Every finding on record at Froh Community Home

Based on observation, interview, and record review, the facility failed to maintain best practices in the food service area resulting in the potential to spread food borne illness to all residents that consume food from the kitchen.Findings Include:On 6/9/26 starting at 6:30 AM, an initial tour of the kitchen was performed with Dietary Manager (DM) K.On 6/9/26 at 6:44 AM, observation of the produce and preparation walk in cooler found a large three-gallon stock pot labeled sweet potato soup. The item was found covered in plastic wrap, with noticeable condensation on the inside top. When asked when this item was prepared, DM K stated it was made last evening and cooled down with an ice wand. When asked what temperature the soup should be at this time, DM K stated it should be at 41F or below. The surveyor measured the temperature of the soup with a digital rapid read thermometer and found it to be 70F in the center. When asked what should be done with the soup, DM K stated it needed to be dumped. When asked to see if this item was on the cooling log, DM K stated it did not make it on the cooling log.On 6/9/26 at 7:07 AM, observation of the clean utensil drawer containing metal spoons found an increase in accumulation of crumb debris in a line on the back of the drawer. When asked how often this area gets cleaned, DM K stated weekly.On 6/9/26 at 7:08 AM, observation of the can opener found a dried sticky red substance on the blade of the opener with sticky debris lining the bar of the can opener as it was pulled from the holder. On 6/9/26 at 7:13 AM, observation of the kitchen microwave found an accumulation of dried debris on the inside ceiling of the unit.On 6/9/26 at 7:21 AM, observation under the back preparation table found two open containers of less sodium soy sauce, one bottle almost empty and the other still full. A review of the manufacturer's directions state to Refrigerate After Opening.On 6/9/26 at 7:24 AM, observation of the inside of the dish machine found black and brown slimy accumulation hanging out of the holes of the rinse sprayer arm. When asked how often the unit gets cleaned on the inside, DM K stated it gets delimed monthly.On 6/9/26 at 12:07 PM, a revisit to the produce and preparation walk in cooler found a large container labeled shepherd's pie, covered tightly with plastic wrap, sitting on ice. When asked what the item was for, DM K stated it was cooling for lunch the next day. At this time, the temperature of the product was taken and found to be 110F. A check of the cooling log did not find evidence that this item was being tracked.According to the 2022 FDA Food Code section 3-501.14 Cooling. (A) Cooked TIME/TEMPERATURE CONTROL FOR SAFETY FOOD shall be cooled: (1) Within 2 hours from 57 C (135 F) to 21 C (70 F); and (2) Within a total of 6 hours from 57 C (135 F) to 5 C (41 F) or less.According to the 2022 FDA Food Code section 3-501.15 Cooling Methods. (A) Cooling shall be accomplished in accordance with the time and temperature criteria specified under S 3-501.14 by using one or more of the following methods based on the type of FOOD being cooled: (1) Placing the FOOD in shallow pans; (2) Separating the FOOD into smaller or thinner portions; (3)Using rapid cooling EQUIPMENT; (4) Stirring the FOOD in a container placed in an ice water bath; (5) Using containers that facilitate heat transfer; (6) Adding ice as an ingredient; or (7) Other effective methods.According to the 2022 FDA Food Code section 3-501.16 Time/Temperature Control for Safety Food, Hot and Cold Holding. (A) Except during preparation, cooking, or cooling.TIME/TEMPERATURE CONTROL FOR SAFETY FOOD shall be maintained: (1) At 57C (135F) or above.(2) At 5C (41F) or less.According to the 2022 FDA Food Code section 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils. (A) EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS 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.

Based on interview and record review the facility failed to ensure residents received annual Level 1 PASARR (Pre-admission Screening and Resident Review) and follow up Level II PASARR to ensure appropriate mental health services were provided for 5 residents (Resident #10, Resident #17, Resident #20, Resident #48, Resident #8) of 5 residents reviewed for PASARR resulting in the potential for residents to not receive appropriate mental health treatment and services and residents to be inappropriately placed in the nursing facility . Findings include: Resident #10 (R10) Review of the Facesheet and Minimum Data Set (MDS) dated [DATE] revealed R10 admitted to the facility on [DATE] with pertinent diagnoses including severe dementia with agitation (decline in mental ability that interferes with daily life and leads to excessive motor activity, verbal aggression, or physical aggression that causes severe distress), psychotic disorder with delusions (mental health condition characterized by a break from reality despite clear evidence to the contrary), depression, anxiety and unspecified intellectual disabilities. Brief Interview for Mental Status (BIMS) reflected a score of 8 out of 15 which indicated R10's cognition was moderately impaired. During an interview on 6/9/2026 at 9:18 PM, R10 asked this surveyor questions and kept mumbling this surveyor's name throughout the conversation. When this surveyor left R10's room, he yelled this surveyor's name multiple times and it could be heard down the hallway. Review of R10's PASARR level I screening dated 4/9/2025 under Section II-Screening Criteria revealed that yes was marked for the following questions: The person has a current diagnosis of mental illness; The person has received treatment for mental illness; The person has routinely received one or more prescribed antipsychotic or antidepressant medications within the last 14 days; There is presenting evidence of mental illness or dementia, including significant disturbances in thought, conduct, emotions, or judgment. Presenting evidence may include, but is not limited to, suicidal ideations, hallucinations, delusions, serious difficulty completing tasks, or serious difficulty interacting with others; The person has a diagnosis of an intellectual disability or a related condition including, but not limited to, epilepsy (neurological disorder that causes seizures), autism (neurodevelopmental condition that affects how individuals communicate, interact, behave and perceive the world), or cerebral palsy (neurological disorder that affects a person's ability to move and maintain balance and posture) and this diagnosis manifested before the age of 22. Under Explain any Yes (questions): Previously received ID/DD (Intellectual Disability/Developmental Disability) services from (name omitted) and had lived in a group home; Zoloft 100 mg (milligrams), depression, increased 10/11/24, xanax (for anxiety) .5 milligrams tid 11/22/24, Risperdal 2 mg hs (evening), failed GDR (Gradual Dose Reduction) 8/2/24, able to express basic needs and has limited reasoning skills. The form indicated If any answers to items 1-6 in Section II is yes, send ONE copy to the local Community Mental Health Service Program (CMHSP). so a level II PASARR could be completed. Further review of R10's chart revealed that there was no annual level I PASARR and follow-up level II PASARR after 4/9/2025 and as of 6/9/2026 at the start of the survey. During an interview on 6/10/2026 at 9:03 AM, Social Service Director (SSD) C stated that he would look into where R10's level I and level II PASARR documentation was. During an interview on 6/10/2026 at 9:05 AM, Director of Nursing (DON) B reported that the facility completed the level I PASARR screenings and then Community Mental Health (CMH) did the level II PASARRs. DON B stated that she would look for R10's level I and level II documentation since it should have been completed. During a follow up interview on 6/11/2026 at 10:41 AM, DON B stated that the previous SSD left on 8/15/2025 and then SSD C started on 9/22/2025. DON B said that she thought SSD C completed the level I PASARR screenings and sent the documentation to CMH so they could complete the level II PASARR. DON B said that she thought SSD C was doing the level I PASARR and didn't realize he wasn't a licensed social worker and couldn't do them. DON B reported that the level I PASARR screenings and the documentation being sent to CMH to have a level II PASARR completed were not being done since the former social worker left on 8/15/2025 and she was unsure of how many residents were missed. Review of PASARR Policy with a review date of 3/11/2025 revealed .I. Goal: To ensure that individuals with mental illness/intellectual/developmental disabilities/related conditions receive the care and services that they need in the most appropriate settings. The PASARR will be evaluated annually and upon any significant change for those individuals identified. R17 According to the Minimum Data Set (MDS) dated [DATE], R17 scored 15/15 on his BIMS (Brief Interview Mental Status) indicating he was cognitively intact with active diagnoses within 7 days of the assessment included bipolar disorder (a mental health condition that causes extreme, cyclical shifts in mood, energy, activity levels, and concentration). Section N-Medications indicated the high-risk drug classes R17 were taking included antipsychotics and anticonvulsants. Review of R17's Form-3877 Level 1 Screening PASARR dated 6/14/25 revealed in Section II, the resident had a current diagnosis of mental illness, received treatment for the mental illness including routinely receiving one or more prescribed antipsychotic or antidepressant medications within the last 14-days. It did not indicate R17 had a diagnosis of dementia (a group of symptoms including memory loss, confusion, and impaired reasoning that interfered with daily life). Review of the Form-3877 Preadmission Screening (PAS)/Annual Resident Review (ARR) indicated Sections II (Screening Criteria) and Section III (Clinician's Statement) must be completed by a registered nurse, licensed bachelor or master social worker, licensed professional counselor, psychologist, physician's assistant, nurse practitioner, or a physician. In any answer to items 1-6 in Section II were Yes, one copy of the Form-3877 must be sent to the local Community Mental Health Services Program with a copy of Form-3878 (Level II Screening) if an exemption is requested. The nursing facility must retain the original in the resident's record. Review of R17's medical records revealed the resident did not have a 2026 annual Form-3877 Level I Screening as of 6/10/26 at 12:00 PM. Review of R17's medical records did not have a copy of Form-3878 Level II Screening in his medical records completed by a community mental health program. The Form-3878 Level II Screening process serves to 1. Confirm Diagnoses: Identify or verify if an individual has a serious mental illness (MI), intellectual disability (ID), or a related condition. 2. Evaluate Placement: Determine if the patient actually requires the high level of care provided in a nursing facility. 3. Identify Specialized Needs: Assess whether the individual requires specialized or rehabilitative mental health services during their nursing home stay. Review of R17's Care Plan (a treatment plan for comprehensive resident-specific needs) did not have a focus for PASARR/OBRA/Level Screening and mental health needs to assist the resident. During an interview on 6/10/26 at 12:01 PM, Social Services (SS) C stated, I am not a licensed social worker and cannot complete the Level I Screening for OBRA (Omnibus Budget Reconciliation Act of 1987 that established sweeping national minimum standards of care and a [NAME] of Rights for residents in nursing homes and long-term care). The facility's Director of Nursing (DON) is doing the resident's Level I screenings. (Name of community mental health agency) is doing Level II Screenings. I started working at the facility in September 2025. During an interview on 6/1026 at 12:03 PM, DON B stated, I thought (SS C) could complete the OBRA forms for Level I Screening. (SS C) thought (name of mental health services agency) could do them. When (SS C) was hired in September 2025 I knew he was not licensed and he could not complete the OBRA Level I Screening forms. R20 According to the Minimum Data Set (MDS) dated [DATE], R20 scored 10/15 on her BIMS (Brief Interview Mental Status) indicating she was cognitively impaired with active diagnoses within 7 days of the assessment that included non-Alzheimer's dementia (an umbrella term for various brain disorders that cause cognitive and behavioral decline severe enough to disrupt daily life, but are not caused by the specific protein build-ups (amyloid plaques and [NAME] tangles) of Alzheimer's disease). Review of R20's Form-3877 PASARR Level 1 Screening dated 5/12/25 indicated the resident was diagnosed with MI (mental illness) and Dem (dementia). Review of R20 medical records did not reveal a Form-3877 PASAR Level I Screening had been completed for 2026 as of 6/9/26 the start of the recertification survey. Review of R20's Form- 3878 Level II Screening dated 5/12/2025, did not indicate it had been sent to the community mental health agency for Level II screening. Review of R20's Care Plan did not have a focus for PASARR/OBRA/Level Screening and mental health needs to assist the resident. R48 According to the Minimum Data Set (MDS) dated [DATE], R48 scored 1/15 on her BIMS (Brief Interview Mental Status) indicating she was severely cognitively impaired. Active diagnoses within 7 days of the assessment included non-Alzheimer's dementia, anxiety disorder (emotion characterized by feelings of tension, worried thoughts, and physical changes like a racing heart), depression (a serious mood disorder characterized by persistent feelings of sadness, hopelessness, and a loss of interest in activities), Schizophrenia (a chronic and severe brain disorder), Schizoaffective disorder bipolar type (a chronic mental health condition where a person experiences symptoms of schizophrenia (like delusions or hallucinations) alongside severe mood swings characteristic of bipolar disorder (manic episodes and sometimes major depression), and borderline personality disorder (a mental health condition characterized by severe instability in emotions, self-image, and behavior). Section N-Medications indicated the high-risk drug classes R48 were taking included antipsychotics, antidepressants, and anticonvulsants. Review of R48's OBRA Form-3878 Level II Screening dated 2/27/25 revealed reevaluation was required in 363 days due to a change in condition. Further review of R48's medical records did not reveal OBRA Form-3878 Level II Screening had been completed within 363 days. R8 According to the Minimum Data Set (MDS) dated [DATE], R8 scored 12/15 on her BIMS (Brief Interview Mental Status) indicating she was moderately cognitively impaired. Active diagnoses within 7 days of the assessment included non-Alzheimer's dementia, and Schizophrenia. Section N-Medications indicated the high-risk drug classes R8 included antidepressants medications. Review of R8's Form- 3877 Level I Screening, dated 3/14/25, indicated the resident had a mental health illness and dementia. Further review of R8's medical records did not reveal an OBRA Form-3878 Level II Screening had been completed for 2025. Review of R8's medical records did not reveal Form-3877 Level I Screening had been completed for 2025. Review of R8's Care Plan did not have a focus for PASARR/OBRA/Level Screening and mental health needs to assist the resident.

Based on interview, and record review, the facility failed to ensure psychotropic medications (prescription drugs that alter brain chemistry to affect mood, thoughts, behavior and perception) were not prescribed and administered without a medical indication for use for 1 (Resident #4) of 6 residents reviewed for chemical restraints, resulting in the potential for a resident to receive psychotropic medications unnecessarily.Findings include: Review of a Psychotropic Medication Policy and Procedure with a reference date of 3/11/25 revealed It is the policy of (facility name omitted) that the Geriatric Psychiatrist and the Primary Care physician will use psychotropic medications appropriately working with the interdisciplinary team to ensure appropriate use, evaluation and monitoring, is done.IV. Procedures: Orders for psychotropic medication only for the treatment of specific medical and/or psychiatric conditions.2. Document rationale and diagnosis for use and identify target symptoms.Resident #4Review of a Face Sheet revealed Resident #4 was originally admitted to the facility on [DATE] with pertinent diagnoses which included: generalized anxiety disorder (persistent, excessive, and uncontrolled worry about everyday topics) and insomnia (persistent difficulty falling asleep, staying asleep, or waking up too early and being unable to return to sleep).Review of a Minimum Data Set(MDS) assessment for Resident #4 with a reference date of 5/22/26, revealed a Brief Interview for Mental Status (BIMS) assessment score of 10/15, which indicated the resident was moderately cognitively impaired.Review of a Care Plan for Resident #4, completed by Director of Nursing (DON) B, with a reference date of 9/12/24, revealed the following problem/goal/approaches: Problem: I receive psychotropic medication for insomnia/mood. Anxiolytic (anti-anxiety medication) was discontinued then added back on 11/8/25. Goal: I will be prescribed the lowest effective dose of medication. Approaches: assess if the resident's behavioral/mood symptoms present a danger to the resident and/or others, assess/record effectiveness of drug treatment.Review of Physician Orders for Resident #4 with a reference date of 11/7/25 revealed Start date: 11/8/25, lorazepam (prescription medication belonging in the benzodiazepine class)-Schedule IV (prescribed drug class subject to strict regulations) tablet; 0.5 mg(milligrams), amt(amount): 0.25 mg; oral at bedtime.Diagnosis: (no information provided).In an interview on 6/10/26 at 2:55pm, Social Worker (SW) C confirmed Resident #4's order for lorazepam did not include a diagnosis and rationale for its use from the physician. SW C reported he monitored the use of psychotropic medications and ensured the medications were prescribed based on a clinical rationale and diagnosis, but this order had not been reviewed.In an interview on 6/11/26 at 12:23pm, DON B confirmed that she reviewed Resident #4's electronic medical record (EMR), and it did not include physician documentation of a clinical rationale and diagnosis related to the order for lorazepam that was initiated on 11/8/25.

Based on observation, interview and record review, the facility failed to provide individualized activities designed to meet the interests and support the mental and psychosocial well-being of 1 (Resident #9) of 1 resident reviewed for activities, resulting in boredom, decreased mental stimulation and decreased satisfaction with personal leisure lifestyle. Findings include:Review of Participating in Activities You Enjoy as You Age, published by the National Institute on Aging, 3/28/22, revealed: Research has shown that older adults with an active lifestyle: .Are less likely to develop certain diseases. Participating in hobbies and other social activities may lower risk for developing some health problems, including dementia, heart disease, stroke, and some types of cancer. Studies looking at people's outlooks and how long they live show that happiness, life satisfaction, and a sense of purpose are all linked to living longer. Doing things that you enjoy may help cultivate those positive feelings. Studies suggest that older adults who participate in activities they find meaningful, .say they feel happier and healthier. When people feel happier and healthier, they are more likely to be resilient, which is our ability to bounce back and recover from difficult situations. Positive emotions, optimism, physical and mental health, and a sense of purpose are all associated with resilience.research suggests that participating in certain activities, such as those that are mentally stimulating or involve physical activity, may have a positive effect on memory- and the more variety the better.Resident #9Review of a Face Sheet Resident #9 was originally admitted to the facility on [DATE] with pertinent diagnoses which included: hypertensive retinopathy (eye damage caused by high blood pressure) and major depressive disorder (a serious mood disorder characterized by intense, persistent feelings of sadness, hopelessness, and loss of interest in daily activities). Section D of the MDS revealed Resident #9 reported she felt down, depressed, or hopeless during 7-11 days of the 14-day assessment period.Review of a Minimum Data Set(MDS) assessment for Resident# with a reference date of 3/27/26, revealed a Brief Interview for Mental Status (BIMS) assessment score of 14/15, which indicated the resident was cognitively intact. Section D of the MDS revealed Resident #9 reported she felt down, depressed, or hopeless during 7-11 days of the 14-day assessment period.Review of a Care Plan for Resident #9 with a reference date of 3/23/26 revealed the following problem/goal/approaches: (Resident #9) is an independent woman and likes to do her own activities.she likes to read.Goal: I will accept items from the media cart as I have need. Approaches.having reading material is important to me. I will review what is offered on the media cart. Staff will offer items from the media cart and remind (Resident #9) of the library in the Gathering place.Review of the most recent Activities Assessment for Resident #9 with a reference date of 6/29/25 revealed Section 3-Psychosocial Well-being, changes in physical, cognitive and/or emotional status: mood fluctuation .Section 4-Activity Participation: She likes both independent and group activities .reading . Review of a Doctor of Optometry Visit Note for Resident #9 with a reference date of 3/26/26 revealed Chief Complaints: 1. Painless and Progressive Visual Loss. This is a [AGE] year-old female who is being seen for . painless and progressive visual loss involving the right eye and left eye. The symptoms are associated with blurred vision, difficulty reading, and difficulty seeing TV.During an observation on 6/9/26 at 11:24am. Resident #9 sat in her wheelchair in her room, unengaged and did not initiate interaction without encouragement.In an interview on 6/9/26 at 11:26am, Resident #9 reported she often felt bored and wanted to have more mental stimulation. Resident #5 reported she used to love to read but could no longer see well enough to do so and she felt unhappy with the opportunities she had for leisure involvement. Resident #5 reported she wanted to be involved in activities that would stimulate her mind but due to her vision, did not feel she could pursue independent activities for mental stimulation anymore. Resident #5 reported she had not been presented with any adaptive options that might improve her abilities to pursue reading such as large print materials or talking books.In an interview on 6/10/26 at 11:19am, Certified Nursing Assistant (CNA) BB reported she regularly cared for Resident #9. CNA BB reported Resident #9 complained of feeling bored in recent months. CNA BB reported she encouraged Resident #9 to read because the resident loved it but had observed that it appeared Resident #9 could no longer read. CNA BB stated She'll look at a book for a little while, but I don't think she can actually read now.In an interview on 6/11/26 at 11:19am, Activities Director (AD) DD it was important for her to be aware of each resident's likes, dislikes, and abilities to ensure individualized activities were provided to meet their needs. When queried regarding Resident #9's current leisure interests, AD DD stated She reads a lot. AD DD reported she only completed leisure assessments with residents upon their admission to the facility because she did not have time to complete follow up assessments. AD DD reported she was not aware of any changes in Resident #5's ability to read or that the resident complained of feeling bored and wanted more mental stimulation. AD DD reported she tried to check in with residents to see if their leisure needs had changed but she did not do so on a scheduled basis and was not always involved in care conference meetings where she could receive feedback from residents and their family members. AD DD reported if she had known about the decline in Resident #5's vision, she would could have attempted new interventions such as offering to have someone read to her or assisting Resident #9 with enrolling in a talking book program.Review of a Activity Department policy with a reference date of 6/18/21 revealed Mission Statement: It is the mission of this Activity Department to provide all residents with a meaningful and interesting program of activities to promote the physical, mental and psychosocial well being of each individual resident.Review of a Activities Director job description with a reference date of 9/28/17 revealed Primary Purpose.2. Assist each resident to reach their maximum potential for social, psychological, mental, and spiritual well-being through varied types and levels of activities.Job Responsibilities.2. Evaluate each resident.and develop a plan of care, goals and the process by which objectives are met. 3. Review and evaluate each nursing center resident on quarterly basis.6. Be alert to any change in condition of residents.8. Evaluate activities. Adapt, terminate, or create new activities to meet the needs of the residents.

