Every finding on record at Anna John Resident Centered Care Community

Based on observation, staff interview, and record review, the facility did not ensure food was stored and prepared in a sanitary manner. This practice had the potential to affect all 42 residents residing in the facility.Ceiling vents, ceiling tiles, and a ceiling grid above the steam table and where clean dishes were stored contained dust particles and dark-colored debris. Cooking equipment contained dust, debris, and dried food particles. The temperature of the water mixed with sanitizing solution in the three-compartment sink and sanitizing buckets was not checked prior to testing parts per million (PPM) of the solution.Findings include: Ceiling Vents/Tiles/Grid and Equipment: The 2022 Food and Drug Administration (FDA) Food Code documents at 6-202.12 Heating, Ventilating, Air Conditioning System Vents: Heating and air conditioning system vents that are not properly designed and located may be difficult to clean and result in the contamination of food, food preparation surfaces, equipment, or utensils by dust or other accumulated soil from the exhaust vents. The 2022 FDA Food Code documents at 6-501.14 Cleaning Ventilation Systems, Nuisance and Discharge Prohibition: (A) Intake and exhaust air ducts shall be cleaned and filters changed so they are not a source of contamination by dust, dirt, and other materials The 2022 FDA Food Code documents at 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils: Equipment, utensils, and linens shall be clean to sight and touch .(B) The food-contact surfaces of cooking equipment and pans shall be kept free of encrusted grease deposits and other soil accumulations. (C) Nonfood-contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris. On 2/26/26 at 9:02 AM, Surveyor conducted an initial tour of the kitchen and noted ceiling tiles and a metal grid that held tiles above the steam table and in an area where clean dishes, including cutting boards, frying pans, steam table bins, bread pans, and other cookware were stored, contained dust particles. Under the ceiling vents in the steam table area, Surveyor observed plastic covers used to cover plated food served to residents. Surveyor also observed dark areas with dust adhered to them on ceiling vents near the steam table. On 2/16/26 at 9:15 AM, Surveyor observed a grease-like film that contained dust and debris on the sides of equipment used to cook and fry food. On 2/16/26 at 11:15 AM, Surveyor interviewed [NAME] (CK)-G who was not sure how often the ceiling was cleaned but stated new ceiling tiles were installed a couple months ago. On 2/16/26 at 1:00 PM, Surveyor interviewed CK-I who confirmed the steam table under the ceiling grid, tiles, and vents that contained debris was the main steam table where cooked food was held and plated for residents. On 2/16/26 at 1:05 PM, Surveyor interviewed Registered Dietitian (RD)-F who stated the facility follows the Federal (FDA) Food Code. RD-F indicated the dark areas on the ceiling vents were from wear. Upon further observation, RD-F confirmed the ceiling tiles and vents contained dust. RD-F stated maintenance staff or RD-F cleaned the ceiling every couple of months. On 2/16/26 at 2:00 PM, Surveyor observed RD-F clean the ceiling tiles and vents and the equipment used to cook/fry food. Surveyor noted there was no dark-colored debris or dust particles where RD-F had cleaned. RD-F confirmed the dark area areas wiped off and were not due to wear. On 2/17/26 at 7:50 AM, RD-F provided Surveyor with a cleaning schedule. RD-F stated RD-F added cleaning the ceiling on a monthly basis and indicated the ceiling had been cleaned every 3 months prior. The cleaning schedule also included an entry for cleaning equipment. Sanitizing Solution: The 2022 FDA Food Code documents as 4-501.114 Manual and Mechanical Ware Washing Equipment, Chemical Sanitization - Temperature, pH, Concentration, and Hardness: A chemical sanitizer used in a sanitizing solution for a manual or mechanical operation at contact times specified under 4-703.11(C) shall meet the criteria specified under 7-204.11 Sanitizers, Criteria, shall be used in accordance with the Environmental Protection Agency (EPA)-registered label use instructions, and shall be used as follows: .C) A quaternary ammonium compound solution shall: (1) Have a minimum temperature of 24 degrees Celsius (C) (75 degrees Fahrenheit (F)), (2) Have a concentration as specified under 7-204.11 and as indicated by the manufacturer's use directions included in the labeling . On 2/16/26 at 12:30 PM, Surveyor reviewed instructions on the Hydrian Quat Dispenser test strip container which stated to dip a strip into the sanitizing solution for 10 seconds and instantly compare the resulting color with the enclosed color chart which matched concentrations of 0-100; 100-200; 200-300; and 300-400 PPM. The container indicated the solution should be between 65 and 75 degrees F when tested. On 2/16/26 at 12:45 PM, Surveyor noted the three-compartment sink and a red bucket with a dish cloth near the sink were filled with water and sanitizing solution. Surveyor reviewed a PPM log located near the sink that contained the month, day, and a column for PPM. The form did not include a space for temperature. On 2/16/26 at 1:00 PM, Surveyor interviewed CK-H who stated the three-compartment sink is used to wash large dishes used for food preparation that do not fit in the dishwashing machine. CK-H stated the solution in the red bucket is used to wipe surfaces in the kitchen, including counters where food is prepared. CK-H confirmed litmus Hydrian test strips near the sink are used to check PPM of the sanitizing solution. CK-H stated the range the litmus should indicate for sanitizer efficacy and confirmed the facility uses Quat sanitizer. CK-H stated the temperature of the water mixed with sanitizing solution in the three-compartment sink and red bucket is not checked when PPM are tested. When Surveyor showed CK-H the instructions for testing PPM which indicated the water temperature should be between 65 and 75 degrees, CK-H stated CK-H tests the solution when the water is luke warm. CK-H confirmed CK-H does not use a thermometer to test the temperature. On 2/17/26 at 10:55 AM, Surveyor interviewed CK-G who stated the temperature of water used in the three-compartment sink is not checked with a thermometer when PPM are tested. On 2/17/26 at 8:52 AM, Surveyor interviewed RD-F who confirmed the temperature of the water mixed with the sanitizing solution is not checked when PPM are tested in the three-compartment sink or the bucket used to clean kitchen and food prep surfaces.

Based on staff interview and record review, the facility did not complete Quarterly Minimum Data Set (MDS) assessments within the required timeframe for 5 residents (R) (R23, R25, R32, R42, and R43) of 42 sampled residents. Review of the facility's MDS assessment submission indicated the following: ~ R23's Quarterly MDS assessment, due December 2025, was not completed.~ R25's Quarterly MDS assessment, due September 2025, was not completed.~ R32's Quarterly MDS assessment, due August 2025, was not completed.~ R42's Quarterly MDS assessments, due March 2025 and September 2025, were not completed.~ R43's Quarterly MDS assessments, due February 2025 and May 2025, were not completed. Findings include: The Resident Assessment Instrument (RAI) Manual, revised October 2025, indicates: .Assuming the resident did not experience a significant change in status, was not discharged , and did not have a Significant Correction to Prior Comprehensive Assessment (SCPA) completed, assessment scheduling would then move through a cycle of three Quarterly assessments followed by an Annual (Comprehensive) assessment .An Omnibus Budget Reconciliation Act (OBRA) assessment (Comprehensive and Quarterly) is due every quarter unless the resident is no longer in the facility. There must be no more than 92 days between OBRA assessments. From 2/16/26 to 2/18/26, Surveyor reviewed R23's medical record. R23 was admitted to the facility on [DATE]. R23 had an MDS assessment (Comprehensive) completed on 9/10/25. R23's next Quarterly MDS assessment (due December 2025) was not completed. From 2/16/26 to 2/18/26, Surveyor reviewed R25's medical record. R25 was admitted to the facility on [DATE]. R25 had an MDS assessment (Comprehensive) completed on 6/25/25. R25's next Quarterly MDS assessment (due September 2025) was not completed. From 2/16/26 to 2/18/26, Surveyor reviewed R32's medical record. R32 was admitted to the facility on [DATE]. R32 had an MDS assessment (Comprehensive) completed on 5/9/25. R25's next Quarterly MDS assessment (due August 2025) was not completed. From 2/16/26 to 2/18/26, Surveyor reviewed R42's medical record. R42 was admitted to the facility on [DATE]. R42 had an MDS assessment (Comprehensive) completed on 11/29/24. R42's next Quarterly MDS assessments (due March 2025 and September 2025) were not completed. From 2/16/26 to 2/18/26, Surveyor reviewed R43's medical record. R43 was admitted to the facility on [DATE]. R43 had an MDS assessment (Quarterly) completed on 11/27/24. R43's next Quarterly MDS assessments (due February 2025 and May 2025) were not completed. On 2/18/26 at 8:17 AM, Surveyor interviewed Nursing Home Administrator (NHA)-A who stated the facility outsourced MDS assessments to a contracted agency in July of 2025. NHA-A acknowledged inaccuracies in the MDS assessments and was aware discrepancies were identified with the contracted agency's completion of the assessments. On 2/18/26 at 8:20 AM, Surveyor interviewed MDS Registered Nurse (RN)-J who stated the contracted agency initiates all MDS assessments, has access to residents' medical records, and completes the nursing sections based on information provided by RN-J, including a history and physical and discharge summary. RN-J stated RN-J transmits the assessments when the contracted agency indicates the assessments are complete.

Based on staff interview and record review, the facility did not accurately code Minimum Data Set (MDS) 3.0 assessments for 4 residents (R) (R14, R2, R43, and R49) of 42 sampled residents. R14 was admitted to the facility on [DATE]. R14 was hospitalized on [DATE] and readmitted to the facility on [DATE]. R14's Tracking MDS assessment, dated 7/21/25, did not contain the correct admission date or entry type. R2's MDS assessment, dated 1/6/26, indicated R2 received Hospice services. R2 did not receive Hospice services in the facility. R43 had diagnoses of schizoaffective disorder and post-traumatic stress disorder (PTSD). R43's MDS assessments, with ARDs of 7/11/25 and 10/20/25, did not contain the diagnoses. R49 was admitted to the facility on [DATE]. R49's Tracking MDS assessment, dated 4/16/25, indicated the entry type was Rentry instead of Admission. Findings include: 1. From 2/16/26 to 2/18/26, Surveyor reviewed R14's medical record. R14 was admitted to the facility on [DATE]. R14 was hospitalized on [DATE] and returned to the facility on 7/21/25. R14's Tracking MDS assessment, dated 7/21/25, indicated the admission Date was 7/21/25 (instead of 10/17/24) and the entry type was admission (instead of Reentry). On 2/18/26 at 8:17 AM, Surveyor interviewed Nursing Home Administrator (NHA)-A who stated the facility outsourced MDS assessments to a contracted agency in July of 2025. NHA-A acknowledged inaccuracies in the MDS assessments and was aware discrepancies were identified with the contracted agency's completion of the assessments. On 2/18/26 at 8:20 AM, Surveyor interviewed MDS Registered Nurse (RN)-J who stated the contracted agency initiates all MDS assessments, has access to residents' medical records, completes the nursing sections based on information provided by RN-J, including a history and physical and a discharge summary. 2. From 2/16/26 to 2/18/26, Surveyor reviewed R2's medical record. R2 was admitted to the facility on [DATE] from another nursing facility and signed off of Hospice services prior to admission. R2's MDS assessment, dated 1/6/26, indicated R2 received Hospice services at the facility. On 2/18/26 at 10:13 AM, Surveyor interviewed NHA-A who confirmed R2's MDS assessment was inaccurate. NHA-A stated the facility had an in-house comfort care program which R2 was signed up for; however, the facility was not a licensed Hospice provider. 3. From 2/16/26 to 2/18/26, Surveyor reviewed R43's medical record. R43 was admitted to the facility on [DATE] and had diagnoses of schizoaffective disorder and PTSD. R43's MDS assessments, dated 7/11/25 and 10/20/25, did not indicate R43 had diagnoses of schizoaffective disorder and PTSD. On 2/18/26 at 10:13 AM, Surveyor interviewed NHA-A who confirmed R43 had diagnoses of schizoaffective disorder and PTSD which should have been reflected on the MDS assessment. 4. From 2/16/26 to 2/18/26, Surveyor reviewed R49's medical record. R49 was admitted to the facility on [DATE]. A Discharge-Return Anticipated MDS assessment, completed by the facility on 3/13/20, indicated R49 had a planned discharge to the community on 3/13/20. R49's Tracking MDS assessment, dated 4/16/25, indicated the entry type was Reentry (instead of Admission). On 2/18/26 at 8:17 AM, Surveyor interviewed NHA-A who stated the facility outsourced MDS assessments to a contracted agency in July of 2025. NHA-A acknowledged inaccuracies in MDS assessments and was aware of discrepancies identified with the contracted agency's completion of the assessments. On 2/18/26 at 8:20 AM, Surveyor interviewed MDS RN-J who stated the contracted agency initiates all MDS assessments, has access to residents' medical records, and completes the nursing sections based on information provided by RN-J, including a history and physical and a discharge summary.

