handled off site by MDS Coordinator A. MDS Coordinator A would periodically make onsite visits. During an interview on 01/06/22 at 09:09 AM, when questioned by phone concerning the residents not having their [MEDICATION(S)] addressed on their last MDS, MDS Coordinator A reviewed the last MDS for both Resident #13 and Resident #26 (specifically their 7 day look back period) and stated, It was marked in error or in essence not marked, both should have had it addressed on their MDS because both did have the medication administered in the look back period. I didn't see the medication and I missed it. I'm going to correct it right now. When questioned as to the consequences of the medication not being address on the MDS's, MDS Coordinator A stated, It was human error, an oversite. There will be no affect because the resident will still receive the medication. The data information is incorrect. It will just be an incorrect MDS data entry. When questioned as to the policy used to ensure the MDS assessment is completed, MDS Coordinator A stated, We follow the RAI manual.

Based on observation, interview and record review, the facility failed to implement a comprehensive care plan for each resident that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment and described the services that were to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for two (Resident #4 and #26) of 16 residents reviewed for comprehensive care plans. -The facility failed to include accurate care planning for Resident #4's DNR status. -The facility failed to include care planning for Resident #26 who had a catheter and [CONDITION(S)] (C-Diff-inflamation of the Colon caused by the bacteria). This failure could affect 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. Findings include: Resident #4 Record Review of Resident #4's face sheet, dated [DATE], revealed an [AGE] year-old female admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The face sheet also indicated Resident #4 was a DNR. Record review of Resident #4's Annual MDS, dated [DATE], revealed a BIMS score of 13 out of 15 which indicated her cognition was intact. She was independent with bed mobility, transferring, and personal hygiene and required supervision with one-person physical assistance with dressing and toilet use. Record review of Resident #4's care plan, dated [DATE], revealed, in part: o I am full code . My Advanced directives will be honored and reviewed quarterly and on change of condition. . Staff will start CPR should [CONDITION(S)] occur and/or breathing independently ceases. Record review of Resident #4's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] DNR Verbal Active .Order date [DATE]. Record review of document in Resident #4's electronic health record titled, Out-Of-Hospital Do-Not-Resuscitate (OOH-DNR) Order, dated [DATE], revealed in Section A, in part: Declaration of the adult person: I am competent and at least [AGE] years of age. I direct that none of the following resuscitation measures be initiated or continued for me: cardiopulmonary resuscitation (CPR), transcutaneous cardiac pacing, defibrillation, advanced airway management, artificial ventilation. Section A was signed by Resident #4. During an interview on [DATE] at 9:33 AM, MDS Coordinator A stated Resident #4's care plan would have been considered inaccurate and it should have been corrected. She stated the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . MDS Coordinator A stated there was no potential negative resident outcome related to this inaccurate care plan. She stated the DNR status would have appeared on the treatment administration record and Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . MDS Coordinator A stated her care plan training coincided with her MDS trainings, which she received from a previous company. She stated she was required to keep up with any additional trainings on her own. During an interview [DATE] at 10:42 AM, DON stated Resident #4 was a DNR and her care plan should also have indicated she was a DNR. DON stated the care plan was what the facility used to direct resident care. She stated not having an accurate care plan could have resulted in staff treating Resident #4 as a full code instead of a DNR. Resident #26 Record review of Resident #26's face sheet, dated [DATE], revealed she was a [AGE] year-old female resident admitted to the facility originally on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #26's admission MDS, dated [DATE], revealed a BIMS of 13 indicating she was cognitively intact, and she had a functionality of requiring one to two-person assistance with all activities. Section H of the MDS indicated Bladder and Bowel, H0100 Appliances, A. Indwelling Catheter . The answer was marked yes. Record review of Resident #26's Lab Report with date of printed [DATE] and an order date of [DATE] revealed the following: C-Diff Toxin: Positive Record review of Resident #26's Order Summary Report with orders active as of [DATE] revealed the following: Foley cath. care every 12 hours for indwelling foley Foley cath. change one time a day every 21 days for urinary retention [MEDICATION(S)] HCL cap 125mg giver 125mg by mouth every 72 hours related to enterocolitis due to [CONDITION(S)], recurrent - end date of [DATE] Record review of Resident #26's care plan with admitted [DATE] revealed no care plans completed for her catheter or her [CONDITION(S)]. Noted in the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . During an observation an interview on [DATE] at 09:57 AM, Resident #26's door had two postings for contact precautions with listed PPE and required cleaning of hands. Per interview with the residents' daughter, who reported that her mother was tired and did not feel like communicating, the daughter verified that her mother had C-diff. Resident #26 was noted to have a catheter hanging from the foot of the bed in a privacy bag. During an interview on [DATE] at 09:19 AM, when questioned concerning Resident #26 not having care plans for the catheter, MDS Coordinator A stated, They were not reported correctly after her new admission. [Resident #26's] care plans have not been competed yet. When asked if the care plan for the catheter should have been in the resident's record, MDS Coordinator A stated, Yes, they should have been completed in the first 21 days. MDS Coordinator A continued to report that the resident had a previous admission, and the catheter care plan was present, but it had resolved unfortunately. When questioned as to the consequences of not having the resident's conditions addressed in the care plans, MDS Coordinator A stated, There would be no consequences because the resident chart still has her treatments and honestly the only thing is the documentation will not reflect accurately. MDS coordinator A reported that she was going to correct the oversite immediately. When questioned if Resident #26 had been care planned for her C-Diff that she had been diagnosed with on [DATE] and was still being treated for [MEDICAL RECORD OR PHYSICIAN ORDER] . I don't see the C-diff in her current care plan. When asked if the C-diff should be in the care plans, MDS Coordinator A stated, Yeah, it should be there. I'm correcting it now. When asked if there would be any consequences to not having the C-diff addressed in Resident #26's care plan MDS Coordinator A stated, There should not be consequences because the resident is still receiving the needed care. When asked what the care plan was used for, MDS Coordinator A stated, The info from the care plan should go into the tasks for the staff, especially the CNA's, that should be looked at by everyone involved in her care. The care plan should drive the care for the residents. During an interview on [DATE] at 09:37 AM, when question if there were any care plans for the Resident #26's catheter or C-diff, DON stated, The MDS person is responsible for making sure they are updated in the residents records so if they are not in the computer system then we don't have them. When asked what the consequences were of not having the care plan address the resident's conditions, DON stated, Then we don't know how to care for the resident. Record review of the facility provided policy titled, Care Plans, Comprehensive Person-Centered undated, revealed the following: Policy Statement: A comprehensive, person-centered care plan which includes measurable objectives and timetable to meet the resident's physical, psychosocial and function needs is developed and implemented for each resident. 12. The comprehensive, person-centered car plan is developed within seven (7) days of the completion of the required comprehensive assessment (MDS) 13. Assessment of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change.

Based on observation, interview, and record review, the facility failed to provide necessary care and services to prevent development and worsening of pressure sores for 2 of 7 residents reviewed for pressure ulcers. (Resident #'s 3 and 4) The facility failed to prevent Resident #3 from developing three pressure ulcers since her return to the facility, had not implemented new wound care interventions when the pressure ulcer on her left foot had worsened and failed to provide wound care for the pressure ulcer on her buttocks. The facility failed to put preventative measures in place for Resident #4 and increase his nutritional status before he developed a stage 2 pressure ulcer at the facility that the charge nurse or the DON was not aware of. This failure could place 35 residents that are in the chair all or most of the time at risk for developing pressure sores and decline in existing pressures sores. Resident #3 Record review of the clinical record face sheet documented that Resident #3 was readmitted to the facility on 3/21/13 and was [AGE] years of age with the following Diagnoses: [REDACTED]. Record review of the resident assessment form to be completed for all resident upon admission documented that the foot condition was normal for the right and left. It documented a skin risk assessment with a score of 12 which is moderate risk of skin breakdown. It documented she had compression boots to the lower extremities. Record review of the annual MDS dated [DATE] documented that she had a cognitive summary score of 5 and that she required extensive assistance with ADL's. It documented that she had 2 unstageable pressure ulcers with measurement of 6cm X 9 cm. with eschar. Record review