Based on observation, interview, and record review, the facility failed to ensure effective pain medication was provided prior to wound care treatments for 1 (Resident #4) of 1 resident reviewed for pain management, resulting in 1. Resident #4 undergoing wound measurements and dressing changes without his requested pain medication. 2. Resident #4 grimacing, verbalizing pain and expressing frustration that he did not receive the pain medication he requested.Findings include: Resident #4Review of a 'Face Sheet revealed Resident #4 was originally admitted to the facility on [DATE] with pertinent diagnoses which included: venous insufficiency (condition causing poor blood circulation) and non-pressure chronic ulcers of right lower leg (wound(s) caused by poor circulation).Review of a Minimum Data Set(MDS) assessment for Resident#4 with a reference date of 5/22/26, revealed a Brief Interview for Mental Status (BIMS) assessment score of 10/15, which indicated the resident was moderately cognitively impaired. Section B revealed Resident #4 always understood others and made himself understood. Section J of the MDS revealed Resident #4 reported he experienced pain frequently.Review of a Care Plan for Resident # 4 with a reference date of 10/17/24 revealed the following problem/goal/approaches: 1. (Resident #4) .has stasis ulcers (open wounds caused by poor circulation) on right leg and heel.Goal: Wound will be free of infection.Approaches: .perform treatments per physician order. 2. (Resident #4) has a potential for pain due to peripheral vascular disease (narrowing of blood vessels causing reduced circulation of blood) .Goal: (Resident #4) will be comfortable through next review. Approaches.staff will anticipate need for pain relief. Instruct/remind resident to request medication before pain becomes too great.During an observation and interview on 6/9/26 at 9:59am, Licensed Practical Nurse (LPN) W reported she was the acting wound nurse for the day and was about to begin wound care on Resident #4's stasis wounds on his right lower leg. LPN W removed the bandage from a wound on Resident #4's right anterior (front) shin and cleaned the wound with gauze saturated with normal saline (sterile mixture of 0.9% sodium chloride (salt) in water). Resident #4 grimaced in pain as the gauze lightly touched the open surface of the wound. LPN W continued the wound care and as she measured the width, length and depth of the stasis wound on Resident #4's right heel, the resident grimaced, stated Ow, that hurts. I asked for acetaminophen (brand name removed) and the pill never arrived today Resident #4 held breath and grimaced for a few seconds after the statement.In an interview on 6/9/26 at 9:59am, LPN W confirmed she did not check to see if Resident #4 had received his pain medications prior to completing wound care for him on this date. Upon reviewing Resident #4's medical record, LPN W reported the resident had not received the acetaminophen he requested prior to the completion of wound care. LPN W reported Resident #4 also had an order for gabapentin (nerve pain medication) but she had not checked to ensure he received it prior to completing his wound care.In an interview on 6/9/26 at 10:03am, Resident #4 reported the wound care had been painful on this date and he wanted to have acetaminophen prior to his wound care, so he asked for it earlier, but it was not provided.In an interview on 6/10/26 at 1:29pm, LPN V, the floor nurse caring for Resident #4 on 6/9/26, reported the nurse should always ensure a resident received any prescribed pain medication prior to completing wound care because doing so would avoid the resident experiencing any avoidable discomfort. LPN V reported she administered acetaminophen to Resident #4 at approximately 11:00am on 6/9/26. Of note, the medication was provided after the resident's wound care was completed.Review of Physician Orders for Resident #4 revealed 1. Acetaminophen tablet; 500mg (milligrams) every 6 hours-PRN (as needed), start date 10/13/25. 2. Gabapentin capsule; 400mg; amt(amount); one; oral (by mouth) three times a day, start date 2/20/26. 3. Cleanse right heel with NS (normal saline), pat dry, apply Calcium alginate (naturally occurring cream-colored, gel-like substance) cover with 4x4 gauze and secure with bordered gauze. Daily and PRN, start date 5/1/26. 3. Cleanse right leg with NS, pat dry, apply calcium alginate cover with 4x4 gauze and secure with bordered gauze. Daily and PRN, start date 5/1/26.Review of a Medication Administration Record for Resident #4 revealed the resident received acetaminophen 500mg at 10:08am on 6/9/26. Further review revealed Resident #4 rated his pain level at a 6(moderate pain) on the Numeric Comparative Rating Scale (NRS) pain scale (0-10, 10 being the worst pain imaginable). Resident #4 had not received the medication in the previous 24 hours/was eligible to receive it when it was requested.Review of a Nursing Progress Note for Resident #4 with a reference date of 6/9/26 at 11:54am, revealed Resident reported pain with wound care. New order noted; ask resident if he would like (name bran omitted) acetaminophen for pain prior to dressing change. In an interview on 6/11/26 at 1:00pm, Director of Nursing (DON) B reported per professional standards of practice, the nurse should ensure a resident received prescribed pain medication and that the medication was effective prior to the completion of wound care.Review of Fundamentals of Nursing E-Book (Kindle Locations 61535-61556) Elsevier Health Sciences, Kindle Edition, [NAME], [NAME], [NAME], Stockert, Hall, revealed Pain is a universal but individual experience and a condition that nurses encounter among patients in all settings. It is the most common reason that people seek health care; yet it is often underrecognized, misunderstood, and inadequately treated. A person in pain often feels distress or suffering and seeks relief. Pain management should be patient centered, with nurses practicing patient advocacy. Effective communication among the patient. and professional caregivers is essential to achieve adequate pain management.Review of a Pain Management policy with a reference date of 8/21/23 revealed GOAL: It the policy of (facility name omitted) to provide an effective systemic approach to recognize, assess, treat and monitor pain, through processes that identify potential barriers while creating a person-centered plan.

Based on observation, interview, and record review, the facility failed to ensure proper label and dating of foods and discarding of foods in the kitchen and kitchenette resulting in the potential to spread food borne illness to all residents that consume food from the kitchen. Findings Include: During the initial tour of the kitchen with Certified Dietary Manager (CDM) D on 5/19/2025 at 7:49 AM, the walk-in refrigerator was observed to have peaches in a large plastic container with no label and date. During the full kitchen tour with CDM D, Chef Manager (CM) C and Food Service Regional Director of Operations (RDO) BB on 5/20/2025 at 8:28 AM, the following was observed: The walk-in refrigerator contained a plastic container with yogurt with an open date of 5/17 and expiration date of 5/19. The reach-in refrigerator contained an open half gallon 2% milk jug with an open date of 5/17 and expiration date of 5/19. The reach in refrigerator also contained an open half gallon 2% milk jug with no label and date. On 5/20/2025 at 9:00 AM, the kitchenette by Maple and Oak Halls were observed to have an open bag of potato chips that was not sealed and did not have a label and date. According to the 2022 FDA Food Code section 3-501.17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking. (A) Except when PACKAGING FOOD using a REDUCED OXYGEN PACKAGING method as specified under S 3-502.12, and except as specified in (E) and (F) of this section, refrigerated, READY-TOEAT, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and held in a FOOD ESTABLISHMENT for more than 24 hours shall be clearly marked to indicate the date or day by which the FOOD shall be consumed on the PREMISES, sold, or discarded when held at a temperature of 5 C (41 F) or less for a maximum of 7 days. The day of preparation shall be counted as Day 1. (B) Except as specified in (E) -(G) of this section, refrigerated, READY-TO-EAT TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and PACKAGED by a FOOD PROCESSING PLANT shall be clearly marked, at the time the original container is opened in a FOOD ESTABLISHMENT and if the FOOD is held for more than 24 hours, to indicate the date or day by which the FOOD shall be consumed on the PREMISES, sold, or discarded, based on the temperature and time combinations specified in (A) of this section and: (1) The day the original container is opened in the FOOD ESTABLISHMENT shall be counted as Day 1; and (2) The day or date marked by the FOOD ESTABLISHMENT may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on FOOD safety .

Based on interview and record review, the facility failed to ensure a Trauma Care Assessment was completed and care plan developed to mitigate triggers of trauma in 2 of 2 residents (R22 and R40) reviewed for history of trauma, resulting in the potential for unidentified re-traumatization. Findings include: Review of facility Matrix received at survey entrance (5/21/25), identified R22 and R40 with PTSD/Trauma. R22 According to the Minimum Data Set (MDS) dated [DATE], R22 scored 5/15 on her BIMS (Brief Interview Mental Status), indicating she was cognitively impaired with diagnoses that included anxiety and depression. Section D-Mood indicated the resident had feelings of being down, depressed or hopeless with times of social isolation. Section A-Identification Information indicated the resident had been admitted [DATE]. Review of R22's medical records did not reveal a Trauma Care Observation Assessment had been completed upon admission or any other time. During an interview and record review on 5/20/25 at 3:29 PM, Social Services (SS) E stated during review R22's Care Plan and medical records, (R22's) has trauma related to her childhood. I've known her for a long time. I did not do a trauma assessment for (R22) and there are not any in her chart. Her Care Plan has a Psychosocial Well-Being focus that talks about her psychological needs. It is dated 5/1/25. It was noted R22's Care Plan was created for the residents' specific-treatment needs almost 5 months after admission without giving staff a treatment plan to follow and meet the residents' needs. R40 According to the MDS dated [DATE], R40 was unable to complete the BIMS, indicating she was not cognitively intact. Her diagnoses included anxiety and depression. Section D-Mood indicated she could be short-tempered and easily angered. Section A-Information Identification indicated R40 was admitted to the facility on [DATE]. During an interview and record review on 5/20/25 09:41 AM, Guardian CC' reported when the guardianship service received their referral from the facility in October 2023, trauma was not indicated on the referral, and they were unaware of care needs. During an interview and record review on 5/20/25 3:20 AM, Social Services E stated while reviewing R40's medical record, I do not have an admission trauma assessment form for (R40). I just had a conversation with the resident. When I do the PHQ-9 (depression/mood) her score was from staff assessment because she could not continue a conversation. There is a Care Plan focus related to neglect under cognition loss and dementia. During an interview and record review on 5/21/25 at 9:49 AM, Director of Nursing (DON) B stated, A trauma assessment should be done for each resident. It would be in the Observation part of the medical records and titled Trauma Informed Observation. This form should be done within the first 14-days of a resident admitting. DON B reviewed R22's and R40's medical chart stating there was not a formal trauma assessment completed upon admission for either resident and No starting point for treatment. I don't know how the resident would be cared for if an assessment with their needs was not completed. Review of facility policy Trauma Informed Care dated 3/11/25, revealed, Goal: It is the policy of (name of facility) to ensure residents who are trauma survivors receive culturally competent, trauma-informed care in accordance with professional standards of practice .Trauma is defined as an event, a series of events, or set of circumstances experienced by an individual as physically or emotionally harmful or life-threatening, that has lasting adverse effects on the individual's functioning and mental, physical, social, emotional, or spiritual well-being .Trauma-Informed Care is defined as an organizational structure and treatment framework that involves understanding, recognizing, and responding to effects of all types of trauma .Procedures: Each resident will be screened for a history of trauma within 14-days of admission by Social Service Director or designee .

Based on observation, interview and record review, the facility failed to ensure cleaning of respiratory equipment for two (R7 and R22) of two residents reviewed for respiratory care, resulting in the potential of harboring bacteria and pathogens causing infection in a vulnerable population. Findings include: R7 According to the Minimum Data Set (MDS) dated [DATE], R7 scored 13/15 on his BIMS (Brief Interview Mental Status) indicating he was cognitively intact and had diagnoses that included heart failure and pneumonia. Section O-Special Treatments and Programs indicated R7 received oxygen therapy via a non-invasive mechanical ventilator (CPAP). Observed on 5/19/25 at 10:15, a CPAP machine ((continuous positive airway pressure) a machine that uses mild air pressure to keep breathing airways open while sleeping) was at R7's bedside with the mask lying on personal items without being protected from dust and debris. During an observation and interview on 5/20/25 at 2:25 PM, R7 was awake in bed with CPAP on dresser next to bed. The CPAP mask was lying on personal items without being protected from dust and debris. R7 stated, I need help getting my mask (CPAP) off in the morning. Staff help me. I don't think it was cleaned this morning. I came here from the hospital with pneumonia and the doctor tells me I am healed. I don't need to get sick again. I could if my CPAP mask is not clean. Is it dirty? Can you see it? During an interview on 5/21/25 at 9:28 AM, Certified Nursing Assistant (CNA) P stated, My job duty for a CPAP is to remove it from the resident in the morning and the nurse will clean it. I do not know if the nurse cleaned (R7's) CPAP mask today. Observed on 5/21/25 at 9:33 AM, a CPAP was at R7's bedside with mask lying on personal items without being protected from dust and debris. During an interview on 05/21/25 09:37 AM, Registered Nurse (RN) EE stated, I clean CPAP masks but (R7) does not have CPAP, he has BiPAP. Review of R7's Order Summary dated 4/23/25 revealed, -Apply CPAP at night, Remove in AM Twice A Day 06:00 - 11:00, 18:00 - 22:00 - Clean CPAP Daily: 1. Remove facial oils from mask by wiping surface with damp cloth and mild detergent. 2. Rinse mask with water tap water. Once A Day 06:00 - 14:00 Review of R7's Care Plan, dated 5/13/25, with a focus on ADL (activities of daily living) Functional Status/Rehabilitation Potential from a short hospital stay for pulmonary embolism and pneumonia, indicated the resident wanted to remain safe using interventions that included using a CPAP at night and removing it in the morning. R22 According to the MDS dated [DATE], R22 scored 5/15 on her BIMS, indicating she was cognitively impaired with diagnoses that included dementia, partial paralysis, and Parkinson's disease. Section O-Special Treatments and Programs indicated R22 had a non-invasive mechanical ventilator (CPAP). Review of R22's Order Summary dated 1/29/25 revealed, -Apply CPAP at bedtime and remove it in the morning. Twice A Day 06:00 - 14:00, 19:00 - 22:00 -Clean CPAP Daily per policy. Remove facial oils from mask by wiping with damp cloth and mild soap, rinse with warm tap water. Once A Day 06:00 - 14:00 Observed on 5/19/25 at 10:26 AM, a CPAP machine was at R22's bedside with the mask covered with a fitted blue fabric. The mask was lying on personal items without being protected from dust and debris. Observed on 5/20/25 at 9:36 AM, a CPAP machine was at R22's bedside with the mask covered with a fitted blue fabric. The mask was lying on personal items without being protected from dust and debris. Observed on 5/20/25 at 2:30 PM, a CPAP machine was at R22's bedside with the mask covered with a fitted blue fabric. The mask was lying on personal items without being protected from dust and debris. Observed on 5/20/25 at 9:30 AM, a CPAP machine was at R22's bedside with the mask covered with a fitted blue fabric. The mask was lying on personal items without being protected from dust and debris. with a stuffed animal on top of the mask. During an interview and record review on 5/21/25 at 10:45 AM, Infection Preventionist (IP) I stated, A CPAP should be cleaned as ordered to protect the resident from respiratory infection. There is a policy for cleaning CPAPs. During an interview and record review on 5/21/25 at 9:39 AM, Director of Nursing (DON) B reviewed facility policy, The Cleaning of the C-PAP System (approved 2/10/2021), stating, The CPAP is cleaned daily wipe mask down with mild soap. I would think they (mask) would be in a bag to protect it and keep it clean. I ordered the fabric coverings for (R22's) mask. She gets a rash from wearing the mask. The staff should switch the fabric coverings out daily. (R7) still has a mask whether it is a CPAP or BiPAP. Review of R22's Care Plan for a comprehensive resident-focused treatment of the CPAP machine, did not indicate a treatment plan had been developed.

Based on observation, interview, and record review, the facility failed to ensure the use of person protective equipment (PPE) (gown and gloves) by staff during high contact care activities for 1 (Resident #45) of 5 residents reviewed for enhanced barrier precautions (EBP) resulting in the potential for the spread of infection, cross contamination, and disease transmission. Findings include: Resident #45 Review of an Facesheet revealed Resident #45 was a male who was originally admitted to the facility on [DATE] and had pertinent diagnoses which included: dementia, candidal sepsis (a fungal infection of the bloodstream), diverticulitis (a bulge in the large intestine) of large intestine with perforation (a break in the large intestine). Review of a Minimum Data Set (MDS) assessment for Resident #45, with a reference date of 4/10/2025 revealed a Brief Interview for Mental Status (BIMS) score of 2/15 which indicated Resident #45 was severely cognitively impaired. (BIMS score 0-7 indicates severe cognitive impairment). Review of Orders for Resident #45 revealed .Enhanced Barrier Precautions: For resident for whom EBP are indicated, EBP is employed when performing the following high-contact resident care activities in any setting in or out of room: Dressing, Bathing/showering, Transferring, providing hygiene, Changing Linens, Changing Briefs, or assist with toileting. Device care or use: central line, urinary catheter, feeding tube, tracheostomy/ventilator, wound care: any skin opening requiring a dressing, glove and gowns are to be utilized. Eye protection when splashing is possible. Every shift with a start date of 3/25/2025. On 5/19/25 at 8:06 am, no signage was noted outside of, nor in Resident #45's room indicated that staff should use EBP during cares. No PPE was observed available in Resident #45's room or bathroom. On 5/19/25 at 9:47 am, signage indicating that Resident #45 was in EBP was noted on the door frame to his room, and a three-drawer plastic bin with gowns, gloves, and masks was noted outside of the bathroom inside Resident #45's room. On 5/20/25 at 11:30 am, Certified Nurse Assistant (CNA) T was observed in Resident #45's room making his bed. CNA T was not wearing any PPE. In an interview on 5/20/25 at 11:35 am, CNA T reported the three-drawer plastic bin with PPE in it was for residents who were on isolation precautions. CNA T reported that Resident #45 was no longer in isolation and that PPE was not needed for any cares with Resident #45. CNA T indicated that the signage posted outside of Resident #45's door should have been taken down, as it was no longer needed for Resident #45. Review of Care Plan for Resident #45 revealed problem/goal/approach .start date 3/25/2025 Problem: Enhanced Barrier Precautions .has an MDRO (multi drug resistant organism) . acute or colonization, requiring enhanced barrier precautions . goal: to provide a safe sanitary and comfortable environment to help prevent the development and transmission of communicable diseases and infections. Reduce the transmission of resistant organisms. Resident to show no signs & symptoms of infection .Approach: Gown and gloves to be worn during high-contact resident care activities that provide opportunities for transfer of MDROs to staff hands and clothing. In an interview on 5/21/25 at 1:31 pm, Assistant Director of Nursing/Infection Preventionist (ADON/IP) I reported that Resident #45 was in enhanced barrier precautions and that her expectations were that staff wore PPE during high contact care activities. ADON/IP I reported linen changes were high contact care activities, and that CNA T should have worn PPE when she was making Resident #45's bed. Review of facility policy Transmission Based Precautions Enhanced Barrier Precautions with a revision date of 5/19/2024 revealed .1. Enhanced Barrier Precautions (EBP) refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employ targeted gown and glove use during high contact resident care activities. High care activities include. changing linens .