Based on staff interview and record review, the facility did not ensure timely transmittal of Resident Assessment Information (RAI)/Minimum Data Set (MDS) assessments for 18 residents (R) (R51, R19, R52, R16, R53, R54, R55, R23, R31, R34, R35, R43, R9, R40, R42, R56, R50, and R26) of 49 sampled residents (42 residents who currently resided in the facility and 7 residents who were discharged ). The facility did not timely transmit RAI/MDS assessments for R51, R19, R52, R16, R53, R54, R55, R23, R31, R34, R35, R43, R9, R40, R42, R56, R50, and R26. Findings include: The Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, Version 1.17.1, dated October 2025, indicates: All Medicare and/or Medicaid-certified nursing homes must transmit required MDS records to the Centers for Medicare and Medicaid Services (CMS) .Required MDS records include Admission, Quarterly, Annual, Discharge assessments and entry tracking records .Transmitted means electronically transmitting an MDS record that passes CMS' standard edits and is accepted into the system within 14 days of the assessment reference date (ARD) (last day of the resident assessment period). From 2/16/26 to 2/18/26, Surveyor reviewed the facility's MDS submissions and noted the following: ~ R51 was admitted to the facility on [DATE] and discharged on 5/16/25. The facility did not transmit a Discharge-Return Not Anticipated MDS assessment until 2/18/26.~ R19 was admitted to the facility on [DATE] and discharged on 8/30/25. The facility did not transmit a Discharge-Return Not Anticipated MDS assessment until 2/18/26.~ R52 was admitted to the facility on [DATE] and discharged on 6/28/25. The facility did not transmit a Discharge-Return Not Anticipated MDS assessment until 2/18/26.~ R16 was due for a Comprehensive MDS assessment on 10/26/25. The facility completed the assessment on 10/28/25 and transmitted the assessment on 10/31/25.~ R53 was admitted to the facility on [DATE] and discharged on 1/31/25. The facility did not transmit a Discharge-Return Not Anticipated MDS assessment until 2/27/26.~ R54 was due for a Comprehensive MDS assessment on 11/13/25. The facility completed the assessment on 11/14/25 and transmitted the assessment on 11/19/25.~ R55 passed away at the facility on 1/25/25. The facility did not transmit a Death Tracking MDS assessment.~ R23 was admitted to the facility on [DATE] and was due for an admission MDS assessment on 9/7/25. The facility completed the assessment on 9/12/25 and transmitted the assessment on 9/24/25.~ R31 was admitted to the facility on [DATE] and was due for an admission MDS assessment on 11/2/25. The facility completed the assessment on 11/4/25 and transmitted the assessment on 11/5/25.~ R34 was admitted to the facility on [DATE] and was due for an admission MDS assessment on 1/1/26. The facility completed the assessment on 1/2/26 and transmitted the assessment on 1/5/26.~ R35 was admitted to the facility on [DATE] and was due for a Comprehensive MDS assessment on 10/16/25. The facility completed the assessment on 10/18/25 and transmitted the assessment on 10/28/25.~ R43 was hospitalized on [DATE]. The facility completed a Discharge-Return Anticipated MDS assessment. The facility did not complete a Reentry Tracking MDS assessment upon R43's return to the facility.~ R9 was due for a Quarterly MDS assessment on 8/18/25. The facility completed the assessment on 8/20/25 and transmitted the assessment on 8/21/25.~ R40 was due for a Quarterly MDS assessment on 8/7/25. The facility completed the assessment on 8/11/25 and transmitted the assessment on 8/13/25.~ R42 was hospitalized on [DATE]. The facility did not transmit a Discharge MDS assessment.~ R56 was admitted to the facility on [DATE]. The facility did not transmit an Entry Tracking MDS assessment.~ R50 was admitted to the facility on [DATE]. The facility completed an admission MDS assessment on 1/30/25 and transmitted the assessment on 3/6/26.~ R26 was admitted to the facility on [DATE]. R26 was due for an Annual MDS assessment on 12/27/25. The facility completed the assessment on 12/31/25 and transmitted the assessment on 2/27/26. On 2/18/26 at 8:17 AM, Surveyor interviewed Nursing Home Administrator (NHA)-A who stated the facility outsourced the completion of MDS assessments to a contracted agency in July of 2025. NHA-A acknowledged inaccuracies in the MDS assessments and was aware discrepancies were identified with the contracted agency's completion of the assessments. On 2/18/26 at 8:20 AM, Surveyor interviewed MDS Registered Nurse (RN)-J who stated the contracted agency initiates all MDS assessments, has access to residents' medical records, and completes the nursing sections based on information provided by RN-J, including a history and physical and a discharge summary. RN-J stated RN-J transmits the assessments to iQIES when the contracted agency indicates the assessments are complete. RN-J was unsure why some assessments were not transmitted timley or not transmitted at all.

Based on observation, staff interview, and record review, the facility did not maintain an infection prevention and control program designed to prevent the transmission of communicable disease and infection for 2 residents (R) (R47 and R12) of 2 residents observed during COVID-19 testing. Registered Nurse (RN)-E did not change a disposable gown between COVID-19 antigen nasal swab tests for R47 and R12. Findings include:According to the Centers for Disease Control and Prevention (CDC) website https://www.cdc.gov/niosh/healthcare/hcp/pandemic/conserving-isolation-gowns.html retrieved 2/19/26, the Strategies for Conserving the Supply of Isolation Gowns, dated 10/22/24, provides guidance to conserve the supply of isolation gowns in healthcare settings when there is limited supply due to increased use and demand (e.g., as may occur during an infectious disease pandemic or epidemic) or supply chain disruption.The CDC website https://www.cdc.gov/niosh/healthcare/hcp/pandemic/conserving-PPE-shortages.html retrieved 2/19/26, Conserving Supplies of Personal Protective Equipment in Healthcare Facilities During Shortages, dated 10/22/24, indicates: .Healthcare facilities should promptly resume conventional capacity practices as soon as practical and by the time personal protective equipment (PPE) supplies increase .The facility did not have a current policy and procedure for the reuse of PPE. Upon entrance to the facility on 2/16/26 at 8:00 AM, a posting indicated the facility was in a COVID-19 outbreak. On 2/17/26 at 11:31 AM, Surveyor observed RN-E complete COVID-19 antigen testing (swabbing of both nasal passages) for R47 and R12. RN-E wore a disposable isolation gown in addition to a surgical mask, eye protection, and gloves. RN-E entered R47's room, swabbed R47's left and right nasal passages, and set the COVID-19 test on a cart used for supplies. RN-E removed gloves and washed hands but did not remove the disposable gown. RN-E then donned clean gloves, entered R12's room, swabbed R12's right and left nasal passages, and set the COVID-19 test on the cart. RN-E removed gloves and completed hand hygiene. Immediately after the observations, Surveyor interviewed RN-E who stated RN-E was conducting COVID-19 testing that day. RN-E stated RN-E could wear the same gown throughout the testing unless a resident was on droplet precautions which required RN-E to dispose of the gown and gloves after the COVID-19 test.On 2/17/26 at 12:02 PM, Surveyor interviewed Infection Preventionist (IP)-C who stated staff wear the same reusable isolation gown when testing residents for COVID-19 unless a resident is symptomatic or on transmission based recautions (TBP) (contact, droplet, airborne which would require the use of specific PPE like a gown, gloves, mask, and eye protection) in which case they should change gowns between each resident. On 2/17/26 at 1:37 PM, IP-C informed Surveyor that the facility did not have a policy for the reuse of disposable isolation gowns. IP-C stated at one point during the COVID-19 pandemic, the facility might have practiced extended use of disposable gowns by reusing disposable gowns due to PPE shortages. IP-C stated the facility was not currently in a PPE shortage. On 2/18/26 at 11:28 AM, Surveyor interviewed Interim Director of Nursing (DON)-B who stated staff have reused disposable gowns since the beginning of COVID-19 for testing unless a resident is on TBP. DON-B verified the practice was outdated and stated the the facility would change it.

Based on observation, staff and resident interview, and record review, the facility did not ensure appropriate respiratory care and services were provided for 1 resident (R) (R8) of 1 sampled resident. R18 had a continuous positive airway pressure (CPAP) machine (a device that treats obstructive sleep apnea (OSA) by keeping the airway open). R8's medical record did not contain a diagnosis of OSA or orders for the use, care, and maintenance of the machine. Findings include:The facility's CPAP/BiPAP Usage in Long-Term Care policy indicates: To ensure residents requiring CPAP or BiPAP receive, maintain, and are monitored for their prescribed therapy to ensure safety, compliance with medical necessity, and optimal respiratory function .Upon admission, identify if the resident uses a CPAP/BiPAP device for obstructive sleep apnea (OSA) or other pulmonary disorders .Obtain a current physician order specifying the type of machine (CPAP/BiPAP), pressure settings .and oxygen flow rate (if applicable) .Ensure a copy of a recent sleep study, if available, is in the chart to support medical necessity .The facility will ensure the machine is in good working order. Any defects must be reported to the Durable Medical Equipment (DME) provider immediately .Use distilled water for the humidifier to prevent mineral buildup .Comfort Settings: These are pre-set and sent to nursing home once sleep study is complete .Mask Fit: Ensure a proper seal to prevent air leaks into the eyes or significant pressure loss .Monitoring and Care .Staff will document daily on the Treatment Administration Record (TAR) the hours of usage and any issues with compliance .Inspect the bridge of the nose and facial areas daily for pressure sores caused by the mask .Cleaning and Infection Control: Daily: Clean the mask and tubing with mild soap and water or follow manufacturer guidelines; Weekly: Thoroughly clean the water chamber and humidifier, allowing all parts to dry; COVID-19/Respiratory Infection: If a resident is suspected of having COVID-19 or another respiratory virus, CPAP/BiPAP therapy should be re-evaluated by a physician, as these are aerosol-generating procedures .Replace masks, tubing, and filters according to the established manufacturer/insurance schedule (e.g., masks every 3 months, cushions twice a month) .Mask Leaks: Adjust headgear straps and check for cracks in the tubingBetween 2/16/26 and 2/18/26, Surveyor reviewed R8's medical record. R8 was admitted to the facility on [DATE]. R8's Quarterly Minimum Data Set (MDS) assessment, dated 1/8/26, had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R8 had intact cognition. R8 was R8's own decision maker. A hospital Discharge summary, dated [DATE], indicated R8 had a sleep study and had OSA/obesity hypoventilation syndrome ([NAME]). It was unclear if R8 was on device therapy for OSA/[NAME] at home. A physician note, dated 2/7/26, indicated: Problem #5: Sleep apnea .Has OSA. CPAP pending. R8's medical record did not contain a diagnosis, physician order, or care plan for use of a CPAP machine. R8's medical record also did not contain monitoring or assessments for use of the machine or instructions for cleaning and maintenance of the machine. On 2/16/26 at 11:54 AM and 2/18/26 at 1:41 PM, Surveyor interviewed R8 and asked about the CPAP machine on R8's nightstand. R8 stated R8 was diagnosed with sleep apnea and used the CPAP machine at night. Surveyor noted the mask and tubing were connected to the machine. Surveyor observed a partially used gallon of distilled water on the ground next to the nightstand. When asked how staff take care of and clean the machine, R8 stated staff clean the mask and tubing two to three times per week. R8 stated the doctor who ordered the CPAP machine told R8 to fill the reservoir with distilled water and clean the machine two to three times per week. R8 stated R8 obtained the CPAP machine after a sleep test in the facility approximately a month ago. R8 stated R8 uses the CPAP machine every night and staff help R8 remove the mask in the morning. On 2/18/26 at 2:08 PM, Surveyor interviewed Nursing Home Administrator (NHA)-A and Registered Nurse (RN)-D. NHA-A reviewed R8's hospital discharge summary which mentioned OSA/[NAME] but could not find further documentation for R8's OSA/[NAME] and CPAP machine. RN-D could not find documentation for R8's CPAP machine except a document from an appointment, dated 9/30/25, with a note for an overnight sleep study that indicated: Will be contacted with next steps when more information is available. NHA-A reviewed R8's medical record and could not find documentation for a CPAP or OSA like-diagnosis for R8 or instructions for care of the machine.