of the quarterly MDS dated [DATE] documented that she had a cognitive summary score(BIMS) of 3 out of 15. She required extensive assistance with ADLs and that she had a stage 2 pressure ulcer. Record review of nurse's note dated 3/22/13 documented "when cleaning feet, noted red area approximately 3 cm in circumference to R heel and L heel purple area measuring 6-5 cm X 9 cm. Areas wrapped for protection and heel protectors applied. " Record review of nurse's note dated 4/4/13 documented "noted to R. buttocks open 4.0 cmX 3.5 cm. area covered for protection. Skin grid in place. Boots in place to protect heels. MD present and recommended protein supplements, Vit C and Zinc. While being on the shower gurney some blood was noted to L heel where black eschar is. Heel cleansed and covered." A nurses note on 4/5/13 documented a dressing to R. buttock intact slight drainage noted. Record review of nurse's note entry dated 3/28/13 documented a wound to the heel but no treatment orders were received until 4/4/13 when there was an order from PT to have the wound to the left heel evaluated by a wound care specialist. Record review of Physician order/ Patient instruction sheet, dated 4/24/13 after Resident #3 had been seen at the wound care center had an order for [REDACTED]. Record review revealed that there was no documented wound care to the heels until 5/1/13. On 5/1/13, treatment with [MEDICATION NAME] to the heels was documented. Record review of initial skin grid - pressure/stasis sheet documented on 3/31/13 a left heel wound that was not present on admission that is a pressure area measuring 8.0cm X 7.0cm and was documented on 4/14/13 as a stage 2 pressure. Documentation continued until 6/30/13 then on 7/7/13 the wound to the L heel is documented as a stage 3 which measured 1.5 cm X1.8 cm X 0.3 cm with purulent drainage, red/yellow in color with a foul odor and slightly deeper noted in the comment section. No new orders were noted for changes in wound care since she was seen at the wound care center. Record review of an initial skin grid pressure/stasis sheet documented on 3/31/13 a right heel pressure ulcer that was not present on admission to be 4 cm X 3 cm. The pressure ulcer was documented on until healed on 5/26/13. During an interview with the DON on 7/10/13 at 10:20 AM, she said that Resident #3 " had a pressure ulcer on her left heel and that she had when she returned from the hospital. She said the charge nurse failed to do a thorough skin assessment and she did not pull back the dressings to assess the skin when she was readmitted . She said that it should have been documented but since it wasn ' t the facility had to own those areas. " Resident #3 returned from the wound care center on 4/24/13 with orders" to paint with [MEDICATION NAME] and cover with gauze form roll daily for R and L heel." No changes were made in the wound care for the heels from 4/24/13 until present, even though the pressure ulcer had worsened from a stage 2 to a stage 3. There was no documented skin assessment sheets from 3/21/13 to 4/14/13. March 2013 treatment records show no documentation of wound care to the heels. During an observation on 7/10/13 at 11:45 AM, with LVN D, she said that " she wears the boots all the time when out of bed but in the bed we float her heels. " She removed the boots and a scab is noted to the left lateral side of the foot. LVN D said that the scab is from her feet rubbing together. No dressing noted to the nickel sized area. A brownish colored shallow crater that was the size of a nickel was noted to the heel of the left foot. A foul smell was noted when the dressing was removed. Some slight serous drainage was noted to the dressing. LVN D said it was a stage 2. During an interview with the DON on 7/10/13 10:00 a.m., she said nurses do weekly skin assessments. They are supposed to do head to toe skin assessments on Sundays. If the CNA find a concern they should report it to the charge nurse and they will evaluate it and decide if the doctor needs to be notified and they will also notify the DON or ADON. Resident #4 Record review of the clinical record face sheet documented Resident # 4 was admitted on [DATE] and was [AGE] years of age, with the following Diagnoses: [REDACTED]. Record review of the admission MDS resident assessment dated [DATE] documented that Resident #4 was unable to complete a mental status interview and that he had short term and long term memory problems and that his cognitive skills for daily living were severely impaired. It documented that he required extensive assistance with bed mobility, transfers and all ADL care. It documented that he was able to eat with supervison and set up. It documented that he was frequently incontinent of bowel and bladder. It documented that weighed 130 lbs. Review of the quarterly MDS resident assessment dated [DATE] documented he required extensive assistance with eating and that one person was needed for physical assist. It documented that he was always incontinent of bowel and bladder. It documented a weight of 120 lbs. It documented that he was at risk of developing pressure ulcers but did not have any pressure ulcers. Record of the facility submitted Resident Weight Report for March 