Based on interview and record review, the facility failed to ensure that Quality Assessment and Assurance (QAA) meetings were held at least quarterly in a census of 62 residents, resulting in the potential for quality deficiencies not being identified or corrected. Findings include: During an interview on 5/02/2024 at 1:03 PM, Director of Nursing (DON) B presented a QAA binder with meeting sign in sheets and notes dated 2/14/2024, 3/20/2024 and 4/10/2024. DON B stated that as of February 2024 the facility changed QAA meetings from quarterly to monthly. DON B was unable to locate the quarterly sign in sheets from September 2023 to January 2024 to show whether QAA meetings were held during that time and who attended. During an interview on 5/02/2024 at 1:30 PM, Assistant Director of Nursing (ADON) X stated that the QAA meeting was scheduled in November 2023 and was cancelled and she didn't know if it was rescheduled. Review of the Quality Assurance and Performance Improvement (QAPI) Policy with a created date of 9/20/2017 and a review date of 4/14/2023 under III. Procedures and 2 a. revealed, Meet at least quarterly and as needed to coordinate and evaluate activities under the QAPI program, such as identifying issues with respect to which quality assessment and assurance activities, including performance improvement projects (PIP) under the QAPI program, are necessary.

Based on observation, interview, and record review the facility failed to ensure proper infection control protocols and practices that included Enhanced barrier precautions (EBP) and/or transmission based precautions per national standards of practice for 5 of 17 residents (#31, #50, #27, #261, #262, #5), 2. ensure adequate hand hygien and hygenic wound care for 1 of 1 resident, and 3. ensure no consumption of personal beverages in resident care areas, resulting in the increased potential for the spread of infection, bacterial harborage, cross contamination, and disease transmission for residents residing in the facility. Findings include: Review of Centers for Disease Control and Prevention (CDC) dated March 20,2024, revealed, .Enhanced Barrier Precautions (EBP) refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and glove use during high contact resident care activities .EBP are used in conjunction with standard precautions and expand the use of PPE to donning of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs to staff hands and clothing .EBP are indicated for residents with any of the following: *Infection or colonization with a CDC-targeted MDRO when Contact Precautions do not otherwise apply; or *Wounds and/or indwelling medical devices even if the resident is not known to be infected or colonized with a MDRO .Effective Date: April 1, 2024 . Resident #31: Review of Orders dated 3/15/24, revealed, .Suprapubic catheter (tube inserted through the skin into the bladder to drain urine) - 12F/5cc . Review of Order dated 4/2/24, revealed, .Change catheter PRN (as needed) . Review of Resident #31's orders revealed no order for enhance barrier precautions. During an observation on 05/01/24 at 10:30 AM, observed no enhanced barrier precautions signage on the door or wall and no personal protective equipment (PPE) available for staff to don. Reveiw of Orders dated 04/01/24, revealed, .albuterol sulfate solution for nebulization; 0.63 mg/3 mL; amt: one; inhalation Special Instructions: BID for wheezing/SOB Twice A Day . During an observation on 05/01/24 at 03:14 PM, Resident #31's room observed in his room on his night stand next to his bed he had the nebulizer machine with the tubing and mask placed in his top drawer with other items. Noted the mask was not in a plastic bag or on a protective barrier in his drawer. Resident #50: Review of Orders dated 2/6/24, revealed, .Foley cath (tube inserted into the bladder to drain urine) 16 fr 10cc balloon; change monthly and PRN (as needed) .Once a day on 1st Tue of the Month . Review of Resident #50's orders revealed no order for enhance barrier precautions. During an observation on 05/02/24 at 09:48 AM, Resident #50's door to his room was open, no PPE and no signage on the door to indicate enhanced barrier precautions was needed for resident cares. Resident #27: Review of an Admission Record revealed Resident #27 was a female with pertinent diagnoses which included pressure ulcer of left ankle, Review of Orders dated 2/17/24, revealed, .FOLEY CATH 16FR 10CC 16 FR; amt: one; Special Instructions: CHANGE AS NEEDED Every Shift - PRN (as needed) . During an observation 05/01/24 at 10:37 AM, noted there was no signage on the door for enhanced barrier precautions or personal protective equipment (PPE) available for staff to don prior to entering the room. Wound Nurse Z entered the room and did not don PPE to perform the treatment. In an interview on 05/01/24 10:45 AM, Wound Nurse Z reported the order was for her leg/ankle area as she had surgery on that area and everytime it rubbed on the sheets it breaks open, since she had been here it had been there. WN Z reported the doctor told her since the area keeps opening said to keep something on it to protect it. During an observation of catheter bag emptying on 05/01/24 at 11:56 AM, Certified Nursing Assistant (CNA) K was noted to be wearing a faceshield and gloves but no gown. Observed CNA K removed the faceshield and placed it on a hook in the bathroom, she did not sanitize it prior to placing it there. In an interview CNA K reported with the type of catheter bag Resident #27 had the spout on it sometimes goes crazy and she reported she wore the mask to protect against being splashed in the face as that had happened before. Review of Resident #27's orders revealed no order for enhance barrier precautions. Resident #261: Review of an Facesheet revealed Resident #261 was a female with pertinent diagnoses which included stroke, dementia, weakness, and displaced spiral fracture of shaft of humerus, right arm. Review of Progress Note dated 4/15/24, revealed, .Resident receiving skilled nursing care for ORIF (open reduction and internal fixation) of right humerus and radial nerve graft on 3/27/24 .Dressing to RUE (right upper extremity) clean/dry/intact . Review of Care Plan created on 4/2/24, revealed the focus, .(Resident #261) had surgery on her right humerus fx (fracture), She has incision to right upper arm . with the intervention .Perform wound care treatments per physician orders . Review of Orders revealed no orders for enhanced barrier precautions or contact precautions. Review of Lab results dated 04/22/24, revealed, resident positive for urinary tract infection. Review of Lab results received on 04/25/24, revealed, Result Final: Proteus Mirabilis . Review of Resident #261's orders revealed no order for Contact Precautions due to her urinary infection diagnosis. Review of Progress Notes dated 04/30/2024 at 6:53 PM, revealed, .1630 (4:30 PM) ATB Cipro continues for UTI. Will accept water as desires. 480cc taken @ evening meal. No frequency to use the BR. States It is uncomfortable sometimes for me. Temp-97.8 . Review of Progress Notes dated 05/01/2024 at 09:51 AM, revealed, .ABT continues for UTI . During an observation on 05/01/24 at 10:19 AM, there was no contact precautions signage or personal protective equipment (PPE) available for staff to don prior to entering Resident #261's room. During an observation on 05/01/24 at 10:23 AM, Certified Nursing Assistant (CNA) E entered Resident #261's room to assist the resident's roomate to the shower. CNA C entered the room to assit with the transfer. Neither CNA had donned PPE prior to entering the resident's room. In an interview on 05/02/24 at 10:22 AM, Infection Preventionist (IFP) X reviewed the culture and sensitivity lab results and reported Resident #261 had proteus mirabilis which was a MDRO (multi drug resitant organism) and when she reported the facility did not have any residents on precautions she was incorrect as Resident #261 should have been on contact precautions due to her infection. Resident #262: Review of an Facesheet revealed Resident #262 was a female with pertinent diagnoses which included cellulitis of right lower limb, pressure ulcer of rigth heel, stage 1, pressure ulcer of left heel, stage 1, celluitis of left lower limb, and malignant neoplasm of skin (skin cancer). Review of Orders dated 4/24/24, revealed, .Santyl ointment; 250 unit/gram; amt: small amount; topical. Special Instructions: Put on crusty areas of right shin .Once a day . Review of Orders dated 4/27/24, revealed, .Nystatin cream; 100,000 unit/gram; amt: to bottom of right foot; topical. Special instructions: Apply to bottom of right foot, cover with ABD, secure with ace wrap x2 weeks .Every shift . Review of Orders dated 4/24/24, revealed, .Cleanse left leg with ns pat dry apply calcium alginate to entire area cover with ABD, kling and cover with ace bandage and leave ace bandage in place till next drsg change .Once A Day . Review of Orders dated 4/24/24, revealed, .Cleanse right shin with ns pat dry apply calcium alginate to open areas (not crusty area) cover the whole shin with ABD wrap with kling and cover with ace bandage. Leave Ace bandage in place till next next drsg change . Review of Progress Notes dated 04/30/2024 at 10:53 AM, revealed, .Resident receiving skilled nursing post hospitalization for BLE (bilateral lower extremity) cellulitis. Oral ABT (antibiotic) completed yesterday .Reported right foot continues to be sore .and resident elevated BLE in recliner after breakfast . In an interview on 05/02/24 at 09:54 AM, RN O reported Resident #262 had cancer with a few open spots, growths to her leg, the nurses called them crusty areas. During an observation on 05/01/24 at 10:30 AM, Resident #262 was not currently in her room. There was no signage to indicate enhanced barrier precautions and no PPE available to use for staff. Review of Resident #262's orders revealed no order for enhance barrier precautions. Resident #5: Review of an Facesheet revealed Resident #5 was a female with pertinent diagnoses which included: Alzheimer's disease, type 2 diabetes mellitus, and pressure wound to the left heel, unstageable. Review of Care Plan dated 4/23/24, revealed the focus, .(Resident #5) is at increased risk to develop skin breakdown due to limited mobility secondary to advanced age, dementia .Blood blister to left heel. Doctor in and it was dx as diabetic ulcer due to h/o diabetic ulcers. Wound on heel opened and doctor re-evaluated and determined it to be unstageable to left heel . Review of Progress Notes dated 04/23/2024 at 1:44 PM, revealed, .open are on right 3rd toe .heel drainage. Calcium alginate and 4x4 gauze was applied . Review of Progress Notes dated 04/24/2024 at 12:57 PM, revealed, .(Medical Doctor) in today to look at abrasion to R foot. During an observation on 05/01/24 at 02:56 PM, Resident #5 was in her room lying in her bed, supine position. There was no signage on the walls or door for enhanced barrier precautions and no PPE available for staff use. Review of Resident #5's orders revealed no orders for enhanced barrier precautions due to her pressure ulcers and open wounds. In an interview on 05/01/24 at 02:50 PM, Infection Preventionist (IFP) X reported the facility had no residents currently under precautions for infection control. In an interview on 05/02/24 at 10:27 AM, Infection Preventionist (IFP) X reported she was not aware of when the changes to implement enhaned barrier precautions had went into place. IFP X reported she had received the information a few days ago but had not read the guidance as of yet. IFP X reported according to the guidance the facility should have been implementing enhanced barrier precautions for those current residents with wounds, pressure ulcers, and indwelling devices. 47955 Review of an Facesheet revealed Resident #5 had pertinent diagnoses which included: Alzheimer's disease, pressure ulcer to the left heel, unstageable, and type 2 diabetes mellitus with other skin ulcer. During an observation on 5/1/24 at 1:50 PM., Certified Nursing Assistant (CNA) E and CNA F were observed transferring Resident #5 via a hoyer lift (mechanical lift used to assist people who have difficulty standing) in her room into her bed from a shower chair. During an observation on 5/1/24 at 2:01 PM., CNA F placed the hoyer lift used to transfer Resident #5 into the clean utility room on station 2. CNA F did not clean the hoyer lift. In an interview on 5/1/24 at 2:17 PM., CNA F reported that she tries to clean the lifts after each use but sometimes she forgets. When asked if CNAF cleaned the hoyer lift, CNA F stated she did not clean the lift after it was used. CNA F reported that the lift should be cleaned after each use. In an interview on 5/1/54 at 2:18 PM., Assistant Director of Nursing (ADON) X reported that her expectation was that a hoyer lift should be cleaned after each resident use. During an observation on 5/1/24 at 2:03 PM., CNA E deposited bagged soiled linen into a barrel in the soiled utility room on Station 2. CNA E was then observed pushing the soiled shower chair used by Resident #5 into the spa room on station 2. While in the spa room, CNA E was observed taking a drink from a personal beverage cup that was sitting on a table inside the spa room on station 2. CNA E was observed exiting the spa room on station 2, gathered linen from the linen closet, and then entered another resident room. At no time did CNA E perform hand hygiene. In an interview on 5/1/24 at 2:13 PM., CNA E reported that she switches her gloves quite often and if she is soiled with feces or urine, then she will wash her hands with soap and water. CNA E reported that she will use hand sanitizer before she enters a resident room. When directly asked if she performed hand hygiene between residents, CNA E replied I did not use hand sanitizer this time or wash my hands. In an interview on 5/1/24 at 2:22 PM., Director of Nursing (DON) B and ADON X reported that hand hygiene should be completed before and after resident care. In an interview on 5/1/24 at 2:28 PM., DON B reported that staff's personal beverages should not be in the spa room or consumed in resident care areas. During an observation on 5/2/24 at 10:30 AM., Wound Nurse (WN) Z and CNA M were prepping to complete Resident #5's dressing change to her left foot. Noted in the room was a pedestal fan, at the foot of Resident #5's bed, that was turned on and was blowing air on Resident #5's feet. While observing WN Z position herself to complete Resident #5's left foot dressing change, the supplies on the over the bed table that WN Z was positioning into her reach prior to starting the dressing changed were blown around and disturbed by the fan. WN Z adjusted the position of the over the bed table with dressing supplies on it to be out of the air circulation created by the pedestal fan. WN Z was observed completing the dressing change to Resident #5's left foot while the pedestal fan was on, circulating air and was pointed directly at Resident #5's feet. In an interview on 5/2/24 at 10:45 AM., WN Z reported that the fan in Resident #5's room was not turned off before the dressing change was complete. WN Z reported should have been turned off before her dressing change was completed. In an interview on 5/2/24 at 10:47 AM., DON B reported that a fan should be turned off before completing any dressing change.

Based on interview and record review, the facility failed to offer the pneumococcal vaccine for 4 (Resident #26, #50, #38, #24) of 5 residents reviewed for immunizations, resulting in a delay in the residents being given the opportunity to receive or decline the pneumococcal vaccination. Findings include: Resident #26: Review of an Facesheet revealed Resident #26 was a female with pertinent diagnoses which included heart failure, diabetes, dementia, chronic ulcer of buttock limited to breakdown of skin, urinary tract infection, and stroke. Review of Preventive Health Care dated 5/2/24, revealed, .Pneumococcal Vaccine: PCV13 given on 12/18/2013 and PPSV 23 given on 08/05/2015 . In an interview on 05/02/24 at 11:31 AM, Infection Preventionist (IFP) X reported she was not aware of the changes to the immunization requirement for the pnuemococcal vaccine. Review of the CDC Vaccine Schedule, the IFP X reported Resident #26 should have been offered the PCV 15 or PCV 20 vaccine. Resident #50: Review of an Facesheet revealed Resident #50 was a male with pertinent diagnoses which included retention of urine, neuromuscular dysfunction of bladder, acute kidney failure, diabetes, acute cystitis without hematuria (inflammation of the urinary bladder). Review of Preventive Health Care dated 5/2/24, revealed, .Pneumococcal Vaccine: PCV13 given on 11/17/2016 and PPSV 23 given on 05/27/2014 . In an interview on 05/02/24 at 11:33 AM, Infection Preventionist (IFP) X reported Resident #50 should have been offered the PCV 15 or PCV 20 vaccine. Resident #38: Review of an Facesheet revealed Resident #38 was a female with pertinent diagnoses which included dementia, parkinson's disease, high blood pressure, sleep terror, and edema. Review of Preventive Health Care dated 5/2/24, revealed, resident was provided the vaccine at an outside setting unknown. In an interview on 05/02/24 at 11:43 AM, Infection Preventionist (IFP) X reported since the resident's vaccine was an outside setting unknown the resident should have been offered the PCV 15 or PCV 20. Resident #24: Review of an Facesheet revealed Resident #24 was a female with pertinent diagnoses which included diabetes, paralysis affecting right dominant side, leukemia, dementia, and hydrocephalus (build up of fluid on the brain causing pressure and can cause brain damage). In an interview on 05/02/24 at 11:35 AM, IFP X reported in the medical record as had received in 2022 unknown outside. IFC X reported she should be in MICR if she had received her vaccines by an outside provider, hospital or pharmacy. IFP X reported she should have been offered the PCV 15 or PCV 20 and then one year after the PPSV23. According to the Centers for Disease Control and Prevention (CDC) PCV20 Vaccination for Adults [AGE] years and Older dated 02/09/23, revealed, .Routine vaccination: Adults [AGE] years or older who have- Previously received both PCV13 and PPSV23, AND PPSV23 was received at age [AGE] years or older: Based on shared clinical decision-making, 1 dose of PCV20 at least 5 years after the last pneumococcal vaccine dose . and .Adults [AGE] years or older who have: - Not previously received a dose of PCV13, PCV15, or PCV20, or whose previous vaccination history is unknown: 1 dose of PCV15 OR 1 dose of PCV20. If PCV15 is used, administer 1 dose of PPSV23 at least 1 year after the PCV15 dose (may use minimum interval of 8 weeks for adults with an immunocompromising condition, cochlear implant, or cerebrospinal fluid leak) . www.cdc.gov/vaccines/hcp/admin/downloads/job-aid- SCDM-PCV20-508.pdf