Based on staff interview and record review, the facility did not thoroughly investigate an allegation of potential neglect for 1 resident (R) (R1) of 1 sampled resident. R1 fell on 4/22/25 during a shower given by Certified Nursing Assistant (CNA)-C. It was reported that CNA-C did not follow R1's care plan which indicated R1 required the assistance of two staff for transfers, pericare, and showers. R1 fell in the shower and incurred a head and left shoulder abrasion. The facility did not thoroughly investigate the allegation of potential neglect. Findings include: The facility's undated Investigation of Allegations of Abuse, Neglect, Misappropriation of Property, Resident to Resident Altercation and Injury of Unknown Source policy indicates: Basic responsibility: All staff .Documentation - written statements of the investigation, care and treatment of what was provided for the resident .Establish a systematic approach for the investigation of alleged violations involving mistreatment or abuse .To meet the state's Bureau of Quality Assurance requirements on reporting all investigations of alleged abuse, neglect, misappropriation of property, and injury of unknown source in a timely and appropriate manner .5. All staff will be trained during their orientation period, annually, and as needed on the following issues related to abuse prohibition practices .11. The Social Worker or designee will interview other staff, residents, resident representatives, visitors, and other possible witnesses .The nurse/designee will interview other residents who were cared for or had contact with the accused person to get written, signed, and dated statements. The staff may sign and date these forms (a minimum of 4 other residents) .Taking steps to prevent further potential abuse .conducting a thorough investigation of the alleged violation .Investigation: The nurse will interview staff, visitors, resident representatives, and residents who have direct knowledge of the allegation .document on the appropriate forms .interview other potentially affected residents .interview staff from all prior shifts for 24 hours .date and time interviews and include date and time in documentation of events . On 6/6/25, Surveyor reviewed R1's medical record. R1 had diagnoses including autism, long term use of anticoagulants, central pain syndrome, abnormalities to gait and mobility, contracture of left hand, and muscle weakness (general). R1's Minimum Data Set (MDS) assessment, dated 3/13/25, had a Brief Interview for Mental Status (BIMS) score of 12 out of 15 which indicated R1 had moderate cognitive impairment. R1 was R1's own decision maker. On 6/6/25, Surveyor reviewed a facility-reported incident that indicated R1 fell on 4/22/25 during a shower given by CNA-C. Surveyor noted the investigation concluded that R1 stood on R1's own during the shower and CNA-C did not instruct R1 to sit down while CNA-C called for another CNA to assist with the transfer. R1 fell in the shower and incurred a head and left shoulder abrasion. Surveyor noted the investigation indicated resident interviews were completed, however, the investigation did not contain documentation of the resident interviews. Surveyor also noted education for all nursing staff on following care plans to prevent accidents and improved communication during cares was included in the investigation, however, the sign-in sheets for the education provided on 5/20/25, 5/22/25, and 5/28/25 did not contain the signatures of fourteen nursing staff. Surveyor noted Registered Nurse (RN)-D was working on 6/6/25 and was not provided education. On 6/6/25 at 10:40 AM, Surveyor requested resident interview documentation from Director of Nursing (DON)-B. On 6/6/25 at 11:06 AM, Surveyor interviewed DON-B who indicated six residents were interviewed during the investigation. DON-B confirmed there was no documentation of the interviews, including which residents were interviewed. DON-B was unsure why the documentation was not retained and submitted with the investigation. On 6/6/25 at 1:51 PM, Surveyor interviewed DON-B who confirmed not all nursing staff were educated on following care plans. DON-B indicated the staff development nurse was aware that not all nursing staff were educated and would set up a meeting with those who missed the education. DON-B confirmed there were nursing staff who worked since the incident on 4/22/25 and had not yet been educated.