2013 to July 2013 revealed a weight loss of 15 lbs. in four months. During an interview with the DON on 7/10/13 10:00 AM, she said Resident #4 had returned to the facility on [DATE] from the hospital after he re-injured his hip after having a [MEDICAL CONDITION]. Standard order for pressure relieving mattress for all residents. The Braden scale is used to assess risk level for skin breakdown. She said there was " no log for turning or repositioning the residents but the charge nurses should be following up to make sure it is done. I would hope that they are turning him. " She said Resident #4 might have some redness to his bottom but he did not have a stage 2 pressure ulcer that she was aware of. She said they are using lantaseptic on the area. During an observation on 7/9/13 at 4:05 p.m., during incontinent care on Resident #4, a red, open, raw area to the right buttock was noted. There was no pressure relieving device noted to the mattress. During an interview with CNA H after incontinent care, the surveyor asked her how long Resident #4 had this area and she stated "2 weeks, then stated 1 week." During an observation on 7/10/13 at 10:30 a.m., in Resident #4 ' s room with the DON and ADON the wound to the right buttock measured 2.5 cm X 1.0. The pressure ulcer was a shallow crater with the top layer of skin removed, it was red in the center. No drainage or odor was noted. Record review of facility's inservice training on skin issues, admission assessments and therapy charting on 4/12/13. It documented 6 nurses had attended the educational training by the DON. It documented the classifications of pressure ulcers, documentation and measuring points, pressure ulcer assessment and reassessment guidelines, proper positioning and pressure points and how to determine if it is a pressure ulcer or something else. No documentation was presented on educating the CNAs concerning turning, reporting any changes in skin condition. Record review of facility policy titled Wound Prevention and Management dated April 2008 that stated the facility strives to ensure that a resident entering the facility without a pressure ulcer does not develp pressure ulcers unless the individual ' s clinical condition demonstrates that they are unavoidable. The facility will implement the following interventions to prevent the development of pressure ulcers: - Identify at risk residents, the specific factors placing them at risk, and implement appropriate preventive interventions. - Reduce occurrence of pressure over bony prominences to minimize injury. - Protect against the adverse effects of external mechanical forces pressure, friction,shear). - Increase the awareness of pressure ulcer prevention though educational programs. It documents the procedure is to assess all residents to determine risk for pressure ulcer development using a Nursing Comprehensive Admission Assessment, Braden Risk Assessment Scale and Nutritional Risk Assessment. The CMS form 672 completed by the DON on 7/8/13 documented a census of 45 residents. Only 1 resident was listed as having a pressure ulcer but 3 more were identified during the survey.

Based on observation, interview, and record review, the facility failed to ensure acceptable nutritional parameters for 2 of 10 residents (Resident #4 and 10). Resident #4 had a weight loss of 15lbs in 3months, which is an 11% weight loss and the facility failed to identify risk and implement measures to prevent weight loss. Resident #10 had a weight loss of 12 lbs in 3 months, which is a9% weight loss, and the facility failed to provide nutritional supplements as ordered and to implement any new interventions to avoid weight loss. This failure could place 23 additional residents with weight loss/weight concerns identified by the facility at risk of further weight loss. Findings included: Resident #4 Record review of the clinical record face sheet documented Resident # 4 was admitted on [DATE] and was [AGE] years of age, with the following Diagnoses: [REDACTED]. Record review of the admission MDS resident assessment dated [DATE] documented that Resident #4 was unable to complete a mental status interview and that he had short term and long term memory problems and that his cognitive skills for daily living were severely impaired. It documented that he required extensive assistance with bed mobility, transfers and all ADL care. It documented that he was able to eat with supervison and set up. It documented that he was frequently incontinent of bowel and bladder. It documented that weighed 130 lbs. Record review of the quarterly MDS resident assessment dated [DATE] documented he required extensive assistance with eating and that one person was needed for physical assist. It documented that he was always incontinent of bowel and bladder. It documented a weight of 120 lbs. It documented that he was at risk of developing pressure ulcers but did not have any pressure ulcers. Record review of the facility submitted Resident Weight Report for March 2013 to July 2013 revealed a weight loss of 15 lbs in four months which is an 11% weight loss in 3 months. March 2013 - 132.6 April 2013 - 132.8 May 2013 - 145.5 June 2013 - 130.5 July 2013 - 117.60 During a meal observation on 7/9/13 at 