Based on observation and interview the facility failed to preserve resident dignity in the dining room during meal service for 3 (Resident #5, Resident #17, and Resident #22) of 17 residents reviewed for dignity resulting in the potential for a reasonable person to experience feelings of embarrassment, shame, and/or a loss of self-esteem. Findings include: Resident #5 Review of an Facesheet revealed Resident #5 had pertinent diagnoses which included: Alzheimer's disease and type 2 diabetes mellitus. Resident #17 Review of an Facesheet revealed Resident #17 had pertinent diagnoses which included: Neurocognitive disorder with Lewy bodies and psychotic disorder. Resident #22 Review of an Facesheet revealed Resident #22 had pertinent diagnoses which included: Alzheimer's disease and cognitive communication disorder. Review of a list provided by the facility for residents who needed assistance with eating, Resident #5 and Resident #22 were listed as full assist and Resident #17 was listed as assist (need varies meal to meal). During an observation on 4/30/24 at 11:50 AM., Resident #5, Resident #17 and Resident #22 were present at different tables in the dining room with other resident with drinks in front of them, unable to consume any liquid without assistance prior to lunch meal service. During an observation on 4/30/24 at 12:01 PM., meal service in the dining room began. During an observation on 4/30/24 at 12:10 PM., there were two staff members present serving residents in the assisted side of the dining room. During an observation on 4/30/24 at 12:14 PM., a resident that was seated at the same table as Resident #5 and Resident #17 was served lunch. Resident #5 and Resident #17 were not served. During an observation on 4/30/24 at 15 PM., a resident that was seated at the same table as Resident #22 was served lunch. Resident #22 was not served. During an observation on 4/30/24 at 12:18 PM., Residents on the assistive side of the dining room were served desserts that included cookies and pudding. Resident #5, Resident #17, and Resident #22 were served desserts. All three residents were unable to consume the dessert without assistance. During an observation on 4/30/24 at 12:19 PM., a second resident seated at the same table as Resident #22 was served lunch. Resident #22 was still not served lunch. During an observation on 4/30/24 at 12:19 PM., meal service began on the independent side of the dining room. The assistive side of the dining room has 15 total residents seated at tables, all had drinks and desserts served to them. Resident #5, Resident #17, and Resident #22 were without a lunch meal served and were not consuming any food or drink on their own. During an observation on 4/30/24 at 12:27 PM., meal service on the independent side of the dining room was complete. During an observation on 4/30/24 at 12:29 PM., Resident #5, Resident #17, and Resident #22 were served lunch. During an observation on 4/30/24, Resident #5, Resident #17 and Resident #22 sat at tables in the dining room with other residents present who were consuming food and drinks and were unable to consume anything independently from 11:50 AM until they were assisted to eat at 12:30 PM. Resident #5, Resident #17, and Resident #22 sat for 40 minutes unable to eat or drink while others around them did eat and drink. Resident #5, Resident #17, and Resident #22 were not able to verbalize their feelings due to a diminished cognitive and communicative ability. In an interview on 5/1/24 at 12:32 PM., Family Member (FM) II reported that Resident #22 wound not like to be left out when eating with other people. In an interview on 5/2/24 at 11:35 AM., Certified Nursing Assistant (CNA) L reported that the dining room service is hall trays first, then the residents that need some assistance such as cueing, and then the independent side of the dining room and the last served are the residents that need full assistance, such as fed. In an interview on 5/2/24 at 12:07 PM., Director of Nursing (DON) B reported that the dining room is not done in any order. In an interview on 5/2/24 at 12:12 PM., CNA K reported that the dining room process is that hall trays come out first, the assistive residents who need more time to eat are served next, then the independent residents, and finally the resident's who need direct assistance are served last. CNA K reported that residents that require direct assistance are not served when the others at their table are served, because staff cannot sit to assist them then. CNA K reported that Resident #5, Resident #17, and Resident #22 were included as residents that needed assistance to eat. When CNA K was asked if the residents who need direct assistance watch their tablemates eat, she stated Yes, they do. In an interview on 5/2/24 at 12:15 PM., Registered Nurse (RN) O was asked if the residents who need direct assistance watch their tablemates eat, she stated There is no perfect way. In an interview on 5/2/24 at 12:17 PM., Assistant Director of Nursing (ADON) X and DON B, DON B reported that residents should not be sitting in the dining room at a table while others eat waiting for food to be served to them. ADON X stated .I wouldn't enjoy that, and I don't think that residents would like it either.

Based on interview and record review, the facility failed to provide a written notice of transfer for 1 of 3 residents (Resident #50) reviewed for hospitalization s, resulting in the potential for residents and/or resident representatives being uninformed of the reason for transfer and their rights. Findings include: Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE] revealed R50's original admitted was 3/6/2023. Brief Interview for Mental Status (BIMS) score was a 14 which indicated his cognition was intact. Resident was discharged to the hospital on 12/11/2023 and returned to the facility on [DATE] with a diagnosis of myocardial infarction (heart attack). During an interview on 4/30/2024 at 11:13 AM, R50 stated that he went to the hospital several months ago because he wasn't responsive and was there for about a week. R50 couldn't remember if he received a written transfer notice when he went to the hospital. Review of the December 2023 Transfer Log revealed that R50 had an emergency transfer to an acute care setting (hospital) on 12/11/2023. Review of R50's chart revealed no evidence that R50 received a written notice of transfer to include the following information: (i) The reason for transfer or discharge; (ii) The effective date of transfer or discharge; (iii) The location to which the resident is transferred or discharged ; (iv) A statement of the resident's appeal rights, including the name, address (mailing and email), and telephone number of the entity which receives such requests; and information on how to obtain an appeal form and assistance in completing the form and submitting the appeal hearing request; (v) The name, address (mailing and email) and telephone number of the Office of the State Long-Term Care Ombudsman; (vi) For nursing facility residents with intellectual and developmental disabilities or related disabilities, the mailing and email address and telephone number of the agency responsible for the protection and advocacy of individuals with developmental disabilities established under Part C of the Developmental Disabilities Assistance and [NAME] of Rights Act of 2000 (Pub. L. 106-402, codified at 42 U.S.C. 15001 et seq.); and (vii) For nursing facility residents with a mental disorder or related disabilities, the mailing and email address and telephone number of the agency responsible for the protection and advocacy of individuals with a mental disorder established under the Protection and Advocacy for Mentally Ill Individuals Act. During an interview on 5/01/2024 at 1:54 PM, Registered Nurse O stated that she didn't know about a transfer notice that should be given to residents or their responsible party at the time of transfer to the hospital. During an interview on 5/02/2024 at 10:32 AM, Director of Nursing (DON) B presented paperwork that is sent with a resident to the hospital and it was observed that a transfer/discharge notice wasn't included in the paperwork. When asked about the transfer notice for R50, DON B said she wasn't sure if it was given to him and would have to talk to the business office. During an interview on 5/02/2024 at 12:51 PM, Financial Assistant (FA) W stated that a transfer/discharge notice hasn't been given to a resident or responsible party in a long time. FA W said that since R50 wanted to go to the hospital they didn't send a transfer/discharge notice with him. Review of the Discharge Planning Policy with a compiled date of 7/16/2020 and a reviewed date of 7/20/2022 under IV. Procedure: Emergency Transfers/Discharges revealed, initiated by the facility for medical reasons or for the safety and welfare of a resident. Under B. The Business Office will provide notice of transfer or discharge to the resident and/or representative within 24 hours or as soon as practicable when a resident is sent out on an emergency basis.

Based on interview and record review the facility failed to ensure that a licensed pharmacist completed a monthly medication regimen review for 1 (Resident #28) of 6 residents reviewed for unnecessary medication use resulting in the potential for medication irregularities in the indication for use, excessive dosage, adverse reactions, and/or medication errors. Findings include: Resident #28 Review of an Facesheet revealed Resident #28 had pertinent diagnoses which included: vascular dementia (altered cognition), insomnia, and other chronic pain. Review of a Minimum Data Set (MDS) assessment for Resident #28, with a reference date of 1/16/2024 revealed a Brief Interview for Mental Status (BIMS) score of 11 out of 15 which indicated Resident #28 was mildly cognitively impaired. Review of Physician Orders for Resident #28 dated 1/26/24 with no end date revealed . lorazepam (Ativan, used for anxiety) tablet 0.5 mg; give 0.5 mg; oral every 6 hours PRN (as needed): PRN 1, PRN 2, PRN 3, PRN 4 . (may take 4 times a day) Review of Care Plan for Resident #28 dated 1/27/24 revealed . problem . receiving psychotropic meds for anxiety and agitation .goal . will be prescribed the lowest effective dose . approach .observe resident's mood and response to medication .pharmacy consultant review as indicated . Review of Resident #28's medical record revealed no monthly medication regimen reviews (MRRs). On 5/2/24 at 12:09 PM, monthly medication regimen reviews were requested for the time frame of January 2024 through April 2024 for Resident #5 from DON B. In an interview on 5/2/24 at 1:53 PM., DON B reported that Resident #5 did not have any monthly medication regimen reviews completed for the time frame of January 2024 to April 2024.

Based on interview and record review the facility failed to ensure that residents of the facility were free from unnecessary psychotropic medication use in 1 (Resident #28) of 6 residents reviewed for unnecessary medication use resulting in incomplete monitoring of the use, potential adverse reactions, and dosage adjustments of an as needed psychotropic medication. Findings include: Resident #28 Review of an Facesheet revealed Resident #28 had pertinent diagnoses which included: vascular dementia (altered cognition), insomnia, and other chronic pain. Review of a Minimum Data Set (MDS) assessment for Resident #28, with a reference date of 1/16/2024 revealed a Brief Interview for Mental Status (BIMS) score of 11/15 which indicated Resident #28 was mildly cognitively impaired. Review of Physician Orders for Resident #28 dated 1/26/24 with no end date revealed . lorazepam (Ativan, used for anxiety) tablet 0.5 mg; give 0.5 mg; oral every 6 hours PRN (as needed): PRN 1, PRN 2, PRN 3, PRN 4 . (may take 4 times a day) Review of Care Plan for Resident #28 dated 1/27/24 revealed . problem . receiving psychotropic meds for anxiety and agitation .goal . will be prescribed the lowest effective dose . approach .observe resident's mood and response to medication .pharmacy consultant review as indicated . In an interview on 5/2/24 at 11:17 AM., Registered Nurse (RN) Q reported that Resident #28 does not take PRN lorazepam 0.5 mg during the day shift. RN Q stated I don't give her that med. RN Q reported that PRN anxiety medication orders are only good for 14 days. RN Q reported that Resident #28's PRN lorazepam 0.5 mg was ordered on 1/26/24 and was listed as open ended with no stop date noted. In an interview on 5/2/24 at 11:59 AM., Director of Nursing (DON) B reported that PRN psychotropic medications should be prescribed for only 14 days. DON B reported that Resident #28's order for lorazepam should have been for 14 days only. In an interview on 5/2/24 at 1:53 PM., DON B reported that new medication orders were reviewed by the clinical team in the daily meeting and all medications were reviewed weekly. DON B reported that there were no audits completed on original orders. When asked if any gradual dose reductions (GDR's) had been completed for Resident #28 and her PRN use of lorazepam 0.5 mg orally as needed, DON B replied no, no GDR's have been done for Resident #28.