Based on staff interview and record review, the facility did not ensure the appropriate care and treatment was provided for 1 resident (R) (R10) of 2 residents reviewed for skin integrity. R10 was admitted to the facility with a venous stasis ulcer on the right great toe and was seen by the wound clinic and vascular surgeon. The facility did not complete weekly wound assessments or notify R10's physician timely when changes were noted in the wound. Findings include: The facility's undated Management of Wounds policy indicates: .4. The wound nurse will monitor all pressure, non-healing wounds, complicated surgical wounds, and any other wounds directed to be monitored by the wound care team or primary care provider (PCP) weekly and consult with the PCP as needed for changes in treatment or updates in changes in the condition of the wound .8. A care plan will be developed for the wound and updated with changes as needed based on resident preferences of treatment and care, this will be maintained in the electronic health record. The facility's Notification of Change of Condition policy, revised on 12/21/21, indicates: Physicians, the Director of Nursing (DON), and responsible family members or legal representatives shall be notified as soon as possible within 24 hours of any changes in the resident's condition based on the acuity. From 11/4/24 to 11/6/24, Surveyor reviewed R10's medical record. R10 was admitted to the facility on [DATE] and had diagnoses including peripheral vascular disease (PVD), type 2 diabetes mellitus with diabetic chronic kidney disease, and presence of cardiac and vascular implant and graft. R10's Admission Minimum Data Set (MDS) assessment, dated 4/3/24, indicated R10 had one venous stasis/arterial ulcer present. R10's most recent Minimum Data Set (MDS) assessment, dated 8/29/24, had a Brief Interview for Mental Status (BIMS) score of 13 out of 15 which indicated R10 was not cognitively impaired. R10 was R10's own decision maker. R10's medical history indicated R10 had a stint placed in R10's leg approximately [AGE] years prior and had not done much follow-up with the stint since then. An initial admission skin assessment, dated 3/26/24, indicated R10 had a diabetic ulcer on the right great toe with black eschar (dead tissue) with no odor. An assessment completed by DON-B, dated 3/27/24, indicated R10 had a venous/arterial ulcer on the right great toe (lateral edge under the nail) that was present upon admission. DON-B was unable to stage the wound due to eschar. The wound bed was dark purple with no drainage. The surrounding tissue was pink and tender to palpation. The area around the edge of wound contained cracked tissue. The wound measured 6.6 centimeters (cm) (length) x 2.2 cm (width) x 3.0 cm (depth) and had necrotic tissue (non-viable tissue due to reduced blood supply). The facility contacted R10's physician on 3/27/24 and indicated R10 appeared to have an arterial ulcer due to the foot pallor (a condition where the skin appears paler than normal), temperature (cool to touch), and no hair on the toe with 100% eschar and tenderness. R10 was willing to be seen by the wound clinic to rule out osteomyelitis. Staff requested R10's toenails be trimmed and indicated R10 needed to see podiatry because R10's toes appeared to have onychomycosis (nail fungus). The facility received wound clinic and podiatry referrals from R10's physician on 3/28/24. A wound clinic note, dated 4/3/24, indicated R10 had a history of diabetes, Hodgkin's and non-Hodgkin's lymphoma, and stroke. R10 was admitted to the hospital on 2/23/24 for renal failure hyperkalemia, hypertension, and anemia related to chemotherapy. Hospice care was discussed but put on hold. R10 had a wound on the distal tip of the right great toe and was not sure how long the wound was present. Dopplerable pulses were weak. The wound measured 2.5 cm x 2.8 cm x .05 cm depth. The note indicated the wound was a pressure injury on the distal right great toe that was unstageable due to non-viable tissue obstructing the wound bed. Recommendations included Betadine daily dressing changes and to follow-up with the vascular surgeon in 2 weeks. The facility initiated an order to apply Betadine and a dry sterile dressing to the right great toe on 4/3/24. A weekly skin observation completed by Registered Nurse (RN-C) on 4/3/24 indicated R10 had ischemic insufficiency on the right great toe with necrotic tissue and pain with palpation. Staff notified R10's physician on 4/22/24 that R10 had a calloused, reddened area on the left second toe that measured 1 cm x .5 cm and was painful to touch and when R10 wore socks. No open area was noted. The physician ordered a Band-Aid to the toe. R10 saw a vascular surgeon on 4/24/24 and was scheduled for an ultrasound on 4/30/24. The facility notified the wound clinic on 4/29/24 that R10's right heel was boggy and tender. R10 had a specialty mattress with heel boots. R10 also had right second toe skin shear and a left second toe scab at the metatarsal head with tenderness. An order was initiated to apply Betadine to the left second toe daily and wear heel boots when resting. The Band-Aid to the left toe was discontinued. A vascular ultrasound, dated 4/30/24, indicated the technologist could not palpate the dorsalis pedis on either side. The findings were consistent with severe stenosis (above 70%) in the distal SFA, the proximal popliteal artery, and the proximal posterior tibial artery, multi-focal moderate stenosis of the anterior tibial artery, and occlusion in the distal peroneal artery with poor blood flow in both feet. A right lower extremity angiogram (a medical imaging technique that visualizes blood vessels and blood flow) was scheduled for 5/20/24. Staff notified R10's facility physician on 5/2/24 that R10 had increased pain in the right great toe and heel related to worsening vascular status and spreading necrotic tissue. R10 took as needed (PRN) Tylenol which was not effective. The physician ordered skin prep to the heel and prescribed tramadol (used to treat moderate to severe pain). A general skin observation note, dated 5/4/24, indicated the tip of R10's right great toe was black with hardened tissue and had increased in size since the last assessment on 4/21/24. Progress notes, dated 5/5/24, indicated R10 reported pain after a wound treatment and was offered interventions for pain management. R10's right great toe was darker in color than the day before and was deep red/purple at the base and black/dark purple at the tip. R10 complained of pain in the heel which was boggy. Skin prep was applied. R10 refused heel boots and was educated. R10 allowed the writer to elevate R10's heels on a pillow while in the recliner. A wound clinic note, dated 5/6/24, indicated R10 complained of pain in the toe and plantar heel likely due to early signs of infection. Antibiotic therapy was prescribed. R10's right great toe was demarcating (boundary between living and dead tissue) with increased redness to the foot. R10 was advised if R10 had increased redness, fever, chills, nausea, vomiting, shortness of breath, or chest pain, R10 should go to the Emergency Department (ED) immediately. The writer was concerned R10 might lose more than a toe consistent with possible TMA (transmetatarsal amputation) versus BKA (below the knee amputation). Recommendations included Betadine daily dressing changes and follow-up in 2 weeks. A progress note, dated 5/11/24, indicated R10's right great toe and second toe were black in color. R10's right second toe contained a scab. R10's left second toe contained a scab and a callous. A progress note, dated 5/12/24, indicated Betadine was applied to blackened necrotic tissue on R10's right great toe, an area medial to the base of the toe, the top of the right foot, and a medial scabbed area on the left great toe. R10 declined tubigrips and heel boots. A progress note, dated 5/13/24, indicated R10's right great toe and second were black and discoloration had spread to the top of the foot. A progress note, dated 5/14/24, indicated R10's right great toe was entirely black/purple in color with discoloration on the top of the foot. The skin was firm. R10 winced with Betadine and PRN medication offer and declined prior to and during treatment. R10's dressing was changed as ordered. A progress note, dated 5/16/24, indicated the writer left a message for the wound doctor regarding the condition of R10's right great toe. The wound doctor's representative was informed that R10's right second toe and top of the foot contained black necrotic tissue. R10 was send to the ED and admitted to the hospital. A wound physician consult note, dated 5/18/24, indicated R10 was admitted to the hospital on 5/16/24 for critical limb ischemia. The only blood flow to R10's right foot was the posterior tibial artery which supplied blood flow to the bottom of the foot. There was little to no flow to the dorsal foot. The wound and vascular surgeons consulted about the possible failure of a TMA. R10 was counseled on treatment options. A possible TMA was discussed with the hope the incision would heal and R10 could function with diabetic shoes and toe filler; however, due to the lack of circulation to the top of the foot, there was a great chance of failure and R10 would then would require a BKA. The goal of surgery was to save the foot, however, R10 would still be at risk of losing the foot if the surgery failed or there were complications with healing. R10 opted to proceed with a BKA. An initial skin assessment upon R10's return from the hospital indicated R10 had a dried scab on the tip of R10's left great toe. An order was initiated to apply Betadine daily. No concerns were noted with documentation or treatments during that time. The facility's wound nurse contacted the wound clinic on 7/2/24 and scheduled an appointment for R10's left toe scab on 7/17/24. Daily Betadine treatments continued between 7/2/24 and 7/17/24 with no concerns noted until 7/15/24. A progress note, dated 7/15/24, indicated Betadine was applied to the scab on R10's left great toe. R10 indicated discomfort with touch. The note indicated the nurse would update the Interdisciplinary Team (IDT). A progress note, dated 7/16/24, indicated Betadine was applied to the scab on R10's left great toe. R10 indicated discomfort with touch. R10 was scheduled to see the wound clinic on 7/17/24. During a wound clinic visit on 7/17/24, the physician was concerned about the possibility of infection since R10 complained of pain the last few days and started R10 on an antibiotic. Betadine to the left toe daily was continued. R10 was seen by the wound clinic and followed by in-house weekly wound care since 7/17/24. R10's in-house weekly wound care assessments did not include measurements of the right great toe between 4/8/24 and 5/13/24, however, staff who completed the treatments documented daily observations of the wound. Surveyor also noted between 5/23/24 (when an area on R10's left toe was noted upon readmission) and 7/17/24, in-house weekly wound assessments with measurements were not completed, however, licensed staff charted daily on R10's left great toe when treatments were completed. Staff noted observations and any concerns with infection. As previously noted, R10 saw the wound clinic on 5/6/24 and was started on an antibiotic due to the possibility of infection. R10's progress noted indicated staff observed more changes in R10's toe(s) beginning on 5/11/24 but did not contact the physician until 5/16/24. On 11/07/24 at 10:50 AM, Surveyor called the wound clinic and spoke with Registered Nurse (RN)-D who indicated R10 was seen on 5/6/24 and was started on antibiotic therapy for a possible infection. RN-D indicated R10's second toe had a little discoloration on 5/6/24 but the great toe was concerning. RN-D indicated the wound doctor was already concerned with infection and the possibility that R10 would lose the toe or more. RN-D indicated R10 had severe blood flow issues and had appointments scheduled for vascular issues, including an angiogram on 5/20/24. RN-D reviewed a wound assessment from when R10 was admitted to the hospital on 5/16/24 and indicated (based on photos) that R10 was losing at least the right great toe and possibly the second toe. When Surveyor indicated staff noted changes in R10's foot on 5/11/24 but did not contact the wound clinic until 5/16/24, RN-D could not say if earlier notification would have made a difference, but indicated they would have wanted to know as early as possible. RN-D indicated if staff would have called earlier, they likely would have been instructed staff to send R10 to the ED which was the fastest way to get assessed. RN-D indicated the wound clinic's records did not contain a call from the facility to the triage nurse before 5/16/24. RN-D indicated R10's vascular surgeon would be back on 11/11/24 and would contact Surveyor if the surgeon felt that contacting the wound clinic on 5/11/24 (when the changes were noted) would have made a difference in the outcome. Surveyor did not receive a return phone call. On 11/6/24 at 10:17 AM, Surveyor interviewed DON-B who indicated DON-B completed R10's initial wound assessment. DON-B indicated shortly after R10 was admitted to the facility, DON-B was off work for awhile and Assistant Director of Nursing (ADON)-E and RN-C completed wound care during that period. DON-B indicated RN-C was wound care certified as of 4/24/24, but was training and following wound care at the facility prior to that time. DON-B reviewed R10's medical record and verified weekly wound care assessments/measurements for R10 were not completed. DON-B indicated weekly wound notes should be completed by the in-house wound care team. In a follow-up interview, DON-B confirmed the in-house wound care team should complete in-house assessments even if a resident was seen by the wound clinic. DON-B confirmed wound notes for R10's left toe should have been completed upon R10's return from the hospital on 5/23/24. DON-B and Surveyor reviewed the progress notes where staff noted changes to R10's foot on 5/11/24 but didn't contact the physician until 5/16/24. DON-B indicated staff should have contacted the physician when there were changes. On 11/6/24 at 10:53 AM, Surveyor interviewed ADON-E who reviewed R10's medical record and verified R10's weekly in-house wound notes did not include measurements for the right and left toes. ADON-E also verified staff did not contact the physician timely when changes that were noted on 5/11/24 and indicated it is staffs' responsibility to contact the physician if they note changes. ADON-E indicated staff should also contact the wound nurse if there are changes. ADON-E confirmed weekly in-house wound notes should be completed for all wounds.

Based on staff interview and record review, the facility did not ensure Preadmission Screening and Resident Review (PASRR) Level I and Level II Screens were completed as required for 1 Resident (R) (R21) of 5 residents reviewed. R21 had diagnoses of schizophrenia, bipolar mood disorder, and depression and was prescribed psychotropic medications. R21 did not have a PASRR Level I or Level II Screen completed as required. Findings include: PASRR information requires that all applicants to Medicaid-certified nursing facilities must be assessed to determine whether they have an intellectual disability or mental illness prior to admission; that is a Level I Screen. The purpose of a Level I Screen is to identify individuals whose total needs require that they receive additional services for their intellectual disability or serious mental illness. Individuals who are identified on the Level I as having a serious mental illness or intellectual disability and/or are prescribed psychotropic medications related to those diagnoses, are then evaluated in depth to confirm the determination of the need for specialized services; that is a Level II Screen. This assessment produces a set of recommendations for necessary services that are meant to inform the individual's plan of care. If a resident receives a new diagnoses of a mental illness, or is prescribed a class of psychotropic medications they were not previously taking, the PASRR should be resubmitted for review. R21 was admitted to the facility on [DATE] with diagnoses that included Parkinson's disease, schizophrenia, bipolar mood disorder, and anxiety disorder. On 4/4/22, a diagnoses of major depressive disorder was added. R21's most recent Minimum Data Set (MDS) assessment, dated 8/9/23, contained a Brief Interview for Mental Status (BIMS) score of 12 out of 15 which indicated R21 had moderately impaired cognition. Between 9/19/23 and 9/20/23, Surveyor reviewed R21's medical record and noted R21 also was prescribed the following psychotropic medications: ~Aripiprazole (an antipsychotic medication) for manic phase of bipolar mood disorder ~Quetiapine (an antipsychotic medication) related to bipolar mood disorder ~Depakote (an antiseizure medication) for bipolar mood disorder ~Wellbutrin (an antidepressant medication) for major depressive disorder On 9/20/23, Surveyor requested copies of R21's PASRR Level I and Level II Screens. The facility was unable to provide a PASRR Level I or Level II Screen for R21. On 9/20/23 at 12:45 PM, Surveyor interviewed Social Worker (SW)-C who confirmed R21 should have had a Level I and Level II Screen. SW-C indicated R21 was admitted from another nursing home in 2019. SW-C thought SW-C requested R21's PASRR Level I and Level II Screens from the previous nursing home. SW-C also indicated the facility's electronic medical record program was updated on 9/19/23 and the last time there was an update to the system, some scanned resident documents were lost. SW-C stated SW-C called R21's previous nursing home to obtain a copy of R21's PASRR Level I and Level II Screens and was working with the company that manages the facility's electronic medical records system to see if they were lost in the update. When Surveyor asked SW-C about the facility's PASRR process, SW-C indicated SW-C ensures all residents have a PASRR Level I Screen upon admission and, if needed, a Level II Screen. SW-C indicated PASRR Level I and Level II Screens are scanned into residents' electronic medical records; however, SW-C indicated SW-C will now also keep a paper copy of PASRR Screens in SW-C's office in case something is lost in an update (although SW-C could not confirm this was the case with R21's PASRR Screens). SW-C stated SW-C did not complete PASRR audits because PASRRs should be scanned into residents' medical records upon admission. When asked about the process SW-C uses to ensure PASRR Level I and Level II Screens are updated when a resident is prescribed a new class of psychotropic medication or receives a new mental illness diagnosis (R21 received a new diagnoses of major depressive disorder on 4/4/22), SW-C could not recall any residents who were prescribed a new psychotropic medication and stated the facility does not usually start residents on new psychotropic medications. SW-C indicated if a psychotropic medication is initiated, and because an improvement would likely be seen in the resident, SW-C did not believe the PASRR needed to be resubmitted.