12:46 PM in the dining room, Resident #4 ate 25% of his meal. Resident #4 was not observed to be assisted with or offered any supplemental nutrition. During an interview on with the DON on 7/10/13 at 9:00 AM, she said she was not aware that Resident #4 had a weight loss. During an interview with the MDS coordinator on 7/10/13 at 2:20 PM, she said that Resident #4's weight loss should have triggered and should have been documented on the roster matrix. She said Resident #4 should be getting offered shakes and ice cream at 10 AM, 2 PM, 8 PM and snack. She said the kitchen staff set them up and the CNAs are responsible for getting them to the residents and assisting them as needed but the charge nurse is responsible for making sure they receive them. She said that they use to have a sheet for meal consumption. Resident #10 Record review of the clinical record face sheet documented Resident #10 was admitted to the facility on [DATE] and was [AGE] years of age, with the following Diagnoses: [REDACTED]. Record review of the significant change undated MDS resident assessment documented that she had a cognitive summary score (BIMS) of 06 and that she had short term and long term memory impairment. It documented that there was a loss of 5% or more in the last month and documented her weight at 120 lbs. It documented that she was independent with eating and setup help only was needed. Record review of the Interdisciplinary Plan of Care on 6/14/13 documented that her appetite was fair and that her weight had gone from 130 lbs to 120 lbs and that she had a 10 lb weight loss but no interventions were documented. The individualized care plan for Resident #10 failed to implement interventions for declining nutrional status. Record review of the facility submitted Resident Weight Report for March 2013 to July 2013 revealed a weight loss of 10 lbs in four months which is a 9% weight loss in 3 months. March 2013 - 127.0 April 2013 - 128.8 May 2013 - 130.0 June 2013 - 120.0 July 2013 - 116.6 Record review of physician orders [REDACTED]. The June 2013 therapy sheet had 14 empty spaces for documentation that the 10 AM supplement was given. The July 2013 therapy sheet had no documentation that the 10 AM supplement was given and had documented that the protein supplement if <50% of meal consumed was given only four times in two days even though it had documented good intake beside regular diet for those meals. Record review of dietary note dated 3/20/13 stated to consider increasing the protein supplement to TID (three times a day). The comprehensive metabolic panel documented an [MEDICATION NAME] level on 5/8/13 was 4.1. The lab results on 6/6/13 documented that the [MEDICATION NAME] level had dropped to 3.6. During on observation/interview on 7/10/13 at 3:20 PM, she said that she did not like the food. She said they bring her supplements but their were no shake glass or containers noted in the room but the nutrition cart had been pushed down the halls prior to this observation. Record review of new physician order [REDACTED]. During an interview with LVN D on 7/10/13 at 3:45 AM, she said that she usually is in the dining room to assist with meals but the aides will get a supplement for a resident that they are feeding if needed. She said they don't document the percentage of food eaten but use a dietary intake chart posted in the dining room that states: Good intake (G) = is 75% or majority of the food is consumed Fair intake (F) = approximately half of the food is consumed Poor intake (P) = 25% approximately eaten or 50% of 1 entree Record review of facility submitted policy titled Nutrition Management Program dated December 2001 states: 1. Identify nutritional status 2. Develop and implement individualized interventions to prevent/reduce the risk of nutritional disorders. example Pharmalogical interventions, supplements (Med pass), snacks. 3. Determine the amount of time the resident needs for adequate intake of meals. 4. Communicate interventions to caregiving team. 5. Provide staff training as needed. 6. Plan for sufficient staff assistance at mealtime for dependent/confused residents. 7. Record percentage of food and fluid intake at each meal unless alternative process implemented to determine if nutrition is adequate to meet the residents needs. 8. Trend and communicate types of foods remaining on plate for reevaluation of food likes and dislikes. Offer food substitutions as needed. 9. Weight residents monthly or more frequently as needed to assure maintaining /reaching Usual Body Weight. 10. Report the following weight loss/gain to immediate Supervisor. a. 5% for one month b. 7.5 % for three months c. 10% for six months 11. Report the weight loss to the Dietitian, Physician, family/caregiver and obtain orders if needed. 12. Develop an interdisciplinary educational plan in collaboration with the resident/family. 13. Review and revise the risk prevention/reduction interventions as needed. The CMS form 672 completed by the DON on 7/8/13 documented a census of 45 residents. Ten residents were documented as being on a mechanically altered diet. A facililty submitted list of residents receiving supplements was received on 7/9/13 with 18 printed names and 7 handwritten names.