This citation pertains to Intake MI00138305. Based on observation, interview and record review the facility failed to prevent the development of a stage 4 pressure ulcer that included physician lead care for the evaluation and treatment for pressure ulcers and facility staff trained in the treatment of pressure ulcers for 1 of 5 residents (Resident #27), reviewed for pressure ulcers, resulting in an Immediate Jeopardy when Resident #27 developed a facility acquired pressure ulcer on the right gluteal (buttock) fold that worsened to an infected Stage 4 pressure ulcer that required hospitalization , IV antibiotics and surgical intervention. Findings include: On 8/2/23, the Nursing Home Administrator was notified of an Immediate Jeopardy that began on 6/7/23, when Resident #27 developed a facility acquired pressure ulcer, that worsened to a Stage 4 pressure ulcer, leading to hospitalization , IV (intravenous) antibiotics and surgical interventions. Review of a Face Sheet revealed Resident #27 was originally admitted to the facility on [DATE], with pertinent diagnoses which included: dorsopathies (diseases of the musculoskeletal system and connective tissue associated with degenerative diseases of the spine) of the cervical (neck) region. Review of a Minimum Data Set (MDS) assessment for Resident #27, with a reference date of 4/19/23 revealed a Brief Interview for Mental Status (BIMS) score of 15, out of a total possible score of 15, which indicated Resident #27 was cognitively intact. Review of the Functional Status revealed that Resident #27 required extensive assistance of 1 person for bed mobility, transfers, and toileting, and that Resident #27 could stand and bear weight with assistance of 1 person. Review of Resident #27's assessment Braden scale for predicting pressure sore risk dated 4/21/23, indicated that the document was not complete, and was void of answers to the questions. This was the most recent assessment prior to Resident #27 developing the Stage 4 pressure wound on Right gluteal fold. Prior to the assessment on 4/21/23, the most recent was completed on 11/3/22, which indicated that Resident #27 was at risk, and the current assessment completed on 7/20/23 indicated that Resident #27 was at high risk. Per the facility policy, Braden assessments are completed quarterly. Review of Resident #27's Pain Care Plan revealed, .at risk due to diagnosis of Stage 4 pressure ulcer (no location) .Created 7/25/23. There were no interventions related to prevention/worsening of pressure ulcers. Review of Resident #27's Skin Care Plan revealed, .at increased risk to develop skin breakdown, due to limited mobility, secondary to severe cervical spine disease, paraplegia, chronic pain, and a history of stage 4 pressure ulcer to sacrum. She has a history of choosing to not lay down at times, frequently requesting to get up when in bed, resorting to outburst of yelling loudly, and crying. She has been educated why laying down is important for her, she states that she understands, but does not care. She is at times incontinent of bladder. She developed a stage 4 pressure ulcer to right sacrum even with interventions. She was readmitted from hospital with stage 2 on sacrum. Edited on 7/25/23 by DON. INTERVENTIONS: Blue boots to bilateral feet while in bed, start date 7/25/23. May be up in chair for therapy and appointments, start date 7/25/23. Wedge cushion to help with turning and repositioning, start date 7/25/23. CNA to check skin daily and PRN (as needed) during care, start date 8/24/21. Nurse to check and document skin condition weekly with first bath of the week. Notify MD and wound care nurse if any problems arise, start date 8/24/21. Moisture barrier cream to any excoriation/irritation PRN. Notify physician if not effective, start date 8/24/21. Perform treatments per physicians order, start date 8/24/21. Provide and encourage supplements as ordered, start date 7/25/23. Assist and encourage with eating and drinking at meal time prn to ensure nutritional and fluid intake are sufficient to maintain healthy skin integrity and promote healing, start date 8/24/21. Ensure that water is within reach at bedside, start date 8/24/21. Alternating pressure mattress to bed and roho (pressure relieving) cushion to wheelchair, start date 7/25/23. Assist/encourage to keep heels elevated off bed. Assist and encourage to turn and reposition every 2-3 hours and side to side and PRN. May be on back for meals, start date 7/25/23, edited 7/25/23. During an observation and interview on 07/31/23 at 11:06 AM Resident #27 was lying in bed on her back, positioned slightly on her left side, with the head of bed (HOB) at 30 degrees. There was a wound vac (a type of therapy for wounds) powered on at the bedside on the night stand, leading to Resident #27's buttock area. Resident #27 reported that she was too weak and too tired to talk. During an observation on 07/31/23 at 01:47 PM Resident #27 was in the same position as the previous observation, lying in bed on her back, positioned slightly on her left side, with the HOB at 30 degrees. During an observation on 07/31/23 at 03:23 PM Resident #27 was in the same position as the previous observation, lying in bed on her back, positioned slightly on her left side, with the HOB at 30 degrees, and there was a visitor in the room. During an observation and interview on 07/31/23 at 03:55 PM Resident #27 was lying in bed on her back in the same position as observed since 11:00 AM. Family Member (FM) J reported that Resident #27 had a large wound on her right lower buttock, and FM J was notified of the wound the first part of June, and informed that it was an abrasion (skin damage from scraping or wearing away) from the elastic of her incontinence brief. FM J reported was never updated that Resident #27's wound was worsening, until she was in the room during a wound dressing change on 7/8/23 and observed it herself. FM J reported that Resident #27 had ultimately became ill and required transfer to hospital on 7/8/23, then was sent to another hospital for surgery for an infected Stage 4 pressure ulcer. FM J reported that Resident #27 had drastically declined from her normal self since developing the wound, requiring her to be bedridden and have a urinary catheter, but that prior to was very active, regardless of being wheelchair bound. Review of Resident #27's Hospital Summary admission on 7/9/23 revealed, .Chief Complaint: Right gluteal decubital (relating to laying down) ulcer with possible infection. History of present illness: .transferred from (other hospital) to (this hospital) for possible gluteal ulcer infection. CT (imaging) at the outside hospital found irregular tissue with pockets of gas concerning for infection or abscess in the upper posterior right thigh extending to the level of the buttock. She was then transferred to (this hospital) .Plan: .will be admitted to hospital .Chronic right gluteal decubital ulcer, likely Stage 4, possible superimposed with infection with pockets of gas on CT .Vancomycin (antibiotic), Cefepime (antibiotic), and Metronidazole (antibiotic) .Operative Summary: .A scissor was used to cut away necrotic (dead) tissue overlying (covering) the wound .1.8 cm diameter wound with 5 cm undermining, unstageable, necrotic devitalized tissue debrided (removed), wound class dirty, PATOS (present at time of surgery). Excisional debridement with scissors down to level of subcutaneous (fat) tissue .Culture tissue/bone: Peptoniphilus asaccharolyticus (bacterial infection sometimes resistant to antibiotic treatment), Finegoldia [NAME] (bacteria) Hospital Course: .presented .from an outside hospital for a possible gluteal ulcer infection .General surgery consulted. Debridement, irrigation and Wound Vac placement was recommended .She was treated with antibiotics which were transitioned to p.o. (oral) antibiotics. Foley catheter placed to help with wound care . In an interview on 08/01/23 at 01:06 PM, Licensed Practical Nurse Wound Nurse (LPN-WN) C reported that the wound on Resident #27's right buttock fold was noted by staff initially on 6/7/23, and that it looked like the top layer of her skin had pushed away from the surface and stated, .I thought it was from her incontinence brief being too tight .Licensed Practical Nurse Wound Nurse (LPN-WN) C reported that she notified FM J at that time, but did not notify the physician of the new wound. Licensed Practical Nurse Wound Nurse (LPN-WN) C reported that the wound was not improving, and started getting worse on 6/22/23, with odor and slough (dead skin cells that accumulate in the wound bed) starting in the wound, and continued to deteriorate. Licensed Practical Nurse Wound Nurse (LPN-WN) C reported that the only notification to the physician would have been the written order changes that Licensed Practical Nurse Wound Nurse (LPN-WN) C made and stated, .he (MD D) had to sign them .I don't know if he physically assessed the wound .Licensed Practical Nurse Wound Nurse (LPN-WN) C reported that Resident #27's wound got much worse on 7/6/23, and at that timeliest Practical Nurse Wound Nurse (LPN-WN) C notified the DON, and changed the wound treatment orders again. Licensed Practical Nurse Wound Nurse (LPN-WN) C reported that over the next couple days, nurses had to change the bandages frequently because of them becoming saturated with wound drainage. Licensed Practical Nurse Wound Nurse (LPN-WN) C reported that FM J was visiting during a wound treatment on 7/8/23 and insisted that Resident #27 be taken to the hospital due to the condition of the wound. Licensed Practical Nurse Wound Nurse (LPN-WN) C reported that Resident #27 had preferred to be up in her chair during the day and didn't like to lay in her bed, and that was the reason that MD D completed the unavoidable wound form on 7/21/23, after Resident #27 returned from the hospital. Licensed Practical Nurse Wound Nurse (LPN-WN) C reported that she did not document Resident #27's refusals to lay down and/or the efforts they had made to encourage her to lay down. Licensed Practical Nurse Wound Nurse (LPN-WN) C was not able to describe any additional interventions that were attempted to relieve pressure when the resident declined to lay down in bed, other than asking Resident #27 to lay down. Licensed Practical Nurse Wound Nurse (LPN-WN) C reported that she did not involve Resident #27's responsible party for additional suggestions, when Resident #27 declined to lay down. In an interview on 08/02/23 at 03:47 PM, Registered Nurse (RN) Q reported that Resident #27 was compliant and the CNA's had not ever reported any trouble with refusing cares. RN Q reported that just prior to going to the hospital, Resident #27's wound dressing was completely saturated, the area around the wound was red and warm, she had spiked a fever, was confused and stated, .(FM J) was adamant that she be sent to the hospital . RN Q reported that she had called MD D and left a message for him regarding Resident #27's condition and that the on-call physician gave the orders to sent to the hospital. Review of Resident #27's Determination of Unavoidable Pressure Wound dated 7/21/23 (3 days after return from hospital) revealed, 1. Was a risk assessment completed upon admission? Yes - 9/12/19 and quarterly .3. Were nutritional interventions implemented and routinely evaluated? (no answer) .Does resident have 2 or more primary risk factors? Yes - Continuous urinary incontinence or chronic voiding dysfunction, Paraplegia (paralysis) .8. Did resident develop malnutrition and/or dehydration .NO .9. The physician has documented unavoidable pressure wound based on residents condition? (no answer). 10. List prevention and treatment implemented despite unavoidable criteria: turn side to side, elevate heels off bed, offer naps at 10:00 AM and 2:00 PM, alternating air mattress, pressure relief cushion, WC (wheelchair) block to rest foot off put pressure to right gluteal fold. The pressure wound located on the right gluteal fold, stage 4, is determined to be unavoidable due to choosing not to lay down, she becomes very angry when even asked. (signed by MD D) In an interview on 08/02/23 at 09:49 AM, MD D reported that Resident #27 did not have a wound until she returned from the hospital and stated, .they found it at the hospital . MD D reported that new wounds may have orders started verbally over the phone, but that a physical assessment would be done the next time the physician was in the facility. MD D reported that he would expect the nurse to notify him of new wounds, but that if he saw an order for a wound treatment, MD D would question the order and stated, .but only if the order catches my eye .because I look at a lot of orders . MD D reported that he did not remember Resident #27 having any orders for wounds. MD D reported that Resident #27 is at very high risk to develop pressure ulcers due to her not cooperating with staff and stated, .I did not know about the wound, so no, I could not say that it was unavoidable . Review of Weekly Meeting notes provided by the DON indicated that Resident #27's right gluteal fold wound was discussed on 6/22/23 and 6/29/23. There was not a physician present for these meetings. In an interview on 08/01/23 at 02:42 PM, DON reported that she had saw the wound about 1 week after it was first identified and at that time agreed that it was an abrasion from the incontinence brief. DON reported that Licensed Practical Nurse Wound Nurse (LPN-WN) C was not certified in wound care, and to have a doctor look at new wounds was not part of their process and stated, .the doctors are usually ok with the orders that (LPN C) writes DON reported that Resident #27's wound was discussed in meetings every week, it was known that the wound was not improving and stated, .we normally have a doctor look at it if its changing .this fell through the cracks . DON reported that she did not think Resident #27's wound had been assessed but a physician, and that there was no documentation to indicate that it was. Review of Resident #27's Wound Sheets revealed the following nursing documentation: 6/7/23: Right gluteal fold, wound type-abrasion, facility acquired, 0.4 cm length x 0.3 cm width x 0.1 cm depth, no undermining, no tunneling, red, small amount of drainage, no odor. 6/15/23: Right gluteal fold, abrasion, facility acquired, 0.7 cm length x 0.5 cm width x 0.1 cm depth, no undermining, no tunneling, red, small amount of drainage, no odor. 6/22/23: Right gluteal fold, abrasion, facility acquired, 1.0 cm length x 1.1 cm width x 0.2 cm depth, no undermining, no tunneling, red, small amount of drainage, mild odor. 6/28/23: Right gluteal fold, abrasion, facility acquired, 1.8 cm length x 1.7 cm width x 0.7 cm depth, no undermining, no tunneling, 1/4 of wound yellow and red, medium amount of drainage, mild odor. 7/3/23: Right gluteal fold, (no type noted), facility acquired, 3.0 cm length x 3.2 cm width x 0.5 cm depth, no undermining, no tunneling, yellow, saturated with drainage, mild odor. 7/7/23: Right gluteal fold, (no type noted), facility acquired, 3.4 cm length x 3.8 cm width x 0.6 cm depth, no undermining, no tunneling, yellow, saturated with drainage, strong odor. Surrounding skin with hard edges and bruising. Review of Resident #27's Written Orders revealed the following orders for wound dressings: 6/7/23: Cleanse right gluteal fold with NS (normal saline) pat dry, apply Mepilex (foam bandage), change every 5 days/PRN (as needed). signed by MD D. 6/15/23: DC (discontinue) Mepilex, new order: Cleanse right gluteal fold with NS pat dry, apply Xeroform (bandage that maintains moist environment) change daily and PRN. signed by MD D. 6/16/23: DC Mepilex. Cleanse right gluteal fold with NS pat dry, apply Xeroform change daily. This was the same order as on 6/15/23. signed by MD D. 6/23/23: DC Xeroform. Cleanse right gluteal fold with NS pat dry, apply Calcium Alginate and border gauze change daily. signed by MD D. 7/3/23: DC Calcium Alginate. Cleanse right gluteal fold with NS pat dry, apply Hydrofera Blue (bandage that provides protection and addresses bacteria and yeast) 4 x 4 gauze, cover with border gauze and change every 3 days/PRN. signed by MD D. 7/6/23: DC Hydrofera Blue, Cleanse right gluteal fold with NS pat dry, apply Collagen (healing) Powder and cover with 4 x 4 border gauze. There was no physician signature on the order. All of these orders were written by Licensed Practical Nurse Wound Nurse (LPN-WN) C . Review of Resident #27's Physician Notes dated 6/23/23, indicated no documentation of a wound and or a skin assessment. Review of Resident #27's Dietary Notes dated 4/19/23 indicated that appetite was usually good, the skin was intact and that there were no supplements in place. There were no further notes until 7/12/23, which indicated appetite was good, skin wound, and resident in the hospital. Review of Resident #27's Hospital Dietician Consult dated 7/9/23 revealed, .PU (pressure ulcer) right buttock .does not meet criteria for malnutrition .maintaining weight. During an observation on 08/01/23 at 09:09 AM Resident #27 was lying in bed on her back, positioned slightly on her right side with the HOB at 30 degrees. During an observation and interview on 08/01/23 at 09:35 AM Resident #27 was lying in bed on her back, positioned slightly on her left side with the HOB at 30 degrees. Certified Nursing Assistant (CNA) P reported that she had just repositioned Resident #27 onto her right side and stated, .we try to turn her every 2 hours .it was supposed to be at 9:00, I was a little late . CNA J reported that she did not know how bad Resident #27's wound was until she saw the soaked bandage just prior to her hospitalization a few weeks ago. CNA J reported that CNA H is Resident #27's regular CNA, so she would know more about her. In an interview on 08/02/23 at 01:58 PM, CNA H reported that Resident #27's wound started small, like an abrasion, the incontinence briefs were not too small, but when Resident #27 was sitting, her buttocks pressed on the edge of the brief. CNA H reported that Resident #27 preferred to be up in her chair during the day, but understood that she needed to get off her bottom, and did not decline laying down for CNA H. CNA H reported that she had been Resident #27's aide for a long time and Resident #27 could stand up, with help to relieve pressure off her bottom and would ask to stand longer to stretch her legs. CNA H reported that she (CNA H) would toilet Resident #27 multiple times a day, just to relief the pressure and stated, .but I was off work a lot during the time her wound started and have been until today . CNA H reported that Resident #27 did drink supplements, but needed encouragement. During an observation on 08/01/23 at 10:40 AM in Resident #27's room, CNA P performed incontinence care on Resident #27. Resident #27's buttocks were observed with a wound vac covering the right lower buttock and a large bandage covering the coccyx (tailbone) area. In an interview on 08/01/23 at 10:57 AM, CNA F reported that she was not aware that Resident #27 had a wound until she went to the hospital for it a few weeks ago. CNA F reported that Resident #27 was very different before she was hospitalized and stated, .she could stand up .could use the bathroom .she liked to go to the dining room .always brushing her hair . Review of the facility policy Skin Assessment and Ulcer Prevention revealed, .Goal: To assess each resident upon admission and at least quarterly for the potential for skin breakdown utilizing the standardized scale (Braden). To assess each resident with wounds for changes and determine proper wound treatments .When a wound is identified the physician will be notified, the resident will be added to the weekly physician wound rounding sheet with wound details. Physician will sign and document that each resident was seen in (electronic health record). The policy was complied by DON on 8/2/23 and approved by NHA on 8/2/23. On 8/2/23, the survey team verified the facility completed the following to remove the Immediate Jeopardy. 1. Resident #27 will be seen by the attending physician and will have a consultation with the wound clinic on August 2, 2023. 2. Any resident with a Stage 1 pressure ulcer or higher will be seen by the attending physician to assess the wound and document review on August 2, 2023. 3. The Pressure Ulcer policy and procedure has been updated as of August 2, 2023, to include immediate notification of physician when a wound is identified and that the resident will be added to the physician's weekly rounds. All licensed nursing staff will be trained in person or over the phone on the updated policy and procedure and acknowledgement of the training will be tracked by signature of the nurse or documentation from the trainer on August 2, 2023. Although the immediate jeopardy was removed on 8/2/23, the facility remained out of compliance with a scope of isolated and severity of actual harm due to all nursing staff had not received training for wound care/skin prevention program and sustained compliance had not been verified by the state agency.

Based on observation, interview, and record review the facility failed to ensure adequate pain monitoring and management for 1 of 1 ( Resident #31) resident reviewed for pain management, resulting in unrelieved pain that impacted the resident's quality of life. Findings include: Review of an Admission Record revealed Resident #31, was originally admitted to the facility with pertinent diagnoses which included sciatica (pain in the lower back that can spread to buttock, groin, and legs) and pelvic mass. Review of a Minimum Data Set (MDS) assessment for Resident #31, with a reference date of 5/3/23 revealed a Brief Interview for Mental Status (BIMS) score of 12/15 which indicated Resident #31 was moderately cognitively impaired. Review of Resident #31's Care Plan revealed, ( Resident #31) has a potential for pain due to recent diagnosis of colitis (inflammation of the colon) and respiratory failure. Approach: Assess/record/report pain characteristics including intensity (0-10), location, onset, duration, and precipitating or relieving factors. Created: 4/27/23 . Observe for non verbal cues of pain, i.e., grimacing, crying, restlessness, irresistibleness, or moaning for possible need for pain intervention. Created: 4/27/23 . Staff will anticipate need for pain relief, instruct remind resident to request medication before pain becomes too great, providing better control of pain. Review of Resident #31's Medication Administration Record revealed, Orders: Morphine (medication to treat severe pain) 20 mg/mL (milligrams per millimeter) solution. Take 0.25 mL (5 MG) every 2 hours as needed for pain or sob (shortness of breath). Tramadol (medication used to treat moderate to severe pain) 50 mg P.O. (by mouth) TID (Three times a day). Review of Resident #31's Medication Administration Record revealed that Resident #31 had received one dose of morphine on 7/20/23, 7/21/23, 7/23/23, 7/26/23 and 7/31/23. During a care observation on 8/01/23 at 10:58 AM, Licensed Practical Nurse Wound Nurse (LPN-WN) C and Certified Nursing Assistant M completed incontinence care and a dressing change for Resident #31. LPN- WN C removed Resident #31's brief and began to wipe Resident #31's perineal area. As LPN-WN C started wiping, Resident #31 began screaming out in pain and begging for staff to stop stating Don't do that! Please don't do that!. CNA M reported that Resident #31 had a vaginal mass that was getting worse and anytime staff had to clean the area around the mass, Resident #31 would scream out in pain. Resident #31 had screamed so loud that another staff member knocked on the door and entered to check on Resident #31 and staff. LPN-WN C reported that she thought Resident #31 had scheduled pain medication but she did not know if Resident #31 had been given any additional as needed medication to provide pain relief prior to providing care for Resident #31. During an interview on 8/01/23 at 1:39 PM, Hospice Nurse (HN) K reported that Resident #31 had increased pain related to the pelvic mass. HN K reported that comfort care and pain management were the most important goals of care for Resident #31. HN K reported that Resident #31 frequently became agitated during care because of the pain that she experienced, so he would expect that staff were providing Resident #31 with the PRN Morphine due to the severity of her pain. During an interview on 8/2/23 at 7:38 AM, Registered Nurse (RN) V reported that Resident #31 did not get the PRN morphine often. RN V reported that Resident #31 often yelled out during care and refused care. RN V reported that she was unaware of staff reporting that Resident #31 was experiencing pain during incontinence care. RN V reported that Resident #31 had not received PRN morphine prior to incontinence care to help with pain. During an interview on 8/2/23 at 9:03 AM, CNA S reported that Resident #31 often yelled out during care, especially incontinence care. CNA S reported that she had noticed an increase in refusal of care and yelling out during incontinence care over the last few months. During an interview on 8/2/23 at 1:22 PM, CNA E reported that she had definitely noticed an increase in pain over the last month, and felt that it was related to Resident 31's pelvic mass. CNA E reported that after the pelvic mass was discovered, providing incontinence care on Resident #31 became much harder to complete because of the pain that Resident #31 experienced during care. CNA E reported that it was common for Resident #31 to scream and cry out during incontinence care. CNA E was unaware if nurses were giving medication prior to incontinence care to assist with comfort and reduce pain. During an interview on 8/2/23 at 11:44 AM, RN V reported that she had administered PRN morphine to Resident #31 at 11:30 AM on this day in preparation for incontinence care to determine if pre-medicating with morphine would assist with the pain Resident #31 experienced during incontinence care. During a care observation on 8/2/23 at 11:50 AM, CNA P and CNA Y removed Resident #31's brief and CNA P began to wipe Resident #31's perineal area. As CNA P wiped Resident #31, she softly said ow but she did not shout out. Resident #31 was relaxed, calm, and did not appear to struggle with perineal care. As CNA P and CNA Y finished completing care, Resident #31 stated see it's much better. CNA P reported that she felt that the morphine medication helped Resident #31 tremendously and that when she (CNA P ) had completed care earlier in the day that Resident #31 was screaming nonstop. CNA P reported that Resident #31 seemed to be able to tolerate incontinence care much better with pain medication. During an interview on 8/2/23 at 12:08 PM, HN K reported that he was under the assumption that Resident #31 was receiving the PRN morphine at least once per shift. HN K reported that the morphine was ordered for breakthrough pain, and that he would expect that the morphine would be given prior to cares anytime Resident #31 was experiencing pain with care. HN K reported he would expect nursing staff to assess Resident #31's pain prior to completing care to determine the need for pain relief due to Resident #31's frequent screaming out during care. During an interview on 8/2/23 at 1:35 PM, Director of Nursing (DON) B reported that she was aware that Resident #31 experienced pain with care, but that staff had not reported any concerns related to Resident #31's increased pain with incontinence care since developing the vaginal mass.