Based on record review and staff interview, the facility did not ensure an accurate nutrition assessment was completed and update the physician for 1 Resident (R) (R15) of 3 sampled residents reviewed for nutrition concerns. The facility did not complete an accurate nutrition assessment and did not update the physician when R15 had a significant weight loss of 28 pounds (14%) between 4/12/22 and 10/11/22. Findings include: The facility's policy, titled Management of AJRCCC Resident Weights, dated 4/22/19, stated The purpose is to determine the resident's weight to provide a baseline and ongoing record of the resident's body weight as an indicator of their nutritional status and medical condition .Significant weight loss: is when the resident has a 5% weight loss in 1 month, 7.5% weight loss in 3 months or 10% in 6 months . 5. When the RD (Registered Dietician) notices a significant weight loss occurs during her MDS assessment the RD will update the PCP (Primary Care Provider) and consult with PCP and resident and determine resident needs. 8. The RD will determine if the resident has had a significant weight loss/gain by reviewing the residents weights for the past year. 12. The RD will consult with the PCP, if applicable, and make appropriate recommendations based on clinical assessment. From 10/11/22 through 10/12/22, the Surveyor reviewed R15's medical record which documented R15 was admitted to the facility on [DATE] and had a BIMS (Brief Interview for Mental Status) score of 13 of 15 indicating R15's cognition was intact. R15 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R15's most recent MDS (Minimum Data Set) assessment documented in section K0300 that R15 had a weight loss of 10 percent or more in the last 6 months and was not on a physician prescribed weight loss program. A nutritional assessment dated [DATE], completed by RD (Registered Dietician)-I document significant weight loss of 16% this quarter due to resident's preference. The Surveyor reviewed R15's documented weights for the quarter (May to August) of 232.2 on 5/12/22 and 225.2 on 8/10/22 and noted R15 did not have a significant weight loss of 16% within that quarter, rather, R15 had a weight loss of 7 pounds which was 3 percent within that previous quarter. On 10/11/22 at 10:55 AM, the Surveyor interviewed RD-I regarding RD-I's calculation of 16% weight loss within RD-I's nutritional assessment dated [DATE]. RD-I initially stated RD-I's calculations were accurate until the Surveyor reviewed the weight calculations with RD-I. RD-I then stated RD-I realized the calculations were incorrect for that quarter. RD-I then stated they thought the calculation of 16% weight loss for R15 was maybe based on the previous 6 months instead of the past quarter, but RD-I was not sure. The Surveyor asked RD-I if the physician was updated regarding R15's weight loss, RD-I stated R15 wanted to lose weight and RD-I was unsure if the physician was updated on the weight loss. RD-I further added RD-I thought it was the nursing staff who were responsible to update the physician when residents experience weight loss. RD-I returned a short time later to update the Surveyor that RD-I was unable to find documentation that R15's physician was updated on R15's weight loss. RD-I then provided a copy of a fax that RD-I completed to R15's physician indicating R15 had a significant weight loss of 14% in the past 6 months. Weight as following: 4/12/22 239# (pounds), 5/10/22 235#, 6/14/22 234#, 8/9/22 224#, 9/13/22 216#, 10/11/22 211#. RD-I then told the Surveyor I should have faxed the physician. The Surveyor interviewed DON (Director of Nursing)-B regarding R15's weight loss and the importance of updating of R15's physician. DON-B agreed R15's physician should have been updated regarding R15's significant weight loss by RD-I. DON-B further indicated there would be upcoming education provided to RD-I regarding completion of accurate nutrition assessments and stated nursing staff would be educated regarding significant weight loss of residents.

Based on staff interviews and record review, the facility did not ensure procedures were developed to address COVID-19 testing refusal by residents, staff, and volunteers. This practice had the potential to affect all 28 residents. Facility COVID-19 policies did not address how to proceed when residents, staff, or volunteers refused COVID-19 testing. Findings include: On 2/1/22, Surveyor reviewed facility COVID-19 policies and procedures and noted testing refusals were not addressed. On 2/1/22 at 11:32 AM, Surveyor interviewed Assistant Director of Nursing (ADON)-C regarding testing refusals. ADON-C indicated that ADON-C communicated with Nursing Home Administrator (NHA)-A and determined a general insubordination Human Resources (HR) policy would be utilized if staff refused testing. ADON-C explained that no residents refused testing to date but the choice to refuse would be honored. Surveyor reviewed HR policy on insubordination with ADON-C. ADON-C confirmed HR policy did not mention COVID-19 testing. At 11:57 AM, ADON-C followed-up with Surveyor to reveal Director of Nursing (DON)-B was contacted by ADON-C and also verified the facility did not have a policy to address COVID-19 testing refusals.

Based on observation, interview and record review, the facility did not ensure implementation of infection control policy designed to prevent the development and transmission of disease and infection for 1 Resident (R) (R10) of 1 sampled residents observed on transmission-based precautions. Licensed Practical Nurse (LPN)-E did not perform hand hygiene upon entering or exiting a room when providing a meal tray to R10. R10 was on transmission-based, contact precautions. Findings include: According to the Centers for Disease Control and Infection (CDC) webpage on Hand Hygiene in Healthcare Settings, healthcare personnel should use an alcohol-based hand rub (ABHR) or wash hands with soap and water for clinical indications including: Immediately before touching a patient and After touching a patient or the patient's immediate environment R10 admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Per R10's most recent quarterly Minimum Data Set (MDS) assessment, dated 9/2/21, R10 was dependent on staff for assistance with transfers and toileting. Section H of the MDS assessment documented that R10 was always incontinent of both stool and urine. R10's Brief Interview of Mental Status (BIMS) score was documented as 9, indicating moderate cognitive impairment. On 9/9/21, Surveyor completed continuous observations of the morning meal tray pass on Resident Wing-F. At 8:08 AM, Surveyor observed LPN-E enter R10's room with a meal tray. Surveyor noted LPN-E did not perform hand hygiene prior to picking up the meal tray or upon entering R10's room. Surveyor observed LPN-E set R10's meal tray on R10's over-the-bed table. LPN-E touched the surface of the table in the process of setting down the meal tray. Surveyor then observed LPN-E assist R10 in sitting up in bed. While assisting R10 to sit up in bed, Surveyor observed LPN-E touch R10's draw sheet, side rail, and side rail bed control buttons. LPN-E then exited R10's room, without performing hand hygiene, and proceeded to Resident Wing-E. At 8:12 AM, Surveyor interviewed LPN-E. LPN-E indicated that LPN-E was new to the facility but identified that R10 was on contact precautions for colonization of ESBL in the urine. LPN-E indicated that gown and gloves would be worn when performing personal cares for R10 that included urine. At 11:57 AM, Surveyor interviewed Director of Nursing (DON)-B related to R10. DON-B stated that R10 was on contact precautions for colonization of ESBL in the urine. DON-B indicated that gloves and gowns were only required during personal hygiene cares with R10, but DON-B did confirm with Surveyor that LPN-E should have performed hand hygiene prior to resident contact and after contact with the resident's environment. DON-B was noted as stating, there was a break in infection control,

Based on observation, interviews, and record review, the facility did not provide consistent care to promote the healing of a pressure injury for 1 Resident (R) (R13) of 5 Residents reviewed for pressure injuries. The facility did not ensure R13's ROHO cushion (brand name of an air cushion used to sit on to decrease the pressure on the sitting area) was properly inflated. Certified Nursing Assistant (CNA)-D was unable to properly perform the appropriate steps to ensure R13's ROHO cushion was properly inflated. R13 had an unstageable pressure injury that showed worsening during wound assessment the day of the under-deflated ROHO cushion was identified. Findings: The facility document titled Prevention and Management of Skin Injury states, Interventions and Preventive Measures: Resident with Risk Factors - 2. Friction and Shear - h. positioning devices must be monitored to avoid pressure to skin. Including ROHO's [sic] they should be checked AM and PM. The facility's ROHO instructions states, 6. The cushion is most effective when there is 1/2 in (inch) to 1 inch (1.5 cm (centimeter) to 2.5 cm) of air between the individual's lowest bony prominence and the seating surface. To adjust the inflation level: (a) slide your hand between the cushion and the individual. Slightly lift the individual's leg and feel for their lowest bony prominence. Lower their leg to a sitting position. R13's most recent quarterly MDS (Minimum Data Set) dated 6/15/21 indicated R13's BIMS (Brief Interview for Mental Status) score was 11, indicating moderately impaired cognition. R13's MDS revealed R13 was at risk for developing pressure injuries. R13's care plan states: 9/30/2020: I am at risk for injuring myself . I need my aides to . ROHO cushion in my w/c (wheel chair) . R13's Guidelines for Daily Care states: Supportive Aids - ROHO cushion in my w/c; Skin Care - ROHO cushion on w/c; Repositioning - ROHO cushion. Special Instructions: With all intake I must be up 30 minutes after meals/snacks. On 9/7/21 at 11:23 AM, Surveyor observed CNA-D, Director of Nursing (DON)-B, and Licensed Practical Nurse (LPN)-F transfer R13 from R13's bed into R13's wheel chair. R13's wheel chair contained a ROHO cushion on top of the seat area. Surveyor asked CNA-D how CNA-D ensures R13's ROHO cushion is properly inflated. CNA-D did not know how to check R13's ROHO cushion for proper inflation. CNA-D and LPN-F verified the cushion was not properly inflated and appeared to be under-inflated. LPN-F stated R13's ischium is touching the bottom. R13 was transferred out of R13's wheel chair. Surveyor asked LPN-F if the under-deflated ROHO cushion could have contributed to R13's worsening pressure injury. LPN-F stated, It's more failure to thrive. LPN-F stated R13 is in her wheel chair for all meals only. On 9/7/21 at 11:36 AM, CNA-D stated CNA-D has had to re-inflate R13's ROHO, Once in a while. CNA-D obtained the air pump for the ROHO cushion. CNA-D pumped up the ROHO cushion after taking the ROHO cushion off the wheel chair and on R13's bed. CNA-D pumped the cushion 29 times. DON (Director of Nursing)-B stated, You have to do it while the ROHO is under the resident. R13 was transferred back to R13's wheel chair and sitting on the ROHO cushion. CNA-D pumped the ROHO cushion 26 times. CNA-D re-checked R13's ROHO cushion. CNA-D and LPN-F verified R13's ROHO cushion was properly inflated. On 9/7/21 at approximately 11:30 AM, LPN-F stated R13's ROHO cushion was last audited by LPN-F last week and R13's ROHO cushion was checked for inflation and was appropriately inflated last week, 8/31/21. On 9/7/21 at 11:55 AM, Surveyor interviewed R13. Surveyor asked R13 if staff check R13's ROHO cushion by putting their hand under R13. R13 stated, No. Surveyor asked R13 if LPN-F checked R13's ROHO cushion by putting LPN-F's hand under R13's bottom. R13 stated, No. R13 stated, The cushion feels flat. On 9/7/21 at 12:15 PM, Surveyor interviewed LPN-F who verified R13's ROHO cushion was not properly inflated. On 9/7/21 at 12:35 PM, Surveyor interviewed CNA-D who stated it had been, Quite a while, since before COVID that CNA-D had been educated on how to check a ROHO cushion. CNA-D stated yearly on-line training does not include education on the ROHO cushion. On 9/7/21, LPN-F provided Surveyor with the CNA In-service Attendance Sheet which included ROHO cushion training. CNA-D was scheduled for 9/18/20 from 2:30 PM to 3:30 PM for the In-service. Next to CNA-D's typed name was CNA-D's signature crossed out with, Left before in-service written next to crossed out signature. On 9/7/21, Surveyor reviewed R13's medical record which included documentation dated 8/19/21 of R13's coccyx wound. R13's coccyx wound had been improving until R13's dressing change was performed the morning of 9/7/21, just prior to the identification of the under-deflated ROHO cushion. 8/30/21 pressure injury assessment stated: Assessment type: Follow-up assessment Pressure ulcer: Unstageable - Wound bed covered by slough and/or eschar (Unstageable: Full thickness tissue loss is when the actual depth of the ulcer is completely obscured by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed.) Area 1 - sacrum Tissue Type: 50% slough, 50% non-granulating tissue (un-healthy tissue) Wound bed: yellow/pale pink Drainage: light serous (thin, watery fluid) Surrounding tissue: Intact Healing progress: appears more clean Description: becoming smaller area: (blank) Length 2.5 cm Width 4.5 cm Depth 0.1 cm Length x width (square cm)=11.25 Area 1 L x W (length times width) score: 8.1 - 12.0 (8) Area 1 exudate amount: Light (1) Areas 1 tissue type score: Slough (3) Area 1 PUSH score: 17 (Pressure Ulcer Scale for Healing - 0-17. Higher scores mean worsening pressure injury. Score was not added correctly. Should be 12). 9/7/21 pressure injury assessment stated: Assessment type: Follow-up assessment Pressure ulcer: Has full thickness of skin lost, exposing the SubQ (subcutaneous) tissues-presents as a deep crater (Pressure Stg. (stage) 3). Wound type: Stage 3 (involves the full thickness of the skin and may extend into the subcutaneous layer (the layer of tissue under the skin)). Tissue type: Necrotic/Eschar 75% 25 non-granulating tissue. Wound bed: pink 25% pink [sic] and 75 brown to yellow tissue Drainage: moderate Surrounding tissue: reddened, to purple tender area: (blank) Length: 3.4 cm Width: 5.4 cm Depth: 0.2 cm Length x width (square cm)=18.63 cm Area 1 L x W (length times width) score: 12.1 - 24.0 (9) Area 1 exudate amount: Moderate (2) Areas 1 tissue type score: Necrotic (4) Area 1 PUSH score: 20 (Score was not added correctly. Should be 15).