Based on observation, interview and record review, the administrator failed to ensure that the nursing staff was supervised and monitored to assure that care and services were provided to attain or maintain the highest practicable physical, mental and psychosocial well-being for 2 of 12 residents (Resident #3 and Resident #4) reviewed for pressure sores and weight loss and failed to ensure acceptable nutritional parameters, such as body weight and protein levels for 2 of 12 residents (Resident #4 and Resident #10) . The administrator failed to ensure the DON and nursing staff were providing the necessary care and services to prevent development and worsening of pressure ulcers. The administrator failed to ensure the facility was operated in a manner that enabled residents to maintain acceptable nutritional parameters to prevent avoidable weight loss. On 7/10/13 at 12:40 pm, substandard quality of care was identified in the areas of quality of care related to pressure ulcers and weight loss. The ADM was notified at this time. The ADM was informed that the survey would be extended. These failures could place 35 residents that are in the chair all or most of the time at risk for developing pressure sores and could result in a worsening of existing pressure sores. This failure could place 23 additional residents identified by the facility with weight loss/ weight concerns at risk of further weight loss and [MEDICAL CONDITION]. Findings include: Resident #3 Record review of the clinical record face sheet documented that Resident #3 was readmitted to the facility on 3/21/13 and was [AGE] years of age with the following Diagnoses: [REDACTED]. Record review of the resident assessment form to be completed for all resident upon admission documented that the foot condition was normal for the right and left. It documented a skin risk assessment with a score of 12 which is moderate risk of skin breakdown. It documented she had compression boots to the lower extremities. Record review of the annual MDS dated [DATE] documented that she had a cognitive summary score of 5 and that she required extensive assistance with ADL's. It documented that she had 2 unstageable pressure ulcers with measurement of 6cm X 9 cm. with eschar. Record review of the quarterly MDS dated [DATE] documented that she had a cognitive summary score(BIMS) of 3 out of 15. She required extensive assistance with ADLs and that she had a stage 2 pressure ulcer. Record review of nurse's note dated 3/22/13 documented "when cleaning feet, noted red area approximately 3 cm in circumference to R heel and L heel purple area measuring 6-5 cm X 9 cm. Areas wrapped for protection and heel protectors applied. " Record review of nurse's note dated 4/4/13 documented "noted to R. buttocks open 4.0 cmX 3.5 cm. area covered for protection. Skin grid in place. Boots in place to protect heels. MD present and recommended protein supplements, Vit C and Zinc. While being on the shower gurney some blood was noted to L heel where black eschar is. Heel cleansed and covered." A nurses note on 4/5/13 documented a dressing to R. buttock intact slight drainage noted. Record review of nurse's note entry dated 3/28/13 documented a wound to the heel but no treatment orders were received until 4/4/13 when there was an order from PT to have the wound to the left heel evaluated by a wound care specialist. Record review of Physician order/ Patient instruction sheet, dated 4/24/13 after Resident #3 had been seen at the wound care center had an order for [REDACTED]. Record review revealed that there was no documented wound care to the heels until 5/1/13. On 5/1/13, treatment with [MEDICATION NAME] to the heels was documented. Record review of initial skin grid - pressure/stasis sheet documented on 3/31/13 a left heel wound that was not present on admission that is a pressure area measuring 8.0cm X 7.0cm and was documented on 4/14/13 as a stage 2 pressure. Documentation continued until 6/30/13 then on 7/7/13 the wound to the L heel is documented as a stage 3 which measured 1.5 cm X1.8 cm X 0.3 cm with purulent drainage, red/yellow in color with a foul odor and slightly deeper noted in the comment section. No new orders were noted for changes in wound care since she was seen at the wound care center. Record review of an initial skin grid pressure/stasis sheet documented on 3/31/13 a right heel pressure ulcer that was not present on admission to be 4 cm X 3 cm. The pressure ulcer was documented on until healed on 5/26/13. During an interview with the DON on 7/10/13 at 10:20 AM, she said that Resident #3 " had a pressure ulcer on her left heel and that she had when she returned from the hospital. She said the charge nurse failed to do a thorough skin assessment and she did not pull back the dressings to assess the skin when she was readmitted . She said that it should have been documented but since it wasn ' t the facility had to own those areas. " Resident #3 returned from the wound care center on 4/24/13 with orders" to paint with [MEDICATION NAME] and cover with gauze form roll daily for R and L heel." No changes were made in the wound care for the heels from 4/24/13 until present, even though the pressure ulcer had worsened from a stage 2 to a stage 3. There was no documented skin