This citation pertains to Intake MI00138305. Based on interview and record review, the facility failed to ensure the physician assessed and monitored a change in condition after reviewing and signing multiple orders for pressure ulcer treatment in 2 of 5 residents (Resident #27 and Resident #30), reviewed for pressure ulcers, resulting in the lack of physician assessment, monitoring, and ultimate hospitalization for Resident ##27 who developed a Stage 4 pressure ulcer with osteomyelitis and lack of consistent physician assessment and monitoring of a pressure ulcer for Resident #30. Findings include: Resident #27 Review of a Face Sheet revealed Resident #27 was originally admitted to the facility on [DATE], with pertinent diagnoses which included: dorsopathies (diseases of the musculoskeletal system and connective tissue associated with degenerative diseases of the spine) of the cervical (neck) region. Review of a Minimum Data Set (MDS) assessment for Resident #27, with a reference date of 4/19/23 revealed a Brief Interview for Mental Status (BIMS) score of 15, out of a total possible score of 15, which indicated Resident #27 was cognitively intact. Review of the Functional Status revealed that Resident #27 required extensive assistance of 1 person for bed mobility, transfers, and toileting, and that Resident #27 could stand and bear weight with assistance of 1 person. During an observation and interview on 07/31/23 at 03:55 PM Resident #27 was lying in bed on her back in the same position as observed since 11:00 AM. Family Member (FM) J reported that Resident #27 had a large wound on her right lower buttock, and FM J was notified of the wound the first part of June, and informed that it was an abrasion (skin damage from scraping or wearing away)from the elastic of her incontinence brief. FM J reported was never updated that Resident #27's wound was worsening, until she was in the room during a wound dressing change on 7/8/23 and observed it herself. FM J reported that Resident #27 had ultimately became ill and required transfer to hospital on 7/8/23, then was sent to another hospital for surgery for an infected Stage 4 pressure ulcer. FM J reported that Resident #27 had drastically declined from her normal self since developing the wound, requiring her to be bedridden and have a urinary catheter, but that prior to was very active, regardless of being wheelchair bound. Review of Resident #27's Hospital Summary admission on 7/9/23 revealed, .Chief Complaint: Right gluteal decubital (relating to laying down) ulcer with possible infection. History of present illness: .transferred from (other hospital) to (this hospital) for possible gluteal ulcer infection. CT (imaging) at the outside hospital found irregular tissue with pockets of gas concerning for infection or abscess in the upper posterior right thigh extending to the level of the buttock. She was then transferred to (this hospital) .Plan: .will be admitted to hospital .Chronic right gluteal decubital ulcer, likely Stage 4, possible superimposed with infection with pockets of gas on CT .Vancomycin (antibiotic), Cefepime (antibiotic), and Metronidazole (antibiotic) .Operative Summary: .A scissor was used to cut away necrotic (dead) tissue overlying (covering) the wound .1.8 cm diameter wound with 5 cm undermining, unstageable, necrotic devitalized tissue debrided (removed), wound class dirty, PATOS (present at time of surgery). Excisional debridement with scissors down to level of subcutaneous (fat) tissue .Culture tissue/bone: Peptoniphilus asaccharolyticus (bacterial infection sometimes resistant to antibiotic treatment), Finegoldia [NAME] (bacteria) Hospital Course: .presented .from an outside hospital for a possible gluteal ulcer infection .General surgery consulted. Debridement, irrigation and Wound Vac placement was recommended .She was treated with antibiotics which were transitioned to p.o. (oral) antibiotics. Foley catheter placed to help with wound care. Found to have a poor appetite She has a history of severe protein calorie malnutrition but had improved and did not meet criteria for that during this hospitalization . In an interview on 08/01/23 at 01:06 PM, Licensed Practical Nurse Wound Nurse (LPN-WN) C reported that the wound on Resident #27's right buttock fold was noted by staff initially on 6/7/23, and that it looked like the top layer of her skin had pushed away from the surface and stated, .I thought it was from her incontinence brief being too tight . Licensed Practical Nurse Wound Nurse (LPN-WN) C reported that she notified FM J at that time, but did not notify the physician of the new wound. Licensed Practical Nurse Wound Nurse (LPN-WN) C reported that the wound was not improving, and started getting worse on 6/22/23, with odor and slough (dead skin cells that accumulate in the wound bed) starting in the wound, and continued to deteriorate. Licensed Practical Nurse Wound Nurse (LPN-WN) C reported that the only notification to the physician would have been the written order changes that Licensed Practical Nurse Wound Nurse (LPN-WN) C made and stated, .he (MD D) had to sign them .I don't know if he physically assessed the wound . Licensed Practical Nurse Wound Nurse (LPN-WN) C reported that Resident #27's wound got much worse on 7/6/23, and at that time Licensed Practical Nurse Wound Nurse (LPN-WN) C notified the DON, and changed the wound treatment orders again, but did not notify the physician. In an interview on 08/01/23 at 02:42 PM, DON reported that she had saw the wound about 1 week after it was first identified and at that time agreed that it was an abrasion from the incontinence brief. DON reported that Licensed Practical Nurse Wound Nurse (LPN-WN) C was not certified in wound care, and to have a doctor look at new wounds was not part of their process and stated, .the doctors are usually ok with the orders that (Licensed Practical Nurse Wound Nurse (LPN-WN) C ) writes DON reported that Resident #27's wound was discussed in meetings every week, it was known that the wound was not improving and stated, .we normally have a doctor look at it if its changing .this fell through the cracks . DON reported that she did not think Resident #27's wound had been assessed but a physician, and that there was no documentation to indicate that it was. Review of Resident #27's Physician Notes dated 6/23/23, indicated no documentation of a wound and or a skin assessment. This was the only physician visit recorded following 6/7/23 when the wound was first identified. Review of Resident #27's Wound Sheets revealed the following nursing documentation: 6/7/23: Right gluteal fold, wound type-abrasion, facility acquired, 0.4 cm length x 0.3 cm width x 0.1 cm depth, no undermining, no tunneling, red, small amount of drainage, no odor. 6/15/23: Right gluteal fold, abrasion, facility acquired, 0.7 cm length x 0.5 cm width x 0.1 cm depth, no undermining, no tunneling, red, small amount of drainage, no odor. 6/22/23: Right gluteal fold, abrasion, facility acquired, 1.0 cm length x 1.1 cm width x 0.2 cm depth, no undermining, no tunneling, red, small amount of drainage, mild odor. 6/28/23: Right gluteal fold, abrasion, facility acquired, 1.8 cm length x 1.7 cm width x 0.7 cm depth, no undermining, no tunneling, 1/4 of wound yellow and red, medium amount of drainage, mild odor. 7/3/23: Right gluteal fold, (no type noted), facility acquired, 3.0 cm length x 3.2 cm width x 0.5 cm depth, no undermining, no tunneling, yellow, saturated with drainage, mild odor. 7/7/23: Right gluteal fold, (no type noted), facility acquired, 3.4 cm length x 3.8 cm width x 0.6 cm depth, no undermining, no tunneling, yellow, saturated with drainage, strong odor. Surrounding skin with hard edges and bruising. Review of Resident #27's Written Orders revealed the following orders for wound dressings: 6/7/23: Cleanse right gluteal fold with NS (normal saline) pat dry, apply Mepilex (foam bandage), change every 5 days/PRN (as needed). signed by MD D. 6/15/23: DC (discontinue) Mepilex, new order: Cleanse right gluteal fold with NS pat dry, apply Xeroform (bandage that maintains moist environment) change daily and PRN. signed by MD D. 6/16/23: DC Mepilex. Cleanse right gluteal fold with NS pat dry, apply Xeroform change daily. This was the same order as on 6/15/23. signed by MD D. 6/23/23: DC Xeroform. Cleanse right gluteal fold with NS pat dry, apply Calcium Alginate and border gauze change daily. signed by MD D. 7/3/23: DC Calcium Alginate. Cleanse right gluteal fold with NS pat dry, apply Hydrofera Blue (bandage that provides protection and addresses bacteria and yeast) 4 x 4 gauze, cover with border gauze and change every 3 days/PRN. signed by MD D. 7/6/23: DC Hydrofera Blue, Cleanse right gluteal fold with NS pat dry, apply Collagen (healing) Powder and cover with 4 x 4 border gauze. There was no physician signature on the order. All of these orders were written by Licensed Practical Nurse Wound Nurse (LPN-WN) C . In an interview on 08/02/23 at 09:49 AM, MD D reported that Resident #27 did not have a wound until she returned from the hospital and stated, .they found it at the hospital . MD D reported that new wounds may have orders started verbally over the phone, but that a physical assessment would be done the next time the physician was in the facility. MD D reported that he would expect the nurse to notify him of new wounds, but that if he saw an order for a wound treatment, MD D would question the order and stated, .but only if the order catches my eye .because I look at a lot of orders . MD D reported that he did not remember Resident #27 having any orders for wounds. MD D reported that Resident #27 is at very high risk to develop pressure ulcers and stated, .I did not know about the wound. Review of Weekly Meeting notes provided by the DON indicated that Resident #27's right gluteal fold wound was discussed on 6/22/23 and 6/29/23. There was not a physician present for these meetings. 41424 Resident #30 Review of the medical record revealed Resident #30 was admitted to the facility on [DATE]. Resident #30 was admitted with diagnoses that included diabetes, osteomyelitis of vertebra, thoracic region, depression, muscle weakness, cauda equina syndrome (nerve roots in the lumbar spine are compressed, cutting off sensation and movement), and fracture of left lower leg, and spinal stenosis, lumbar region. Review of Physician Note dated 5/17/23 at 12:45 PM, revealed, no documentation in the note of the resident admitting with pressure ulcers nor any assessment of the pressure ulcers by the physician. Note contained notation of .Review of system: 10 point review of system conducted and is negative except for stated above in HPI . Review of assessment and plan revealed no noted assessment or plan for Resident #30's pressure ulcers. Review of the medical record revealed the following physician entries dated 5/17/23, 7/12/23, 7/14/23, 7/19/23 and 8/2/23. Review of the full medical record revealed facility staff first documentation of a pressure ulcer in Resident #30's was in Nursing progress notes on 5/19/23 at 4:19 PM, which revealed, .Cleanse left proximal/medial and medial/distal ankle with ns pat dry apply Mepilex change every 7 days. Cleanse left second toe with ns pat dry apply small Mepilex change every 7 days. Moisture barrier cream to right to sacrum, right buttock, right gluteal fold, right upper thigh at all times. Nurses to ensure that this is done at least once a shift. Monitor left ankle daily Monitor right ankle/shin daily monitor back incision daily . Review of Nursing Progress Notes dated 6/16/23 at 00:04 AM, revealed, .Resident continues with tx to coccyx-area with darker spots in middle/pink, open areas noted surrounding darker sloughing tissue. Will continue to monitor . This note indicated that Resident #30's coccyx wound had worsened. Review of Order dated 6/16/23, revealed, .D/C monitor (L) ankle, (R) ankle, (L) shin and back .D/C moisture barrier cream .Cleans buttock .NS Pat dry Apply Calcium Alginate ABD, Tape Change Daily & PRN . Note: This order was not signed by the physician nor dated. Further review of the medical record showed no documentation of a physician note for the month of June 2023. Review of Physician Progress Note dated 7/12/23 at 1:00 PM, revealed, .Acute visit: [AGE] year-old female is being seen today to evaluate her decubitus ulcer. Patient has had a decubitus ulcer since admission. She is currently improving. She is doing well. She is having dressing change with calcium alginate and ABD pad to be changed daily. She has significant improvement since admission. Patient is currently on antibiotics for osteomyelitis/discitis, She is doing well with the antibiotics .On examination: Her vital signs are recorded as stable, She is afebrile .Examination of the decubitus lesions shows a large decubitus ulcer over the left gluteal area extending up to the inner margin. The margins are irregular and has healthy granulated tissue with yellow slough covering about 40% of the ulcer. The ulcer measures 11.5 cm in length 13.6 cm wide and 6 mm deep. This is a stage III ulcer .Assessment and plan. 1) large decubitus stage III ulcer .-Continue calcium alginate with ABD pad dressing secured and change daily . In an interview on 08/02/23 at 01:47 PM, Licensed Practical Nurse Wound Nurse (LPN-WN) C reported she would write out the orders and the doctor reviewed and signed the orders. Licensed Practical Nurse Wound Nurse (LPN-WN) C reported the providers come in the facility three times per week. Licensed Practical Nurse Wound Nurse (LPN-WN) C reported one physician comes in three times per week, then the other physician comes in three times per week. Licensed Practical Nurse Wound Nurse (LPN-WN) C reported she started off treating the pressure ulcer with Calcium alginate started off as that on ABD. Licensed Practical Nurse Wound Nurse (LPN-WN) C reported the order was changed to include the calcium alginate with silver to assist in cleaning up the wound and that was started on 7/6/23. Licensed Practical Nurse Wound Nurse (LPN-WN) C reported she was unsure why there were black specks in the wound and a culture was not ordered. Licensed Practical Nurse Wound Nurse (LPN-WN) C reported black specks would be seen occasionally, not very often, and the resident's whole buttocks were black when she admitted to the facility. When queried what she thought the black specks were, Licensed Practical Nurse Wound Nurse (LPN-WN) C reported she was unsure. Licensed Practical Nurse Wound Nurse (LPN-WN) C reported the lateral ankle and shin ran together and now they were two different wounds as the middle of it had healed. Licensed Practical Nurse Wound Nurse (LPN-WN) C reported the right buttock ulcer and sacrum ulcer merged on 6/22/23 and that was why the sacrum wound got bigger and then merging was not a bad thing. Review of the record on 8/2/23 showed a physician note entered for 6/16/23 at 2:33 PM recorded as a late entry on 8/2/23 at 2:33 PM. No assessment and plan of care for the pressure ulcer was mentioned in the note. Review of policy Physician Services revised on 2/28/21 revealed, .5. The Physician will see the resident .must review the resident's total program of care including medications and treatments each visit and date, write and sign a progress note for that visit .7. Sign and date all orders except for flu and pneumococcal vaccines which may be administered per physician approved policy after an assessment for contraindications .

Based on observation, interview, and record review the facility failed to: 1. Ensure proper cooling methods of potentially hazardous foods; 2. Thoroughly clean food and no-food contact surfaces to sight and touch; 3. Provide air gaps on all on drains originating from food contact surfaces; and 4. Properly store emergency food product. These conditions resulted in an increased risk of contaminated foods and an increased risk of food borne illness that affected 61 residents who consume food from the kitchen. Findings Include: 1. During the initial tour of the kitchen, starting at 10:20 AM on 7/31/23, an interview with Cook BB found that the facility does not routinely cool food and doesn't have anything cooling at this time. During a walkthrough of the walk-in cooler, at 10:25 AM on 7/31/23, it was observed that a full-size six-inch chaffing pan was found with the prepared ingredients for cooking au gratin potatoes. At this time, the dish was covered tightly with saran wrap with increased condensation and melted butter on the top. An interview with cook BB found that she added hot water to the pan to finish preparation this morning. Using an infra-red thermometer, the outside of the chaffing dish was found to be 46F. According to the 2017 FDA Food Code section 3-501.15 Cooling Methods. (A) Cooling shall be accomplished in accordance with the time and temperature criteria specified under S 3-501.14 by using one or more of the following methods based on the type of FOOD being cooled: (1) Placing the FOOD in shallow pans; (2) Separating the FOOD into smaller or thinner portions; (3)Using rapid cooling EQUIPMENT; (4) Stirring the FOOD in a container placed in an ice water bath; (5) Using containers that facilitate heat transfer; (6) Adding ice as an ingredient; or (7) Other effective methods. (B) When placed in cooling or cold holding EQUIPMENT, FOOD containers in which FOOD is being cooled shall be: (1) Arranged in the EQUIPMENT to provide maximum heat transfer through the container walls; and (2) Loosely covered, or uncovered if protected from overhead contamination as specified under Subparagraph 3-305.11(A)(2), during the cooling period to facilitate heat transfer from the surface of the FOOD. 2. During a tour of the facility, at 10:28 AM on 7/31/23, observation of the ice machine found increased amounts of black accumulation along the top portion of the white inside shield. When asked if she could see the accumulation, Registered Dietitian (RD) L stated yes. Further review of the ice scoop holder found increased amounts of crusted debris accumulation in the bottom of the holder. When shown to RD L she took the holder to get washed. When asked how the ice machine is cleaned, RD L stated that housekeeping takes care of the ice machines. During the initial tour of the kitchen, at 10:45 AM on 7/31/23, a review of the drink area found increased accumulation on the spout of the juice dispenser. When asked how often the juice machine gets cleaned, RD L stated that staff soak it in hot water overnight. Further review of the area found increased accumulation around the underside portions of the coffee and hot chocolate machines. During the initial tour of the kitchen, at 10:47 AM on 7/31/23, a review of the single door [NAME] and True reach in units found increased amounts of debris in the top portions of the gaskets. During a tour of the facility, at 11:01 AM on 7/31/23, it was observed that the microwave in the kitchen was found with bubbling, pitting, and scoring on the inside top seams of the unit. When shown to RD L she stated she has been meaning to get a new unit. During the initial tour of the facility, at 2:21 PM on 7/31/23, on station one clean utility, it was found that an increased amount of debris accumulation was evident on the inside right portion of the ice machine. According to the 2017 FDA Food Code section 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils. (A) EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS 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. 3. During the initial tour of the kitchen, at 10:35 AM on 7/31/23, it was observed that no air gap (a physical gap between the drain line and sewer line to prevent the backflow or backsiphonage of wastewater into equipment) was present on the sanitizer compartment of the three-compartment sink and that it was directly connected to the wastewater line. When asked if she knew why there was not an air gap installed, RD L stated that it's something that always gets brought up and she is unsure. When asked if there was a variance associated with the lack of an air gap, RD L could not remember, but stated it always comes up when they get inspected. During the initial tour of the kitchen, at 10:50 AM on 7/31/23, it was observed that the preparation sink was found with a direct connection of the wastewater line. Further review found an unapproved check valve installed on the direct connection. During the initial tour of the station 2 clean utility room, at 2:21 PM on 7/31/23, it was observed that the drains coming from the ice machine were found sunken into the floor drain, no longer making an air gap for proper protection from the backflow of wastewater. According to the 2017 FDA Food Code section 5-402.11 Backflow Prevention. (A) Except as specified in (B), (C), and (D) of this section, a direct connection may not exist between the SEWAGE system and a drain originating from EQUIPMENT in which FOOD, portable EQUIPMENT, or UTENSILS are placed. (B) Paragraph (A) of this section does not apply to floor drains that originate in refrigerated spaces that are constructed as an integral part of the building. (C) If allowed by LAW, a WAREWASHING machine may have a direct connection between its waste outlet and a floor drain when the machine is located within 1.5 m (5 feet) of a trapped floor drain and the machine outlet is connected to the inlet side of a properly vented floor drain trap. (D) If allowed by LAW, a WAREWASHING or culinary sink may have a direct connection. 4. During an interview with RD L, at 11:10 AM on 7/31/23, it was found that the emergency food used to be stored off site, but she is not sure where it is currently stored. During a tour of the emergency food product, with Maintenance Director Z, at 12:50 PM on 7/31/23, found that the product was stored underneath a wastewater line in the basement of an offsite facility. According to the 2017 FDA Food Code section 3-305.12 Food Storage, Prohibited Areas.FOOD may not be stored: .(F) Under sewer lines that are not shielded to intercept potential drips; .