Based on record review and staff interview, the facility did not revise care plans in accordance with current care needs for 2 Residents (R) (R1 and R32) of 15 sampled residents. R1 fell at the facility on 2/27/21 and 2/28/21 and sustained non-displaced fractures to the left hand. Facility did not update R1's care plan to reflect current fall interventions in place. Additionally, the facility did not provide documentation that new interventions were put into place after R1's fall on 2/27/21. R32 was hospitalized for a Gastrointestinal (GI) Bleed (bleeding from somewhere in GI tract, the level of bleeding can range from mild to severe and can be life-threatening) then returned to facility. The facility did not revise R32's care plan to address monitoring for signs and symptoms of GI bleed. Findings include: 1. The facility policy titled Falls Management, undated, states: 3. The nurse will develop a plan of care for all residents who have risk for falls or injury. a. The MDS Coordinator will review this with each MDS and as needed with changes b. Licensed nurses will update the plan of care based on resident needs. 4. When a resident falls the nurse will .j. Put interventions in place .q. Update plan of care (hand write them on plan of care initial and date) make a copy and place it under MDS coordinator door. On 9/7/21, Surveyor reviewed R1's medical record. R1 admitted to the facility on [DATE]. R1 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Between 9/7/21 and 9/9/21, Surveyor reviewed the falls incident reports for R1 over the last eight months and noted the following interventions in place: 1/10/21: No injury with resident educated on use of call light for assistance 2/27/21: Injuries to include laceration to the forehead; abrasions to the leg, thigh abdomen, coccyx, and upper lip; and bruises to posterior hands, nose, and left shoulder. The immediate intervention enacted by the licensed nurse included signs placed in the resident's room as a reminder to call for help with transfers. Care planned interventions already in place included 15-minute checks, hourly toileting, female caregivers, and staff to remain with resident in bathroom. 2/28/21: Injury included bruise with possible fracture to left palm, wrist, and hand. A physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Interventions immediately taken by staff included resident teaching and staff teaching for completion of 15-minute checks. Surveyor noted, through record review of R1's care plans, that R1's care plan had included mention of a reminder sign to prevent falls since 5/2/19 and that the immediate intervention from 2/27/21 was not a novel intervention. On 9/9/21 at 1:28 PM, Surveyor interviewed Licensed Practical Nurse (LPN)-F related to R1's care-planned fall interventions. LPN-F explained to Surveyor that, during the period surrounding R1's 2/27/21 and 2/28/21 falls, R1 was diagnosed with a urinary tract infection and was not acting per R1's baseline. LPN-F provided Surveyor with a urine culture and sensitivity lab report completed on 3/4/21. LPN-F indicated to Surveyor that R1 was put under direct supervision after returning to the facility on [DATE] and had not fallen since. LPN-F provided Surveyor with a copy of R1's care plan which documented R1's fall prevention care plan had been updated on 3/2/21. When asked by Surveyor what new interventions were put into place after R1's fall on 2/27/21 to mitigate the risk of falling again, LPN-F indicated a reminder sign was put into R1's room. LPN-F referenced R1's current care plan and Certified Nursing Assistant kardex which both included the sign intervention. LPN-F and Surveyor entered R1's room. Surveyor did not observe, and LPN-F was not able to locate a sign in R1's room reminding R1 to call for assistance. LPN-F confirmed with Surveyor that the sign intervention was not accurately reflected and the care plan was not updated. At 2:01 PM, Surveyor met with Director of Nursing (DON)-B and Assistant DON (ADON)-C related to R1's falls at the facility. DON-B stated that R1 had fallen frequently since admitting to the facility and that it is the facility's expectation to revise and update care plan interventions timely and regularly to prevent falls. When asked by Surveyor about new or revised interventions for R1 on 2/27/21, DON-B indicated that the biggest intervention was getting R1 out to the emergency room to see the doctor at that point. ADON-C explained that the falls on 2/27/21 and 2/28/21 happened over a weekend which is why the electronic care plan was not formally updated until March. ADON-C did indicate, however, that an update to the care plan would have been handwritten after the event. At 2:42 PM, Surveyor followed-up with DON-B. DON-B was not able to provide Surveyor with a copy of the handwritten care plan that addressed what new interventions were implemented to prevent the fall on 2/28/21. DON-B indicated that there was no concrete way to say what updated interventions were put into place after the fall on 2/27/21 and prior to the fall on 2/28/21, however, DON-B explained that R1 had not fallen since and was now under direct supervision throughout the day. 2. On 9/7/21, Surveyor reviewed R32's medical record. R32 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R32's medical record contained the following nursing progress notes: ~5/15/21: noted resident had one large loose dark tinge bloody stool this AM (morning) upon rising (0700) (7:00 AM), more blood than stool noted, resident denied pain . ~5/15/21: abnormal labs . send to ER (emergency room ) . d/t (due to) low Hgb (hemoglobin; a protein in red blood cells that carries oxygen throughout the body) at 8.4 (normal for R32 should be in range of 13.5 to 17.5) . admitted to [named hospital] . R32's medical record indicated R32 was readmitted to the facility on [DATE] and that R32 was diagnosed with Asymptomatic (without typical symptoms) GI Bleed as reason for hospitalization . On 9/08/21, Surveyor reviewed R32's care plan. R32's care plan did not mention or address hospitalized history of R32's GI bleed. On 9/09/21 at 9:36 AM, Surveyor interviewed Director of Nursing (DON)-B who verified R32's care plan did not contain mention of R32's GI bleed. DON-B verified R32's hospitalized history of GI bleed should have been added to R32's care plan for monitoring of symptoms.

Based on record review and interview, the facility did not ensure implementation of the antibiotic stewardship program for 2 of 5 sampled Residents (R) (R13 and R6) reviewed for antibiotic use. R13 was ordered and administered a seven day course of antibiotics for a skin infection without implementing the facility's antibiotic use protocols. R6 admitted to the facility with orders for an antibiotic eye ointment. R6 received the antibiotic ointment without an appropriate duration or documented appropriate clinical indication for use. Findings include: 1. The facility policy and procedure titled Antibiotic Stewardship Policy states, Procedure: 1. All residents will be monitored for infections. 2. The nurse will track and monitor the need for antibiotic therapy. 5. The nurse will clarify with the MD the need for the antibiotic treatments. If the MD (Medical Doctor) chooses to treat prior to the culture and sensitivity report, the MD must provide rationale for the nurse to document in the resident's medical record in ECS (an electronic health record) under Physician Contacts in charting tab. 11. The Infection Preventionist/designee will fill out the line list as appropriate based on the McGeer's criteria (guidelines used to ensure proper use of antibiotics). R13 was on the facility line list in August 2021 indicating R13 had a skin infection. On 8/19/21, R13 was prescribed [MEDICATION(S)] (antibiotic used to treat a wide variety of bacterial infections) 500 mg twice a day for seven days. The facility did not have a McGeer's Criteria form in the facility infection control binder. R13 did not have a wound culture and sensitivity ordered to determine the most appropriate antibiotic to treat R13's wound infection. On 9/9/21 at 12:39 AM, Surveyor interviewed DON-B and IP-G. DON-B and IP-G stated a culture and sensitivity was not ordered for R13. DON-B stated the MD wanted to treat R13 aggressively due to the redness, pain, swelling, and drainage. DON-B stated R13 was given [MEDICATION(S)] in the past and has worked. DON-B and IP-G stated the MD was not questioned regarding the prescription of [MEDICATION(S)] for R13. DON-B and IP-G stated the facility follows McGeer's Criteria and verified McGeer's criteria was not used to determine if [MEDICATION(S)] was warranted for R13. R13's medical record did not contain documentation justifying the MD's use of [MEDICATION(S)]. 2. Per the Mayo Clinic webpage on the antibiotic [MEDICATION(S)], [MEDICATION(S)] ophthalmic preparations are used to treat infections of the eye. They also may be used to prevent certain eye infections of newborn babies, such as neonatal [CONDITION(S)] and ophthalmia neonatorum. (https://www.mayoclinic.org/drugs-supplements/[MEDICATION(S)]-ophthalmic-route/description/drg- 673) Contraindications and precautions noted with [MEDICATION(S)] use, as documented on the Prescribers' Digital Reference webpage, include the following: Antibiotic therapy can result in superinfection or suprainfection with non susceptible (sic) organisms. Overgrowth of [MEDICATION(S)] can occur with [MEDICATION(S)] therapy. Patients should be monitored closely during therapy . Geriatric patients, especially those with renal or hepatic function impairment, may be at increased risk for developing hearing loss from systemic [MEDICATION(S)]; hearing impairment is a rare side effect .The federal Omnibus Budget Reconciliation Act (OBRA) regulates medication use in residents of long-term care facilities (LTCFs). According to OBRA, use of antibiotics should be limited to confirmed or suspected bacterial infections. (https://www.pdr.net/drug-summary/[MEDICATION(S)]-Ophthalmic-Ointment-[MEDICATION(S)]-709.331) On 9/8/21, Surveyor reviewed the electronic medical record for R6. R6 most recently readmitted to the facility 4/6/18 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Per R6's quarterly Minimum Data Set (MDS) assessment, dated 8/26/21, R6 scored a 15 on the Brief Interview for Mental Status (BIMS) indicating R6 was cognitively intact. On Section B of the MDS, related to hearing and vision, staff documented that R6 had minimal difficulty with hearing and wore hearing aids. Additionally, R6's vision was noted to be impaired, and R6 used corrective lenses. R6's MDS also documented that R6 received a daily antibiotic. Review of the facility-provided resident matrix did not indicate that R6 had an active infection in R6's eyes or any other body system at the time of the annual survey. Surveyor reviewed R6's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . HS [hour of sleep] DRY Eye Syndrome (Dry Eyes caused by Deficiency of Tears). Surveyor noted in R6's record documentation that the [MEDICATION(S)] had been in use since readmission on 4/6/18. However, orders for the [MEDICATION(S)] were in place prior to 2018. A discontinued order from 6/27/16, contained administration instruction that Patient needs to continue this [opthalmic [MEDICATION(S)]] indefinitely per [named physician]. The current order from 8/2/21 did not include this administration instruction. On 9/9/21 at 12:36 PM, Surveyor interviewed Director of Nursing (DON)-B related to antibiotic use and stewardship at the facility. When asked about R6's use of the [MEDICATION(S)] eye ointment, DON-B explained that the facility staff were aware of the antibiotic for dry eye syndrome use and that the staff had multiple conversations with R6's physician related to the ointment's use. DON-B indicated that conversations related to stopping the antibiotic ointment were a struggle and that R6 also wanted to continue use of the [MEDICATION(S)]. DON-B explained that R6's antibiotic use was discussed in regular quality assurance (QA) meetings and that the facility pharmacist does not review the antibiotic during monthly drug regimen reviews. DON-B stated the facility was lucky that antibiotic resistance had not yet been noted or discovered related to R6's antibiotic use. At 1:01 PM, Surveyor interviewed R6 related to the [MEDICATION(S)] eye ointment. R6 indicated that facility staff had not discussed continuing or discontinuing the antibiotic eye ointment with R6. R6 also explained that staff had not talked with R6 about the risks or benefits attributed to use of the antibiotic ointment. R6 explained that R6 does see an ophthalmologist related to R6's eye conditions and that R6 had utilized the antibiotic ointment for a while but did not believe the ointment helped R6's dry eye condition. When asked by Surveyor if R6 would be open to discontinuing the antibiotic ointment or exploring other treatment options, R6 indicated that R6 would be open to that idea.