assessment sheets from 3/21/13 to 4/14/13. March 2013 treatment records show no documentation of wound care to the heels. During an observation on 7/10/13 at 11:45 AM, with LVN D, she said that " she wears the boots all the time when out of bed but in the bed we float her heels. " She removed the boots and a scab is noted to the left lateral side of the foot. LVN D said that the scab is from her feet rubbing together. No dressing noted to the nickel sized area. A brownish colored shallow crater that was the size of a nickel was noted to the heel of the left foot. A foul smell was noted when the dressing was removed. Some slight serous drainage was noted to the dressing. LVN D said it was a stage 2. During an interview with the DON on 7/10/13 10:00 a.m., she said nurses do weekly skin assessments. They are supposed to do head to toe skin assessments on Sundays. If the CNA find a concern they should report it to the charge nurse and they will evaluate it and decide if the doctor needs to be notified and they will also notify the DON or ADON. Resident #4 Record review of the clinical record face sheet documented Resident # 4 was admitted on [DATE] and was [AGE] years of age, with the following Diagnoses: [REDACTED]. Record review of the admission MDS resident assessment dated [DATE] documented that Resident #4 was unable to complete a mental status interview and that he had short term and long term memory problems and that his cognitive skills for daily living were severely impaired. It documented that he required extensive assistance with bed mobility, transfers and all ADL care. It documented that he was able to eat with supervison and set up. It documented that he was frequently incontinent of bowel and bladder. It documented that weighed 130 lbs. Review of the quarterly MDS resident assessment dated [DATE] documented he required extensive assistance with eating and that one person was needed for physical assist. It documented that he was always incontinent of bowel and bladder. It documented a weight of 120 lbs. It documented that he was at risk of developing pressure ulcers but did not have any pressure ulcers. During an interview with the DON on 7/10/13 10:00 AM, she said Resident #4 had returned to the facility on [DATE] from the hospital after he re-injured his hip after having a [MEDICAL CONDITION]. Standard order for pressure relieving mattress for all residents. The Braden scale is used to assess risk level for skin breakdown. She said there was " no log for turning or repositioning the residents but the charge nurses should be following up to make sure it is done. I would hope that they are turning him. " She said Resident #4 might have some redness to his bottom but he did not have a stage 2 pressure ulcer that she was aware of. She said they are using lantaseptic on the area. During an observation on 7/9/13 at 4:05 p.m., during incontinent care on Resident #4, a red, open, raw area to the right buttock was noted. There was no pressure relieving device noted to the mattress. During an interview with CNA H after incontinent care, the surveyor asked her how long Resident #4 had this area and she stated "2 weeks, then stated 1 week." During an observation on 7/10/13 at 10:30 a.m., in Resident #4 ' s room with the DON and ADON the wound to the right buttock measured 2.5 cm X 1.0. The pressure ulcer was a shallow crater with the top layer of skin removed, it was red in the center. No drainage or odor was noted. Record review of facility's inservice training on skin issues, admission assessments and therapy charting on 4/12/13. It documented 6 nurses had attended the educational training by the DON. It documented the classifications of pressure ulcers, documentation and measuring points, pressure ulcer assessment and reassessment guidelines, proper positioning and pressure points and how to determine if it is a pressure ulcer or something else. No documentation was presented on educating the CNAs concerning turning, reporting any changes in skin condition. Record review of facility policy titled Wound Prevention and Management dated April 2008 that stated the facility strives to ensure that a resident entering the facility without a pressure ulcer does not develp pressure ulcers unless the individual ' s clinical condition demonstrates that they are unavoidable. The facility will implement the following interventions to prevent the development of pressure ulcers: - Identify at risk residents, the specific factors placing them at risk, and implement appropriate preventive interventions. - Reduce occurrence of pressure over bony prominences to minimize injury. - Protect against the adverse effects of external mechanical forces pressure, friction,shear). - Increase the awareness of pressure ulcer prevention though educational programs. It documents the procedure is to assess all residents to determine risk for pressure ulcer development using a Nursing Comprehensive Admission Assessment, Braden Risk Assessment Scale and Nutritional Risk Assessment. Record review of the facility submitted Resident Weight Report for March 2013 to July 2013 revealed a weight loss of 15 lbs in four months which is an 11% weight loss in 3 months. March 2013 - 132.6 April 2013 - 132.8 May 2013 - 145.5 June 2013 - 130.5 July 2013 - 117.60 During a meal observation on 7/9/13 at 12:46 PM in the dining room, Resident #4 ate 25% of his meal. Resident #4 was not observed to be assisted with or offered any supplemental nutrition. During an interview on with the DON on 7/10/13 at 9:00 AM, she said she was not aware that Resident #4 had a weight loss. During an interview with the MDS coordinator on 7/10/13 at 2:20 PM, she said that Resident #4's weight loss should have triggered and should have been documented on the roster matrix. She said Resident #4 should be getting offered shakes and ice cream at 10 AM, 2 PM, 8 PM and snack. She said the kitchen staff set them up and the CNAs are responsible for getting them to the residents and assisting them as needed but the charge nurse is responsible for making sure they receive them. She said that they use to have a sheet for meal consumption. Resident #10 Record review of the clinical record face sheet documented Resident #10 was admitted to the facility on [DATE] and was [AGE] years of age, with the following Diagnoses: [REDACTED]. Record review of the significant change undated MDS resident assessment documented that she had a cognitive summary score (BIMS) of 06 and that she had short term and long term memory impairment. It documented that there was a loss of 5% or more in the last month and documented her weight at 120 lbs. It documented that she was independent with eating and setup help only was needed. Record review of the Interdisciplinary Plan of Care on 6/14/13 documented that her appetite was fair and that her weight had gone from 130 lbs to 120 lbs and that she had a 10 lb weight loss but no interventions were documented. The individualized care plan for Resident #10 failed to implement interventions for declining nutrional status. Record review of the facility submitted Resident Weight Report for March 2013 to July 2013 revealed a weight loss of 10 lbs in four months which is a 9% weight loss in 3 months. March 2013 - 127.0 April 2013 - 128.8 May 2013 - 130.0 June 2013 - 120.0 July 2013 - 116.6 Record review of physician orders [REDACTED]. The June 2013 therapy sheet had 14 empty spaces for documentation that the 10 AM supplement was given. The July 2013 therapy sheet had no documentation that the 10 AM supplement was given and had documented that the protein supplement if <50% of meal consumed was given only four times in two days even though it had documented good intake beside regular diet for those meals. Record review of dietary note dated 3/20/13 stated to consider increasing the protein supplement to TID (three times a day). The comprehensive metabolic panel documented an [MEDICATION NAME] level on 5/8/13 was 4.1. The lab results on 6/6/13 documented that the [MEDICATION NAME] level had dropped to 3.6. During on observation/interview on 7/10/13 at 3:20 PM, she said that she did not like the food. She said they bring her supplements but their were no shake glass or containers noted in the room but the nutrition cart had been pushed down the halls prior to this observation. Record review of new physician order [REDACTED]. During an interview with LVN D on 7/10/13 at 3:45 AM, she said that she usually is in the dining room to assist with meals but the aides will get a supplement for a resident that they are feeding if needed. She said they don't document the percentage of food eaten but use a dietary intake chart posted in the dining room that states: Good intake (G) = is 75% or majority of the food is consumed Fair intake (F) = approximately half of the food is consumed Poor intake (P) = 25% approximately eaten or 50% of 1 entree Record review of facility submitted policy titled Nutrition Management Program dated December 2001 states: 1. Identify nutritional status 2. Develop and implement individualized interventions to prevent/reduce the risk of nutritional disorders. example Pharmalogical interventions, supplements (Med pass), snacks. 3. Determine the amount of time the resident needs for adequate intake of meals. 4. Communicate interventions to caregiving team. 5. Provide staff training as needed. 6. Plan for sufficient staff assistance at mealtime for dependent/confused residents. 7. Record percentage of food and fluid intake at each meal unless alternative process implemented to determine if nutrition is adequate to meet the residents needs. 8. Trend and communicate types of foods remaining on plate for reevaluation of food likes and dislikes. Offer food substitutions as needed. 9. Weight residents monthly or more frequently as needed to assure maintaining /reaching Usual Body Weight. 10. Report the following weight loss/gain to immediate Supervisor. a. 5% for one month b. 7.5 % for three months c. 10% for six months 11. Report the weight loss to the Dietitian, Physician, family/caregiver and obtain orders if needed. 12. Develop an interdisciplinary educational plan in collaboration with the resident/family. 13. Review and revise the risk prevention/reduction interventions as needed. The CMS form 672 completed by the DON on 7/8/13 documented a census of 45 residents. Ten residents were documented as being on a mechanically altered diet. A facililty submitted list of residents receiving supplements was received on 7/9/13 with 18 printed names and 7 handwritten names.