Based on observation, interview, and record review, the facility failed to maintain the facility boiler mixing valve and domestic hot water supply temperatures within acceptable parameters for 14 (2, 17, 18, 19, 20, 21, 23, 24, 26, 28, 32, 38, 48, 50) of 24 sampled resident rooms, resulting in Immediate Jeopardy when the boiler mixing valve was discovered to not be functioning to maintain hot water temperatures at or below 120 degrees Fahrenheit, and resident's bathroom water temperatures exceeded 120 degrees Fahrenheit, placing 78 residents who had the use of the hot water at a high risk for [MEDICAL CONDITION]/or injury. Findings include: On 8/26/19 at approximately 2:42 PM, the sink in Resident room [ROOM NUMBER]'s bathroom was noted to feel hot when the surveyor rinsed the soap from their hands during hand hygiene. The surveyor had to pull their hands back from the water due to the hot water temperature. On 08/26/19 at 03:13 P.M., Hot water temperatures were monitored utilizing a ThermoWorks Super-Fast Thermapen model CR2032 digital thermometer. The following resident room hand sink hot water temperature was recorded: Resident room [ROOM NUMBER] - 124.3 degrees Fahrenheit* On 08/26/19 at 03:16 P.M., Hot water temperatures were monitored utilizing a ThermaWorks Super-Fast Thermapen model CR2032 digital thermometer. The following resident room hand sink hot water temperatures were recorded: Dogwood Hall Resident room [ROOM NUMBER] - 120.4 degrees Fahrenheit* Resident room [ROOM NUMBER] - 124.3 degrees Fahrenheit* Resident room [ROOM NUMBER] - 120.7 degrees Fahrenheit* Resident room [ROOM NUMBER] - 121.2 degrees Fahrenheit* Resident room [ROOM NUMBER] - 120.3 degrees Fahrenheit* Resident room [ROOM NUMBER] - 119.0 degrees Fahrenheit Resident room [ROOM NUMBER] - 124.5 degrees Fahrenheit* Resident room [ROOM NUMBER] - 126.1 degrees Fahrenheit* Cottonwood Hall Resident room [ROOM NUMBER] - 114.3 degrees Fahrenheit Resident room [ROOM NUMBER] - 122.1 degrees Fahrenheit* Willow Brook Resident room [ROOM NUMBER] - 122.4 degrees Fahrenheit* Resident room [ROOM NUMBER] - 124.6 degrees Fahrenheit* Resident room [ROOM NUMBER] - 118.9 degrees Fahrenheit Resident room [ROOM NUMBER] - 128.1 degrees Fahrenheit* Resident room [ROOM NUMBER] - 116.6 degrees Fahrenheit Resident room [ROOM NUMBER] - 119.3 degrees Fahrenheit Maple Hall Resident room [ROOM NUMBER] - 115.3 degrees Fahrenheit Resident room [ROOM NUMBER] - 116.6 degrees Fahrenheit Resident room [ROOM NUMBER] - 120.6 degrees Fahrenheit* Resident room [ROOM NUMBER] - 122.0 degrees Fahrenheit* Oak Hall Resident room [ROOM NUMBER] - 116.8 degrees Fahrenheit Resident room [ROOM NUMBER] - 118.1 degrees Fahrenheit Resident room [ROOM NUMBER] - 119.7 degrees Fahrenheit Resident room [ROOM NUMBER] - 121.6 degrees Fahrenheit* Note: (*) Water Temperature - Water may reach hazardous temperatures in hand sinks, showers, tubs, and any other source or location where hot water is accessible to a resident.[MEDICAL CONDITION] to hot water/liquids may also be due to spills and/or immersion. Many residents in long-term care facilities have conditions that may put them at increased risk [MEDICAL CONDITION] by scalding. These conditions include: decreased skin thickness, decreased skin sensitivity, [MEDICAL CONDITION], decreased agility (reduced reaction time), decreased cognition or dementia, decreased mobility, and decreased ability to communicate. The degree of injury depends on factors including the water temperature, the amount of skin exposed, and the duration of exposure. Some States have regulations regarding allowable maximum water temperature. The State of Michigan requires hot water temperatures range between 105-120 degrees Fahrenheit or 40.555-48.888 degrees Centigrade. Table 1 illustrates damage to skin in relation to the temperature of the water and the length of time of exposure. Table 1. Time and Temperature Relationship to [MEDICAL CONDITION] Water Time Required for a 3rd Degree Temperature Burn to Occur _________________________________________________________________ 155°F 68°C 1 sec 148°F 64°C 2 sec 140°F 60°C 5 sec 133°F 56°C 15 sec 127°F 52°C 1 min 124°F 51°C 3 min 120°F 48°C 5 min 100°F 37°C Safe Temperatures for Bathing (see Note) _________________________________________________________________ NOTE:[MEDICAL CONDITION] occur even at water temperatures below those identified in the table, depending on an individual's condition and the length of exposure. Based upon the time of the exposure and the temperature of the water, the severity of the harm to the skin is identified by the degree of burn, as follows. o First-[MEDICAL CONDITION] the top layer of skin (e.g., minor sunburn). These may present as red and painful to touch, and the skin will show mild swelling. o Second-[MEDICAL CONDITION] the first two layers of skin. These may present as deep reddening of the skin, pain, blisters, glossy appearance from leaking fluid, and possible loss of some skin. o Third-[MEDICAL CONDITION] the entire thickness of the skin and permanently destroy tissue. These present as loss of skin layers, often painless (pain may be caused by patches of first- and second-[MEDICAL CONDITION] third-degree burns), and dry, leathery skin. Skin may appear charred or have patches that appear white, brown, or black. On 08/26/19 at 05:03 P.M., An interview was conducted with Director of Maintenance F concerning hot water temperature monitoring logs. Director of Maintenance F stated: We monitor resident room hand sink temperatures Mondays, Wednesdays, Fridays, and Saturdays. Director of Maintenance F additionally stated: We check the boiler mixing valve daily except for Sundays. On 08/26/19 at 05:07 P.M., Record review of the Nursing Center Domestic Water Temps log for the last three months revealed hot water mixing valve temperatures of 121 degrees Fahrenheit on 6/8/19 and 122 degrees Fahrenheit on 7/10/19. Record review of the Nursing Center Domestic Water Temps log for the last three months further revealed Laundry Service hot water temperatures of 128 degrees Fahrenheit on 8/3/19 and domestic hot water temperatures of 124 degrees Fahrenheit in resident room [ROOM NUMBER] on 8/24/19. On 08/27/19 at 08:15 [NAME]M., An interview was conducted with Director of Maintenance F concerning a specific Policy/Procedure for monitoring and recording domestic hot water temperatures. Director of Maintenance F stated: Yes. We have a policy for checking hot water temperatures. On 08/27/19 at 08:33 [NAME]M., Record review of the Policy/Procedure entitled: Domestic Hot Water Temperature Checks dated 9/12/17 revealed under Goal: It is the policy of Thurston Woods Village Maintenance Department to provide routing temperature checks for safety and infection control needs. Record review of the Policy/Procedure entitled: Domestic Hot Water Temperature Checks dated 9/12/17 further revealed under Procedures: (1) Water temperatures to be maintained between 105 and 120 degrees. On 08/27/19 at 09:08 [NAME]M., Hot water temperatures were monitored utilizing a ThermoWorks Super-Fast Thermapen model CR2032 digital thermometer. The following shower/spa hot water temperatures were recorded: Station I Spa: Hand Sink: 124.3 degrees Fahrenheit* Shower Wand Assembly: 107.5 degrees Fahrenheit Willow Brook Spa: Hand Sink: 116.1 degrees Fahrenheit Shower Wand Assembly: 116.4 degrees Fahrenheit Station II Spa: Hand Sink: 120.5 degrees Fahrenheit* Shower Wand Assembly: 116.2 degrees Fahrenheit On 8/27/2019, at 10:31 AM, the Administrator was notified of the Immediate Jeopardy that was identified on 8/26/2019, and began on 8/24/2019 when a review of the facility's Nursing Center Domestic Water Temps log reflected that water temperatures had not been monitored since the facility documented a hot water temperature of 124 degrees Fahrenheit in room [ROOM NUMBER] on 8/24/19, and a new boiler mixing valve that was ordered by the facility had not arrived to the facility for replacement. On 8/27/2019, this surveyor verified that the facility implemented the following to remove the Immediate Jeopardy: A) Beginning 8/27/2019 all resident sinks will be blocked from use utilizing yellow tape across each sink area. This process began immediately and was completed on all halls by 11:20 AM on 08/27/2019. B) Beginning 8/27/2019 all staff will have access to sinks in the nursing center kitchenettes, shower rooms, and soiled utility room to obtain water for peri care and other areas for resident use, relying on their ability to monitor hot water by adding cold water. This was identified by staff as solution to ensure residents are still provided with care. On-going until notified by Administrator. C) Beginning 8/27/2019 all staff has access and will utilize hand sanitizers for personal and resident use. Staff verified understanding of this practice indicating this in a current practice, and always carry appropriate equipment, and there are many stations in public areas as well. D) Beginning 8/27/2019 all staff were educated on the water temperatures that should be between 105-120-degree Fahrenheit, and the potential risks [MEDICAL CONDITION] elevated temperatures. They expressed understanding that according to the State Operations Manual, residents can [MEDICAL CONDITION] to 3rd [MEDICAL CONDITION] elevated temps in as little as one minute if temperatures reach 127 degrees Fahrenheit. It was requested that should they feel the temperatures are too hot for their use, it is most likely too hot for resident use. There was discussion regarding that the majority of the residents do not use the bathroom sinks without supervisor, and it was further explained that although we have had no residents [MEDICAL CONDITION] any kind, there was always the risk and it is up to us to provide safety at all times. On 8/27/2019 as the Administrator was handling the staff meeting, the Director of Nursing was meeting with the maintenance department to attempt to facilitate an earlier delivery date for the new mixing valve. During this meeting the following steps were put into place: A) On 8/27/2019 he maintenance department stated that if they ran the water in the maintenance sink at a continuous basis it will have impact on the hot water. B) On 8/27/2019 the Maintenance Director had ordered the replacement valve. It has been shipped from Alabama and will arrive in the Chicago warehouse for delivery on Thursday. This was done on 08/27/2019 at around 7 am. C) On 8/27/2019 the Director of Nursing was given the name of several other suppliers and with the help of the Director of the Assisted Living they were able to locate another mixing valve in Elkhart, Indiana approximately an hour away. The Director of Nursing requested the Thurston Woods Village Chaplain go to get the valve instead of waiting for it to be shipped. D) On 8/27/2019 the Maintenance Director replaced the mixing valve by 02:45 P.M. E) On 8/27/2019 the maintenance department was reminded to report any unusual events when they are making their preventative maintenance rounds to the Director of Maintenance, the Assistant Director of Maintenance and in the absence of both to the Administrator. On 8/27/2019, it was determined to not stop shipment of the previously ordered mixing valve, which will ensure this is an isolated incident and will not be repeated in the future, allowing the facility to have an extra part always available. The part is anticipated to arrive on date 08/29/2019. On 08/27/2019, the Assistant Director of Maintenance checked all the temperatures identified in the Immediate Jeopardy, and it was determined the repaired mixing valve was working and the temperatures were going down. Although the Immediate Jeopardy was removed on 8/27/2019, the facility remained out of compliance at a scope of widespread and a severity of no actual harm with the potential for more than minimal harm that is not Immediate Jeopardy. Sustained compliance has not yet been verified by the State Agency. On 08/27/19 at 12:27 P.M., An interview was conducted with Director of Maintenance F regarding a specific Policy/Procedure for correcting excessive hot water temperatures. Director of Maintenance F stated: We would monitor temperatures in adjacent rooms and correct the issue as soon as possible. On 08/27/19 at 01:00 P.M., Director of Maintenance F stated: The new mixing valve is approximately fifteen minutes out. On 08/27/19 at 01:15 P.M., The new domestic hot water mixing valve arrived to the facility per staff courier (Chaplain). While the Immediate Jeopardy was removed on 08/27/19, the facility remains out of compliance with deficient practice at widespread scope and severity with no actual harm with potential for more than minimal harm that is not immediate jeopardy as sustained compliance could not be verified by the state agency.

BASED ON OBSERVATION, INTERVIEW AND RECORD REVIEW, THE FACILITY FAILED TO MINIMIZE THE TENSION PLACED ON A RESIDENT'S FRAGILE SKIN DURING ASSISTED POSITIONAL CHANGES FOR 1 OF 5 RESIDENTS (#4) REVIEWED FOR PRESSURE SORES, FROM A TOTAL SAMPLE OF 21 RESIDENTS, RESULTING IN AN INJURY THAT DEVELOPED INTO AN AVOIDABLE STAGE III PRESSURE SORE AND RESTRICTIONS IN THE RESIDENT'S NORMAL ACTIVITIES AND AN INCREASED RISK FOR CLINICAL COMPLICATIONS, INCLUDING INFECTIONS. FINDINGS INCLUDE: ACCORDING TO THE ADMISSION FACE SHEET DATED 07/19/2012, RESIDENT #4 WAS A [AGE] year OLD FEMALE WITH [DIAGNOSES REDACTED]. ACCORDING TO THE MDS (MINIMUM DATA SET) assessment dated [DATE], RESIDENT #4'S BIMS (BRIEF INTERVIEW FOR MENTAL STATUS) SCORE WAS "4" OUT OF A POSSIBLE "15" REFLECTING SEVERE COGNITIVE IMPAIRMENT. REVIEW OF THE MDS dated [DATE], UNDER SECTION M (SKIN CONDITIONS) REFLECTED "ZERO" UNDER M0210, WHICH ASKS, "DOES THIS RESIDENT HAVE ONE OR MORE UNHEALED PRESSURE ULCER (S) AT STAGE I OR HIGHER?" THE MDS dated [DATE], SECTION M (SKIN CONDITIONS) WAS ALSO CODED ZERO UNDER M0210. DURING INTERVIEW AND WALKING TOUR OF THE FACILITY ON 03/17/2013 AT 1:50 PM, LICENSED PRACTICAL NURSE (LPN) (O) WAS ASKED IF ANY OF THE RESIDENTS HAD BLADDER CATHETERS. STAFF (O) INDICATED THAT RESIDENT #4 HAD A BLADDER CATHETER PLACED BECAUSE OF A PRESSURE ULCER ON HER COCCYX (TAILBONE), BECAUSE SHE WAS "ALWAYS WET." LPN (O) WAS ASKED IF RESIDENT #4'S PRESSURE ULCER WAS FACILITY ACQUIRED (I.E., HAD DEVELOPED AT THE FACILITY) AND LPN (O) STATED, "YES." WOUND CARE WAS OBSERVED DURING AN OBSERVATION ON 03/19/2013 AT 10:00 AM IN RESIDENT #4'S ROOM. RESIDENT #4 WAS REPOSITIONED ON HER RIGHT SIDE BY CNA (CERTIFIED NURSING ASSISTANT) (E) BY MEANS OF A TURNING PAD WHILE LPN STAFF (D) PROCEEDED TO DO THE DRESSING CHANGE. THE OLD DRESSING WAS SOILED, WITH GREEN/YELLOW DRAINAGE, AND A SLIGHT ODOR WAS PRESENT. STAFF NURSE (D) IRRIGATED THE WOUND WITH NORMAL SALINE, THEN PLACED CALCIUM ALGINATE (AN ABSORPTIVE MATERIAL) IN THE OPEN WOUND, FOLLOWED BY 4 X 4 GAUZE, THEN COVERED THE AREA WITH A TAPED ABD (ABDOMINAL) PAD FOLDED IN HALF. THE WOUND WAS YELLOW AND RED IN COLOR. ACCORDING TO THE SKIN CONDITION SHEET DATED 03/20/2013, RESIDENT #4'S WOUND HAD BEEN MEASURED AT 5.0 CENTIMETERS (CM) IN LENGTH BY 3.4 CM IN WIDTH, AND THE DEPTH WAS 2.3 CM WITH UNDERMINING OF 1.3 CM. A physician's orders [REDACTED]. REVIEW OF RESIDENT #4'S CARE PLAN DATED 03/07/2013, UNDER THE HEADING OF SKIN, REFLECTED: "...RESIDENT HAS A STAGE III ON COCCYX ...ON 02/09/2013, SHE WAS FOUND TO HAVE SLIT IN THE CREASE OF HER BUTTOCKS WHICH APPEARED TO BE FROM STAFF REPOSITIONING HER AND CREATING TENSION ON THE CREASE OF HER BUTTOCK CREATING A TEAR..." ACCORDING TO THE "CENTERS FOR MEDICARE & MEDICAID SERVICES LONG-TERM CARE FACILITY RESIDENT ASSESSMENT INSTRUMENT USER'S MANUAL 3.0" (APRIL 2012), A STAGE 3 (III) PRESSURE ULCER IS DEFINED AS A WOUND WITH THE FOLLOWING CHARACTERISTICS: "FULL THICKNESS SKIN LOSS. SUBCUTANEOUS FAT MAY BE VISIBLE BUT BONE, TENDON OR MUSCLE IS NOT EXPOSED. SLOUGH (DEAD TISSUE) MAY BE PRESENT BUT DOES NOT OBSCURE THE DEPTH OF THE TISSUE. MAY INCLUDE UNDERMINING OR TUNNELING." DURING AN INTERVIEW ON 03/19/2013 AT 10:00 AM, STAFF LPN (D) WAS ASKED ABOUT THE REASONS WHY RESIDENT #4 DEVELOPED THE PRESSURE ULCER TO HER COCCYX. STAFF (D) STATED, " STAFF WAS TURNING HER WITHOUT A PAD OR DRAW SHEET UNDER HER, AND WHEN THEY TURNED HER THEY PUT TOO MUCH PRESSURE ON HER COCCYX AND HER SKIN SPLIT BETWEEN HER BUTTOCKS." DURING AN INTERVIEW ON 03/20/2013 AT 10:20 AM, CNA STAFF (E) WAS ASKED HOW RESIDENT #4 HAD ACQUIRED A PRESSURE ULCER ON HER COCCYX. STAFF (E) STATED, "I THINK IT HAPPENED WHEN PEOPLE TURNED HER AND (WERE) PULLING ON HER SKIN. WE HAVE SOME NEW STAFF ON SECOND SHIFT. WE ALL WENT TO A SPECIAL INSERVICE TRAINING AFTER SHE (RESIDENT #4) HAD THIS AREA OPEN UP, AND WE WERE INSTRUCTED HOW TO PROPERLY TURN AND REPOSITION RESIDENTS." STAFF (E) WAS ASKED IF RESIDENT #4 WAS USING THE HIGH BACK WHEELCHAIR IN HER ROOM. STAFF (E) STATED, "NO, SHE IS BEDFAST FOR THE LAST TWO WEEKS. I USED TO WALK HER TO THE BATHROOM BEFORE SHE GOT THIS SORE, AND NOW WE ARE TO TURN HER EVERY 2 HOURS AND SHE STAYS IN BED." DURING AN INTERVIEW ON 03/20/2013 AT APPROXIMATELY 2:45 PM, ACTIVITY DIRECTOR STAFF (H) WAS ASKED ABOUT ACTIVITIES FOR RESIDENT #4. STAFF (H) STATED, "WE PROVIDE 1 TO 1 VISITS IN HER ROOM SINCE SHE WAS PLACED ON BED REST FOR HER SORE." DURING AN INTERVIEW ON 03/20/2013 AT 3:15 PM, CNA STAFF (F) WAS ASKED WHY RESIDENT HAD A PRESSURE ULCER AND STAFF (F) STATED, " SHE DID NOT HAVE A PAD FOR TURNING AND PEOPLE WOULD PULL ON HER SKIN. WE HAD A INSERVICE, AFTER THIS HAPPENED TO THE RESIDENT..." RECORD REVIEW OF THE MDS dated [DATE], SECTION G (FUNCTIONAL STATUS) REFLECTED THAT RESIDENT #4 HAD BEEN ABLE TO WALK IN HER ROOM WITH EXTENSIVE ASSISTANCE OF STAFF. HOWEVER, REVIEW OF THE C.N.A. CARE PLAN (NO DATE), UNDER SKIN, REFLECTED: "... TURN EVERY 2 HOURS, TWO PADS ON BED...BED REST 03/15/2013." REVIEWING THE PHYSICIAN ORDERS [REDACTED]. CHANGE FOLEY CATH PRN, INDICATION WOUND HEALING..." THE physician progress notes [REDACTED]. ACCORDING TO THE FACILITY'S SKIN CONDITION SHEET DATED 02/11/2013, PROVIDED BY STAFF LPN (D), RESIDENT #4'S WOUND WAS IDENTIFIED ON 02/11/2013 AND WAS FIRST CODED AS A LACERATION-SLIT. THEN, ON 03/1/2013, THE WOUND WAS CODED AS A STAGE III. THE SIZE OF THE WOUND ON 02/11/2013 WAS 2.2 CM (LENGTH) BY 1.4 CM (WIDTH) BY 0.3 CM (DEPTH). THE WOUND SUBSEQUENTLY ENLARGED AND, BY 03/20/2013, MEASURED 5.0 CM BY 3.4 CM BY 2.3 CM. REVIEW OF THE FACILITY INSERVICE DATED 02/13/2013, UNDER "REMINDERS OF HOW WE TAKE CARE OR (SIC) RESIDENTS AND THEIR SKIN" PARAGRAPH NUMBER 5 INSTRUCTED: "...WHEN TURNING RESIDENTS YOU NEED TO USE THEIR PAD OR DRAW SHEET, DO NOT TURN THEM BY PUSHING THEIR BOTTOM AREA AS THIS IS CAUSING TEARS IN THEIR COCCYX FROM THE UPWARD MOVEMENT. DO NOT HOLD THEM 'OVER' BY PUSHING ON THEIR BOTTOM; PLACE YOUR HANDS ON THEIR LOWER BACK AND THEIR UPPER THIGH..." SIGNATURES ON THE FORMS WITH THE INSERVICE REFLECTED THAT THE INSERVICE WAS GIVEN TO NURSES AND CNAs. ANOTHER FACILITY FORM TITLED: SKIN ISSUES FEBRUARY 18 TH - 22 TH AND SIGNED BY NURSE (D) DOCUMENTED: "...WHEN TURNING RESIDENT WE NEED TO USE THE DRAW SHEET OR PAD TO TURN THEM AND WE DO NOT EVER PLACE OUR HANDS ON THEIR BUTTOCK, THE CENA'S WERE SHOWN BY DEMONSTRATION WHERE THEIR HANDS WERE TO BE MID BACK OR SHOULDER AND THIGH." ( )