Based on record review and staff interviews, the facility did not ensure that appropriate corrective action was taken for an allegation of abuse for 1 Resident (R) (R1) of 1 alleged violations of abuse, neglect, and /or mistreatment. The facility found Licensed Practical Nurse (LPN)-C to have been verbally abusive towards R1 and did not provide any education to the rest of the facility staff in order to correct and prevent future occurrences of abuse. Findings include: The facility policy, entitled Investigations of Abuse, Neglect, Misappropriation of Property, Resident to Resident Altercation and Injury of Unknown Source, dated 11/28/18, states: Training is to occur .as needed in the following areas: .How to recognize signs of burnout, frustration, and stress that may lead to abuse and identify ways to prevent such from occurring. It also states Verbal/Psychological Abuse: Administration: Examine the facility policies and procedures to determine how to prevent caregiver misconduct, improve reporting .Plan education in-services and/or workshops, as needed, outside the annual in-servicing. On 8/18/20, the Surveyor reviewed a facility self-report about an allegation of abuse. Per the facility self-report, LPN-C was assigned 1:1 supervision for R1 on 6/15/20. LPN-C made sarcastic comments about R1 to other staff and had a cold demeanor towards R1 throughout the shift. It was noted that R1 makes frequent requests to use the bathroom. Certified Nursing Assistant (CNA) - D assisted LPN-C transfer R1 into bed. R1 changed their mind mid-transfer and wanted to go to R1's chair. When CNA-D observed LPN-C continue to transfer R1 to bed after R1 changed their mind, CNA-D ensured R1's safety and reported the incident to Registered Nurse (RN) - F. RN-F immediately went to R1's room, assisted LPN-C with transferring R1 to R1's chair as requested, and removed LPN-C from R1's care while ensuring R1's safety. LPN-C went to the Social Worker's office, wrote a statement, and did not return to the facility. The facility determined that LPN-C was being abusive towards R1 and that it was likely due to frustrations with R1's many requests. On 8/18/20 at 12:15 PM, the Surveyor interviewed the Director of Nursing (DON)-B, who verified that, after this incident, there was no facility-wide training in order to prevent future incidents of abuse and/or burnout.

Based on observation, record review and staff interview, the facility did not maintain an infection control program designed to help prevent the transmission of disease and infection during linen handling. This had the potential to affect multiple residents in the facility. During observations of the tasks of collecting soiled laundry, sorting soiled laundry and folding clean laundry, LA (Laundry Aide)-D repeatedly allowed soiled and clean laundry to contact LA-D's clothing without the use of appropriate protective equipment. Findings include: Facility provided policy titled Laundry and Bedding, Soiled stated, Soiled laundry/bedding shall be handled in a manner that prevents gross microbial contamination of the air and persons handling the linen . Anyone who handles soiled laundry must wear protective gloves and other appropriate protective equipment (e.g., gowns if soiling of clothing is likely) . The Environmental Services Director or supervisor will ensure that forceps/tongs or similar safe sorting devices are available for sorting laundry. On 12/02/19 at 10:09 AM, during initial tour of laundry area, Surveyor observed LA-D folding clean laundry. During the folding of three separate clean items, these clean items brushed up against LA-D's clothing. During this tour, Surveyor asked LS (Laundry Supervisor)-E what protective equipment staff wore when picking up soiled laundry. LS-E indicated laundry staff wore gloves during pick-up. On 12/02/19 beginning at 10:56 AM, Surveyor observed LA-D collect dirty laundry from every facility wing with a large cart. LA-D wore protective gloves. LA-D did not wear a protective gown. Each resident room contained a small closet with doors that provided access both from inside the resident room and from the hall. Each closet contained a small laundry cart with a clear plastic bag. LA-D opened the closet door from the hall for every room which housed a resident to check for soiled laundry. There were 40 residents housed in the facility. If there was soiled laundry in the cart, LA-D would remove the plastic bag and place it in the large cart, then fasten a clean plastic bag (kept at the bottom of the small laundry cart) onto the small laundry cart. If there was no soiled linen in the small laundry cart, LA-D closed the door and went to the next closet. During this observation which ended at 11:17 AM, Surveyor observed bags containing soiled laundry brush against LA-D's clothing twelve times. On 12/02/19 starting at 11:19 AM, Surveyor observed LA-D sort the soiled laundry collected. With gloved hands and no protective gown, LA-D removed each plastic bag from the large bin and dumped the soiled laundry contained in the bag into a blue bin. LA-D then placed the empty bag into a large plastic bag for disposal. After each individual bag was emptied into the blue bin, LA-D removed one soiled laundry item at a time and placed it in the area designated for the type of laundry it was. During this observation which ended at 11:25 AM, empty plastic bags touched LA-D's clothing three times and soiled laundry items touched LA-D's clothing ten times. One of the items was a soiled cushion with a cover. LA-D struggled getting the cushion cover off and both the foam cushion and the cover touched LA-D's clothing during the removal process. On 12/02/19 at 11:26 AM, Surveyor interviewed LA-D who indicated LA-D would again be folding clean laundry during LA-D's shift on 12/2/19. LA-D was asked what the facility policy was regarding linen handling and infection prevention. LA-D indicated LA-D would take gloves off and wash hands before touching anything else. When asked, LA-D indicated laundry was to be handled away from staff body. LA-D verified wearing the same clothing throughout the day and that clean laundry could brush up against LA-D's clothing during the folding process. When asked, LA-D indicated the facility had not offered the use of protective gowns or trained LA-D to use protective gowns during the tasks of collecting, sorting or folding. On 12/03/19 at 2:42 PM, Surveyor interviewed IP (Infection Preventionist)-F who indicated when asked that it was expected nursing staff carry bags containing soiled laundry away from staff uniforms. When asked, IP-F stated, I don't know what they do in laundry but they should not hold laundry against their uniforms because that would be a risk for contamination. On 12/03/19 at 2:50 PM, Surveyor interviewed LS-E who indicated bags and laundry were not supposed to touch staff's body or clothing. LS-E indicated the use of gowns is not currently mandatory for laundry staff unless it (laundry) touches you. LS-E verified there was a potential for contaminated staff clothing to cross-contaminate clean laundry during folding process because the same staff collect and sort soiled laundry prior to the folding task. LS-E verified laundry staff did not have access to protective gowns at that time.

Based on record review and staff interview, the facility did not provide the necessary care and services to maintain the highest practical well-being for 1 Resident (R) (R3) of 14 sampled residents. R3 had documented open areas to skin per nurses notes. Staff did not notify the wound care team to ensure a skin assessment was completed to the open areas. Findings include: R3 was admitted to the facility on [DATE]. R3's most recent annual, MDS (Minimum Data Set) dated 11/14/19, documented R3 to be dependent on staff for ADLs (activities of daily living.) R3's MDS document R3 to be at risk for developing pressure injury. R3's most recent Braden score (a tool used to predict pressure injury risk) completed on 11/25/19, documented R3 to be at risk for pressure injury. R3's medical record did not include any skin skin assessments to open areas. Nurses notes documented R3 had an open area to left buttocks which were noted on 11/26/19 and an open area to right buttocks on 11/30/19. From 12/02/19-12/04/19, the Surveyor reviewed R3's medical record. R3's nurses notes section included the following documentation: On 11/26/19 at 1:24 P.M., General skin observation pin point superficial open area to left buttocks: small bleeding in the morning. Peri wound intact. Resident denies pain. Cleansed, sensicare applied. PCP made aware. On 11/27/19 at 1:29 P.M., General skin observation L (left) lower buttocks OA (open area) continues with no s/s (signs or symptoms) of infection. Barrier cream applied with AM cares. On 11/28/19 at 12:00 P.M., General skin observation small open area remains to left buttocks with no drainage or s/s infection. On 11/29/19 at 12:58 P.M., General skin observations small OA to L buttocks continues, area cleansed and sensicare applied. No s/s infection. Slight serosanguineous (drainage with contains both blood and plasma) drainage. On 11/30/19 at 2:49 [NAME]M., General skin observation note: small OA to L buttocks continues, small amount of blood noted. Area cleansed and sensicare applied. No s/s of infection. On 11/30 /19 at 9:26 P.M., General skin observations note: sensicare applied to small open area to right buttocks. On 12/01/19 at 10:43 P.M., General skin observations superficial open area remains to left buttock, appears dry, red, sensicare applied after cleaning. On 12/02/19 at 9:44 [NAME]M., General skin observation note: area on bottom is slightly larger compared to yesterday per day nurse. Applied cream and asked desk nurse to notify doctor. On 12/03/19 at 12:44 [NAME]M., General skin observation small open area remains to left buttocks, dark pinkish-red in color, remains superficial. Sensicare applied after cleansing. On 12/03/19 at 12:09 P.M., communication to the physician stated On 11/26/19 a pinpoint open area was noted to the right buttock. Hygiene, sensicare, repositioning. Today the area remains superficial but increased in size: 0.3 cm (centimeters) diameter. Continues with occasional bleeding. On 12/04/19 at 10:43 [NAME]M., the Surveyor interviewed LPN (Licensed Practical Nurse)-G who is responsible for the facility's wound care program. LPN-G stated she was updated yesterday regarding the open area to R3's right buttock. LPN-G stated she was not aware of any previous documentation related to R3's right buttocks, and was under the impression it first opened yesterday. LPN-G stated she was not aware that R3 had an additional open area to left buttocks. LPN-G stated staff on the unit should have notified the wound care team immediately upon discovery of an open area so an assessment could have been completed to the open area on the left and right buttocks. LPN-G stated wound prevention is especially important for R3 because R3 has fragile skin which could break down quickly.

Based on staff interview and record review, the facility did not develop comprehensive care plans for 1 Resident (R) (R32) of 14 sampled residents. R32's medication regimen included [MEDICATION NAME] (an antibiotic medication) daily. R32's plan of care did not address the high risk medication or important monitoring and interventions related to the medication. Findings include: 1. The Surveyor reviewed R32's medical record from 12/02/19 through 12/04/19. R32 was admitted to the facility on [DATE]. R32's medication regimen included long-standing [MEDICATION NAME] with current dosing orders of: [MEDICATION NAME] 100 mg (milligram) by mouth daily for: Urinary Tract Infection [MEDICATION NAME] with a order date of 04/26/19. R32's most recent MDS (Minimum Data Set) was a quarterly assessment with an ARD (Assessment Reference Date) of 10/25/19. The Assessment indicated that during the 7 day look back period, R32 received antibiotic medication all 7 days. R32's comprehensive plan of care did not address R32's use of [MEDICATION NAME] including potential side effects to monitor for while taking the medication. On 12/04/19 at 11:57 [NAME]M., the Surveyor interviewed DON (Director of Nursing)-B regarding R32's use of [MEDICATION NAME] medication. DON-B verified R32 was prescribed long term [MEDICATION NAME] which is high risk medication. DON- B verified R32's plan of care did not address the use of daily [MEDICATION NAME] medication, and verified it should do so.

Based on record review and staff interviews, the facility did not ensure that alleged violations involving abuse and neglect were reported to the State Survey and Certification Agency for 3 Residents (R) (R342, R8 and R10) of 14 sampled residents and 3 supplemental sampled residents. On 11/22/18, a CNA (Certified Nursing Assistant) alleged that an LPN (Licensed Practical Nurse) had used force to make R342 do exercises. Although the facility completed an investigation, the allegation of possible abuse was not reported to the State Survey and Certification Agency. On 1/21/18, R8 was left to sit in a wheelchair from 8:00 PM to 5:00 AM. R8 had rung for assistance at 10:00 PM. R8's care plan included intervention for staff to check R8 every three hours during the night. Although the facility completed an investigation, the allegation of possible neglect was not reported to the State Survey and Certification Agency. On 9/11/19, a housekeeper alleged a CNA either called R10 lazy, or stupid. R10 was noted to be crying after the incident. Although the facility completed an investigation, the allegation of potential abuse was not reported to the State Survey and Certification Agency. Findings include: Facility provided policy titled, Investigation of Allegations of Abuse, Neglect, Misappropriation of Property, Resident to Resident Altercation and Injury of Unknown Source stated, Report all alleged violations and all substantiated incidents to the state agency and to all other agencies, as required, and take all necessary corrective actions depending on the results of the investigation. On 12/03/19 at 10:14 AM, Surveyor reviewed facility complaint/grievance binder which included the investigations for the following incidents and included these statements: 1) On 11/22/18, a CNA alleged via a written Employee Concern Form that R342, .refused to go for a walk/exercise (LPN name) continued to rip the blanket off resident and forcefully made resident stand up and walk to exercise room. Once in the exercise room LPN forced resident on elliptical machine even as resident continued to refuse and c/o (complain of) knee pain and being tired. LPN made (R342) complete the exercise. Nurse was rude and way to (sic) pushy. Resident expressed it was her right to refuse nurse did not care and continued to move forward to making resident complete. 2) On 1/21/18, R8 stated, (R8) watches wrestling every Monday and Tuesday nights and it usually ends at 10:00pm. On Monday evening, (MONTH) 21st, (R8) goes to (R8's) room at 6:30pm and was taken care of by (CNA1 name). (CNA1 name) provided care per (R8's) request and set (R8) up for wrestling. (CNA1 name) reported off to (CNA2 name) that (R8) was in (R8's) room watching wrestling and (R8) would ring when (R8) was ready to get into bed . Night shift CNA, (CNA3 name), came from another team to care for this resident at 10pm. (R8) stated (R8) had placed (R8's) call light on around 10pm and no one came in to put (R8) into bed. The resident fell asleep in (R8's) W/C (wheelchair). (CNA3 name) and (RN name) failed to hear (R8) versus badge light which is a device that sends a signal to the nurses and CNA phones. (This is not a call light and only will ring once and send to the phone). At 5am, (CNA3 name) went into the resident's room and saw (R8) up in the chair and was horrified. Both (CNA3 name) and the nurse failed to check (R8) q (every) 3 hours when asleep per the resident's plan of care . 3) On 9/11/19, the facility received a report from a housekeeper that stated, The nurse working the east side (Nurse name) came into to explain that the housekeeper reported that (R10) was called lazy (CNA name). Included was a hand-written statement from the housekeeper which stated, I (Housekeeper name) witness (sic) a CNA talking loud to a resident ((R8)). Told (R8) (R8) was stupid I found (R8) in the hallway after that and (R8) was crying . On 12/03/19 at 10:42 AM, Surveyor interviewed Social Worker (SW)-C regarding the above allegations of abuse/neglect. SW-C stated, When we receive an allegation, we look into it to see if it was a misunderstanding or if it falls under definitions of abuse, neglect, etc. If it is something minor we will handle in-house. If we need to send into State we do. When asked if the incident that occurred on 11/22/18 as described above should have been reported to the State, SW-C stated, Yes. When asked if the incident that occurred on 1/21/19 as described above should have been reported to the State, SW-C stated, Now that you talk about it probably. When asked if the incident that occurred on 9/11/19 as described above should have been reported to the State, SW-C stated, Probably reportable. On 12/03/19 at 2:12 PM, Surveyor interviewed NHA-A, who verified each of the above three incidents should have been reported to the State.

Based on record review and staff interview, the facility did not ensure that 1 (resident #2) of 4 residents reviewed for falls, from a total of 10 sampled residents, received adequate supervision and assistance devices to prevent accidents. Resident #2 had a history of [REDACTED]. The plan of care was not consistently or effectively updated after each fall to prevent or reduce the chance for similar falls. On 3/14/12, resident #2 sustained fractures of the tibia and fibula after falling and was admitted to the hospital for surgery. Findings include: On 8/7/12 surveyor # reviewed the medical record of resident #2. The 4/28/09 facesheet contained within the medical record revealed resident #2 was admitted to the facility 12/31/98 with [DIAGNOSES REDACTED]. The most recent "re-admission" MDS (Minimum Data Set) assessment dated [DATE], revealed resident #2 was cognitively impaired. The CAA (Care Area Assessment) dated 7/10/12 revealed the following about resident #2 related to cognition: "...dementia, confusion, disorientation, forgetfulness, mental errors, impulsivity, poor safety awareness, short attention span." Related to mobility and falls, the 7/10/12 CAA indicated, "resident #2 is at risk for falls, has history of falling, difficulty maintaining standing position, gait problem even with mobility aid or personal assistance, musculoskeletal problem..." *Nurses notes dated 1/30/12 revealed resident #2 fell without injury while ambulating. The facility "Incident Report and Follow Up Investigation Assessment," completed 2/1/12, revealed a magnetic pull alarm and floor sensor mat while in bed were already in place for resident #2 . Documentation on the above form indicated the plan of care was not revised except to include, "Reinforced to call for help, but difficult to tell if (resident) retained info." A follow up nurses note for resident #2, on 1/30/12 indicated, "due to alcohol dementia does not absorb information, staff will monitor." No documentation was presented to reflect how or when the staff would monitor resident #2 for falls. *Nurses notes dated 2/4/12 revealed resident #2 experienced a fall, "while reaching for a perfume bottle." When safety instructions were reviewed with resident #2, nurses notes from that day indicated, "resident argumentative, refuses to participate, unable to teach due to alcohol dementia and OCD." The "Incident Report and Follow Up Investigation Assessment," completed 2/6/12, indicated an "alarmed floor mat when in bed and magnetic pull alarm" were in place. The intervention documented to prevent future falls, "de-clutter area if resident allows." Specific details regarding the fall, whether resident #2 was standing, lying, sitting or fell from bed, chair or while ambulating were not described. The ICT (Interdisciplinary Care Team) met on 2/9/12, the following was noted, "...recent behavior of hoarding food/condiments....staff should check drawers/closet daily at HS and remove uneaten food items." It should be noted, resident #2 was reaching for perfume, not food items. *On 2/11/12, nurses notes revealed resident #2 experienced another fall. Regarding safety instructions, the nurses note stated, "(resident) refuses to participate, will reinforce as needed." The "Incident Report and Follow Up Investigation Assessment," completed 2/14/12, does not reveal where or how the fall occurred but indicated the magnetic pull alarm and alarmed floor mat were in place when the resident was in bed. The intervention documented to prevent future falls was, "cue for assistance, but very forgetful and gets consumed by OCD." The plan of care was revised to include "gripper material in recliner." Specific details regarding the fall, whether resident #2 was standing, lying, sitting or fell from bed, chair or while ambulating were not described. *On 3/1/12, nurses notes revealed resident #2 experienced a fall while trying to move an alarmed floor mat away from the bed. The "Incident Report and Follow Up Investigation Assessment," completed 3/7/12, indicated education was provided to staff to remove the alarmed floor mat in the morning, as this fall resulted in resident #2 . Corrective actions regarding the fall were to "instruct resident to use the call light for assistance when getting anything off the floor." *On 3/6/12, nurses notes revealed resident #2 experienced a fall while transferring. The "Incident Report and Follow Up Investigation Assessment," completed 3/6/12, indicated the magnetic pull alarm and alarmed floor mat were in place while resident #2 was in bed and the intervention documented was "resident teaching and re-enforcement to ensure enough room to move around." No other care plan revision was documented. On 3/8/12, the ICT met, documentation indicated resident #2 was attempting to sit in a favorite chair in the lobby, but another resident was there. After the fall, resident #2 was noted to have an abrasion of the forehead. No revisions were noted to the plan of care. *On 3/14/12, nurses notes revealed resident #2 fell while ambulating to the bathroom. The "Incident Report and Follow Up Investigation Assessment," completed on 3/15/12, indicated alarms and floor mat were in use for resident #2, but only when in bed, not at the time of the fall. Additionally, this assessment revealed resident #2 had "6 similar incidents...falls most often occur in resident room...most often occurred in the evening, as (resident #2) has trouble getting set for bed." No evidence was presented to demonstrate the ICT evaluated this pattern of falls to review and revise the plan of care. Interventions related to this fall include "evaluate current arrangement of baskets, bags, etc. on walker. Resident becoming very agitated with discussion about altering layout." The ICT notes dated 3/15/12 indicated, "(resident #2) currently in hospital awaiting surgery...ankle fractured yesterday." Hospital discharge summary dated 3/20/12 indicated resident #2 was admitted to the hospital 3/14/12 with "displaced fractures of right tibia and fibula...procedure performed: open reduction internal fixation right distal tibia fracture and open reduction internal fixation lateral malleolus fracture." *Nurses notes dated 6/20/12 indicated resident #2 fell while "ambulating with therapy...sat down before wheelchair was all the way under.." The "Incident Report and Follow Up Investigation Assessment," completed 6/22/12, revealed no interventions were suggested, no revisions made to the plan of care." On the written plan of care for falls, the intervention "I need to be checked frequently for my safety" was added 7/17/12. No direction was included to describe how often or when that intervention would occur. On 8/9/12 at 2:00 p.m., surveyor # interviewed DON (Director of Nursing)-C regarding the falls interventions for resident #2. The above falls and interventions were verified. Given the [DIAGNOSES REDACTED], dementia and mental illness of resident #2, DON-C confirmed the intervention of "resident re-enforcement or re-education of safety measures" may have been in-effective. DON-C stated a review of resident #2's medications was not conducted as they relate to frequent falls. The fall of 1/30/12, involved ambulation, the intervention of "resident education and re-enforcement" was trailed. Subsequent falls on 2/11/12, 3/1/12, 3/6/12 documented the same intervention. The fall of 3/14/12 involved ambulation and resulted in multiple lower leg fractures. After the fall of 2/4/12, the plan of care was to de-clutter the room. The fall of 3/14/12, involved clutter around resident #2's walker and room.