BASED ON OBSERVATION, INTERVIEW AND RECORD REVIEW, THE FACILITY FAILED TO PROVIDE ADEQUATE HYDRATION FOR 1 OF 7 RESIDENTS (#8) REVIEWED FOR HYDRATION, FROM A TOTAL SAMPLE OF 21 RESIDENTS, RESULTING IN CONTINUED INCREASED RISK FOR INSUFFICIENT FLUID INTAKE; RESIDENT #8 WAS hospitalized for [REDACTED]. FINDINGS INCLUDE: ACCORDING TO THE ANNUAL MINIMUM DATA SET (MDS) ASSESSMENT, DATED 10/17/12, RESIDENT #8 WAS ORIGINALLY admitted to the facility on [DATE] WITH A BIMS (BRIEF INTERVIEW FOR MENTAL STATUS) SCORE OF 3 OUT OF 15, INDICATING SEVERE COGNITIVE IMPAIRMENT. RESIDENT #8 REQUIRED EXTENSIVE ASSIST OF ONE STAFF FOR EATING. ACCORDING TO THE RESIDENT ADMISSION RECORD (UNDATED), RESIDENT #8 WAS RE-admitted to the facility on [DATE], FOLLOWING hospitalization , WITH [DIAGNOSES REDACTED]. BASED ON REVIEW OF THE HOSPITAL HISTORY AND PHYSICAL, DATED 2/13/13, THE FOLLOWING WAS DOCUMENTED: "...THIS [AGE] year OLD PATIENT...RESIDENT OF (NAME OF FACILITY)...admitted UNDER MY CARE WITH CONFUSIONAL STATE, CHANGE IN MENTAL STATUS AND WAS FOUND TO HAVE SEVERE DEHYDRATION AND [MEDICAL CONDITION] IN THE emergency room . SHE HAS BEEN hospitalized . HISTORY OF PRESENT ILLNESS: THE PATIENT WHO HAS DEMENTIA AND CONFUSION APPARENTLY FOR THE LAST 2 TO 3 DAYS HAS BECOME VERY LETHARGIC AND ALMOST TO THE POINT OF BEING UNRESPONSIVE...THERE HAS NOT BEEN ANY HISTORY OF FEVER...PHYSICAL EXAMINATION: [AGE] year-OLD FEMALE PATIENT WHO IS VERY LETHARGIC AND BARELY AROUSABLE, OPENS HER EYES AND MUMBLES IN WORDS THAT CANNOT BE UNDERSTOOD...IMPRESSION: 1. SEVERE DEHYDRATION 2. [MEDICAL CONDITION]" BASED ON REVIEW OF THE FACILITY'S NURSES PROGRESS NOTES ENTERED BETWEEN 2/4/13 AND 2/12/13, THERE WERE NO ASSESSMENTS OF RESIDENT #8'S HYDRATION DOCUMENTED IN THE NOTES (SUCH AS THE CONDITION OF HER MUCOUS MEMBRANES, TONGUE AND LIPS, URINE OUTPUT, OR SKIN TURGOR). THE PROGRESS NOTES ENTERED ON 02/06/2013 DOCUMENTED "...FLUIDS TAKEN POORLY TENDS TO TALK WHILE SIPPING...", BUT THERE WERE NO INTERVENTIONS DOCUMENTED TO ENCOURAGE INCREASED FLUID INTAKE DURING THE TEN DAYS PRIOR TO THE RESIDENT'S DISCHARGE TO THE HOSPITAL. A PHYSICIAN TELEPHONE ORDER FOR RESIDENT #8 THAT WAS SIGNED AND DATED BY THE PHYSICIAN ON 2/11/13 REFLECTED: "CHEST X-RAY, CBC (COMPLETE BLOOD COUNT, AND CMP (COMPREHENSIVE METABOLIC PANEL)." A PHYSICIANS PROGRESS NOTE DATED 2/11/13 BY PHYSICIAN (L) REFLECTED THE FOLLOWING FOR RESIDENT #8: ...SHE LOST NINE POUNDS IN THE LAST WEEK. THE CHEST X-RAY SHOWED NO ACUTE [MEDICAL CONDITION] INFILTRATES. THE BLOOD TEST, HOWEVER, WAS SIGNIFICANT FOR PANIC HIGH SODIUM LEVEL...TEMPERATURE 100.2, BLOOD PRESSURE 94/64, PULSE 84, RESPIRATIONS 22. SKIN IS DRY AND DEHYDRATED. HER EYES ARE SUNKEN...A:(ASSESSMENT) 1. UPPER RESPIRATORY INFECTION, 2. ELECTROLYTES DISORDER..." NURSES PROGRESS NOTES FOR RESIDENT #8 DATED 2/12/13 AT 10:10 A.M. REFLECTED: "LAB (LABORATORY) CALLED WITH SODIUM OF 164 MMOI/L" (NORMAL RANGE IS 135-145 MMOI/L), "WBC (WHITE BLOOD CELL COUNT) 37.7 CU MM" (NORMAL RANGE IS 4.8-10.8 CU MM), FAMILY CALLED TO SEND RESIDENT #8 TO (HOSPITAL NAME) HOSPITAL FOR EVALUATION AND TX (TREATMENT) DR (PHYSICIAN), (L) NOTIFIED...REPORT CALLED TO ER (emergency room ) AT 8:17 A.M...". ON 3/18/13 BETWEEN 12:00 P.M. AND 12:30 P.M., RESIDENT #8 WAS OBSERVED IN THE MULTI- PURPOSE DINING ROOM (MPR) BEING ASSISTED BY A CERTIFIED NURSE AIDE (CNA) STAFF (M) WITH LUNCH. RESIDENT REQUIRED CNA (M ) TO ASSIST HER WITH BOTH EATING AND DRINKING. RESIDENT #8 WAS HEARD TO MAKE CONTINUAL VERBALIZATIONS OF "CAN I GO?' AND REQUIRED CUES AND REMINDERS FROM CNA (M ) TO TAKE BITES OF FOOD AND DRINK HER LIQUIDS. RESIDENT #8 WAS NOT OBSERVED TO INITIATE EATING OR DRINKING ON HER OWN. REVIEW OF THE NURSES PROGRESS NOTES FOR RESIDENT #8, ENTERED BY THE FACILITY DURING THE PERIOD 2/4/13 THROUGH 2/12/13, REFLECTED THE FOLLOWING: ON 2/4/13 AT 10:43 A.M. RESIDENT #8 DEMONSTRATED AN ELEVATED TEMPERATURE OF 99.9 F (DEGREES FARENHEIT). ON 2/5/13 AT 10:38 A.M. RESIDENT #8 HAD A FEVER OF 101.2 F. ON 2/6/13 AT 10:23 A.M. NURSES DOCUMENTED: "...ON (PHYSICIANS NAME) ROUNDS FOR THIS EVENING..." ON 2/7/13 AT 13:04 (1:04 P.M.): "...CONTINUES WITH S&S (SIGNS AND SYMPTOMS) FOR A FEBRILE EPISODE OF UNKNOWN ORIGIN. SLIGHT FLUSHING OF FACE NOTED...RESIDENT RESTING QUIETLY IN RECLINER IN ROOM..." ON 2/8/13 AT 7:57 A.M. NOTES REFLECTED: "TEMP 101.5..." AND ON 2/8/13 AT 10:36 A.M.: RESIDENT UP SITTING IN RECLINER SLEEPING...NOT EATING OR DRINKING WELL." ON 2/9/13 AT 10:17 A.M.: "TEMP 98.3 IS UP IN RECLINER...REMAINS LETHARGIC..." ON 2/11/13 AT 13:45 (1:45 P.M.): "T-101.8 CONTINUES FOR S&S FOR FEVER OF UNKNOWN ORIGIN...LESS THAT 25% OF MEALS CONSUMED. RESIDENT RESTING IN BED WITH EYES CLOSED..." THE NURSES PROGRESS NOTES FOR RESIDENT #8 DATED 2/12/13 AT 10:10 A.M. REFLECTED: "LAB (LABORATORY) CALLED WITH SODIUM OF 164 MMOI/L" (NORMAL RANGE IS 135-145 MMOI/L), "WBC (WHITE BLOOD CELL COUNT) 37.7 CU MM" (NORMAL RANGE IS 4.8-10.8 CU MM), FAMILY CALLED TO SEND RESIDENT #8 TO (HOSPITAL NAME) HOSPITAL FOR EVALUATION AND TX (TREATMENT) DR (PHYSICIAN), (L) NOTIFIED...REPORT CALLED TO ER (emergency room ) AT 8:17 A.M..." AN INTERVIEW WAS CONDUCTED IN THE DIRECTOR OF NURSING (DON) OFFICE ON 3/20/13 AT 11:00 A.M. WITH THE ADON (A), ADON (G) AND CERTIFIED DIETARY MANAGER (CDM) STAFF (J). DURING THE INTERVIEW, ADON (A) AND CDM (J) CONFIRMED THAT RESIDENT # 8 HAD NOT BEEN ASSESSED FOR SIGNS AND SYMPTOMS OF DEHYDRATION DURING THE PERIOD BETWEEN THE ONSET OF HER ELEVATED TEMPERATURE ON 2/04/13 TO HER DISCHARGE TO THE hospital on [DATE], NOR WERE INTERVENTIONS DOCUMENTED AS HAVING BEEN ADDED BY DIETARY OR NURSING STAFF TO INCREASE THE RESIDENT'S FLUID INTAKE AND PREVENT DEHYDRATION. DURING THE INTERVIEW, NO EVIDENCE WAS PROVIDED TO SHOW THAT RESIDENT #8 WAS PLACED ON FLUID INTAKE AND OUTPUT MONITORING PRIOR TO BEING SENT TO THE hospital on [DATE]. BOTH ADONS (A) AND (G) CONFIRMED THAT ASSESSMENTS FOR SIGNS AND SYMPTOMS OF DEHYDRATION WOULD BE DOCUMENTED IN NURSES PROGRESS NOTES AND SAID THAT COMMUNICATIONS REGARDING RESIDENTS WHO WERE AT RISK FOR DEHYDRATION WERE HANDLED VIA NURSE/CNA WORKSHEETS. THE FACILITY WAS UNABLE TO PROVIDE COPIES OF THOSE WORKSHEETS FOR RESIDENT #8 FOR THE PERIOD 2/4/13 THROUGH 2/12/13, BECAUSE THE FACILITY'S PRACTICE WAS TO THROW THEM AWAY AFTER REVIEW. ADON (A) EXPLAINED THAT NOTIFICATION OF RESIDENT #8'S CONTINUED ELEVATED TEMPERATURE WAS NOT REPORTED TO PHYSICIAN (L) FOR 5 DAYS (2/6/13 TO 2/11/13) BECAUSE THE FACILITY WAS EXPERIENCING A WIDE SPREAD OUTBREAK OF GASTROINTESTINAL (GI) EPISODES AMONG RESIDENTS THAT INCLUDED RESIDENTS HAVING AN ELEVATED TEMPERATURE. ADON (A) SAID THAT RESIDENT #8 WAS NOT HAVING GI PROBLEMS AT THE TIME OF HER INCREASED TEMPERATURES. ADON (A) ALSO CONFIRMED THAT THE FACILITY HAD ONLY CONTACTED PHYSICIAN (L) ONCE, ON 2/6/13, AND NO FURTHER CALLS WERE MADE UNTIL THE LABORATORY TESTS WERE ordered on [DATE], SO THE PHYSICIAN WAS NOT AFFORDED AN OPPORTUNITY TO TIMELY INVESTIGATE THE CAUSE OF RESIDENT #8'S ABNORMAL TEMPERATURE. DURING AN INTERVIEW ON 3/20/13 AT 12:00 P.M., RESIDENT #8'S RESPONSIBLE PARTY (P) STATED THAT RESIDENT #8 HAD NEVER BEEN A "GOOD DRINKER", SO SHE WAS NOT SURPRISED BY THE [DIAGNOSES REDACTED]." REVIEW OF RESIDENT #8'S NUTRITION CARE PLAN (PROBLEM START DATE OF 10/31/11) REFLECTED THAT RESIDENT #8 WAS AT RISK FOR POTENTIAL ALTERATION IN NUTRITION AND HYDRATION. APPROACHES ON THE CARE PLAN WITH THE START DATE OF 10/31/2011 INCLUDED: "I KNOW THE STAFF IS GOING TO ENCOURAGE ME TO DRINK FLUIDS WITH MEALS...STAFF: WATCH FOR S/S OF DEHYDRATION; FEVER, DRY CRACKED LIPS, OUTPUT > (GREATER THAN) INPUT, INCREASED CONFUSION, ELEVATED SODIUM, BUN (BLOOD UREA NITROGEN), [MEDICATION NAME], POOR SKIN TURGOR, DRY MUCOUS MEMBRANES." BASED ON REVIEW OF THE CARE PLAN, THERE WERE NO NEW INTERVENTIONS ADDED TO REFLECT RESIDENT #8'S INCREASED RISKS RELATED TO THE FEVER AND CHANGE IN CONDITION THAT SHE EXPERIENCED FROM 2/4/13 TO 2/12/13. RESIDENT #8'S NUTRITION CARE PLAN (WITH PROBLEM START DATE OF 2/22/13) REFLECTED THAT RESIDENT #8 WAS AT RISK FOR POTENTIAL ALTERATION IN NUTRITION/HYDRATION, BUT DID NOT REFLECT THAT RESIDENT #8 HAD RECENTLY BEEN hospitalized for [REDACTED]. DURING AN INTERVIEW ON 3/21/13 AT 10:55 A.M., ADON (A) STATED THAT THE FACILITY HAD NO OTHER INFORMATION TO PROVIDE TO SHOW THAT RESIDENT #8'S SEVERE DEHYDRATION, [MEDICAL CONDITION] AND hospitalization HAD BEEN UNAVOIDABLE. ( )

Based on observation, interview and record review, the Facility failed to prevent Resident to Resident sexual abuse for 2 of 4 sampled Residents (#102 and #103), resulting in Resident #102 becoming both emotionally and mentally distressed and afraid after Resident #101 was observed with his hand near Resident #102's groin, between her legs and she was not able to stop him, and the potential for Resident #103 to have emotional distress. Findings include: Review of the clinical record revealed that Resident #101 was a [AGE] year old man admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. He was able to ambulate without assistance. Review of the closed, clinical record revealed that Resident #102 was a [AGE] year old woman admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Review of the Death Record revealed Resident #102 died on [DATE] due to complications of [MEDICAL CONDITION] and [MEDICAL CONDITION] Infarction. Review of the Minimum Data Set ((MDS) dated [DATE] revealed Resident #102 required a wheelchair and she was dependant on staff for locomotion both on and off the unit. According to the Discharge Summary Resident #102 died on [DATE]. The Record of Death recorded the cause of death was [MEDICAL CONDITION] and [MEDICAL CONDITION] Infarction. Review of the clinical record revealed that Resident #103 was an [AGE] year old woman admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED].#103 had no behavior problems and required extensive assistance for all activities of daily living. An observation on [DATE] at 1:45PM revealed Resident #103, sitting in a wheelchair, in her room with the TV on. An interview was attempted, but due to cognitive deficits, she was not able to answer the surveyors questions. During a phone interview, on [DATE] at 11:00 AM, RN "F' said he worked on [DATE] and he had written a note and kept it at his home about this incident. The note said, at about 4:45 PM, an altercation occurred with Resident #102 and Resident #101 and we put a "tweeter on his (Resident #101's) bed so it wouldn't happen again." RN "F" explained that a tweeter is an alarm. RN "F" said a Certified Nurse Aide (CNA) told him what had happened and that she brought Resident #102 to her room and RN "F" said he brought Resident #101 to his room and told him it was inappropriate. RN "F" said there was another incident that occurred on [DATE] when Resident #101 put his hand up Resident #103's pant leg to her groin area. RN "F" said he reported it to the Director of Nursing (DON). Review of the "Behavior Tracking System" notes for Resident #101 revealed that on [DATE] at 5:20PM, and signed by Registered Nurse (RN "F") documented, "Resident put his hand up (named Resident #103),'s pant leg to her peri area while they were in the activities center. A Nurse Aide walked in saw what was going on and told Resident it was time for dinner. Nurse aide said that he stopped right away The nurse aide then removed (named Resident #103) from area and asked if she was okay. (Named Resident # 103) said she was okay. Resident (Resident #101) went back to his room. I notified (named Director of Nursing) what happened and she went to talk with (named Resident #101). The Facility's Social Worker (SW), in an interview on [DATE] at 11:50 AM, said Resident #101 "only had one incident of Resident to Resident inappropriate sexual behavior". When asked if she was aware of the incident that occurred on [DATE] with Resident #103, SW said, "yes". When asked if she reported the Resident to Resident inappropriate sexual behavior to the State, SW said, "No it wasn't a reportable. She showed no signs of distress, no harm." When asked if there were any interventions after the [DATE] incident when Resident #101 sexually abused Resident #103 to prevent Resident #101 from abusing any other Residents, SW said "No". SW then said, Resident #103 "smiled through the whole thing". When asked how she knew she smiled while Resident #101 touched her inappropriately, SW said, "I mean when I interviewed her". When asked when the interview occurred and where the interview documentation was SW looked through her office file cabinet and in both Resident's the clinical records and could not locate any documentation of an interview she had with Resident #103 after she was sexually abused by Resident #101. Review of the nurse's notes dated [DATE] at 11:10 PM and signed by RN "F" revealed the following note was written regarding Resident #102 from the incident that occurred earlier that day when Resident #101 put his hands up her pants while she waited for Church services to begin, "no physical damage noted, but she brought up the subject several times tonight and said she was scared." Continued review of the nurse's notes dated [DATE] at 11:00 PM and signed by the night shift nurse Licensed Practical Nurse (LPN "G") was written, "...Tylenol given for [MEDICAL CONDITION]. Resident seemed distraught about incident with other Resident." Review of the Social Worker note dated [DATE] at 9:15 AM revealed SW was informed of an incident that occurred on [DATE] at 4:30 PM. The note stated, "A male Resident put his hands between her legs close to the groin area. She stated "I know where his hand was headed but I didn't yell because I was in Church and I was raised not to yell in Church. I couldn't see who he was and I'm glad of it. He held my hand and tried to move my hand towards his privates and I was never so grateful to see that Nurse when she came and took me away from him." She is able to talk about incident and stated, "I know they took care of it." But still displayed signs of distress at 8:15 AM." In an interview on [DATE] at 12:15 PM, Certified Nurse Assistant (CNA "E") said she worked on [DATE] and at about 4:45 PM she wheeled a Resident (did not recall who the Resident was), into the dining room for the Church service. CNA "E" said Resident #102 "gave me a weird look. She was distraught, upset, like she was being violated". CNA "E" said Resident #102 was in a wheelchair in the back of the dining room and Resident #101 was in a regular dining room chair, sitting so close to her their chairs were touching. CNA "E" said Resident #102 had a clear plastic tray over her lap and Resident #101's hand was between her legs, near her groin. I just scooped her up and she said she wanted to go to her room. CNA "E" said Resident #102 told her thank you several times. CNA "E" said she reported it to RN "F". CNA "E"s eyes began to tear up and said, "We were all upset that night because it shouldn't have happened." CNA "D" said, in an interview on [DATE] at 2:05 PM that she was assigned to take care of Resident #102 on [DATE] in the evening but she didn't take her to activities. CNA "D" said every Sunday at 4:00 PM Church services are held in the dining room for Residents to attend. CNA "D" said Resident #102 was very upset that night because Resident #101 had his hand under her tray table top and between her legs and was moving his hand. CNA "D" said Resident #102 was "distressed". Resident #102 told her she didn't know how to make him stop. She said she kept squeezing her legs but couldn't get to his hand because the table tray was in the way. CNA "D" began to cry and said, "This is hard because she was such a sweetheart". CNA "D" said, Resident #102 had a little Elmo doll and she kept holding onto Elmo near her breast so he couldn't touch her top. When she got back to her room, Resident #102 did not want to leave her room. CNA "D" said, "the whole night she said thank-you for getting me away from that man." The whole night she just wanted to stay in her room. I can't forget how upset she was. The whole night was a mess. Her daughter came in and was very upset and told her that her mother was still upset. CNA "D" said Resident #101 has all sorts of alarms now. An observation on [DATE] at 9:45 AM, revealed Resident #101 sitting in a lounge chair, across from the Nurse's station. There was an alarm attached to a string that was clipped to the back of his shirt. When he attempted to stand the clip detached from the chair and an alarm sounded that alerted staff that he was leaving the chair. A CNA escorted Resident #101 to his room for an interview. An interview was attempted but Resident #101 made jesters on his thigh with his hand and spoke non-sensical. Review of the Resident Council Meeting minutes dated [DATE] revealed that Residents had a concern about the Sunday Church Activity (prior to the incident of abuse on [DATE]), and requested that "there be someone there to oversee and assist Residents that are disruptive and start talking during the service. They need to be corrected or removed." The next meeting was on [DATE] which responded that they were trying to arrange for activity personnel to be present, during the Church activity. ( )