Every finding on record at Hillsboro House Nursing Home

Based on observation, interview and record review, the facility failed to store and prepare food in accordance with professional standards for food service safety.Findings include:Observation on 4/27/26 at approximately 12:00 p.m. with Staff A (Executive Director) revealed the following unsanitary conditions in the main kitchen:a build up of a white substance on the floor to the left side of the dishwasher;a wet hand towel on the floor under the left corner of the dishwasher;a wet washcloth on the floor under the right corner of the dishwasher;a large amount of debris on the floor under the rinse sink;a pink container filled three quarters full of a cloudy liquid sitting under the drain under the rinse sink;an area missing the laminate flooring directly in front of the rinse sink, measuring approximately 4.5 inches by 5 inches;a large amount of debris under the sanitizing sink;a large amount of dust between wall and the left side of oven;a large amount of debris under the oven;a build up of debris and grease on the hood vent;the center island was noted to have debris under it and the shelves under it had built up debris where the bread was being stored;the corner shelf had three cases of soda and a six pack of beer stored on the floor. Interview on 4/27/26 at approximately 12:00 p.m. with Staff A confirmed the above observations.Review on 4/27/26 of the FDA Food Code 2017 revealed, 4-101.19 Nonfood-Contact Surfaces. Nonfood-contact surfaces of equipment routinely exposed to splash or food debris are required to be constructed of nonabsorbent materials to facilitate cleaning. Equipment that is easily cleaned minimizes the presence of pathogenic organisms, moisture, and debris and deters the attraction of rodents and insects. Cleanability 6-201.11 Floors, Walls, and Ceilings. Except as specified under S 6-201.14 and except for antislip floor coverings or applications that may be used for safety reasons, floors, floor coverings, walls, wall coverings, and ceilings shall be designed, constructed, and installed so they are SMOOTH and EASILY CLEANABLE.

Based on observation, interview, and record review, it was determined that the facility failed follow currently accepted professional principles for labeling and/or storing drugs and biologicals in 1 of 1 medication rooms and 1 of 1 medication carts observed. (Resident identifiers are #7 and #2.)Findings include:Observation on 8/5/25 at approximately 8:15 a.m. of the facility medication cart revealed two unlabeled medication cups in the top draw. One medication cup had medications crushed in pudding and the other medication cup had whole pills in it. Interview on 8/5/25 at approximately 8:15 a.m. with Staff A (Licensed Practical Nurse) revealed the medication cup with whole pills in it was Resident #7's morning medications and the medication cup with crushed pills in it was Resident #2's morning medications. Further interview confirmed that neither medication cup was labeled with a resident identifier or what it contained.Observation on 8/5/25 at approximately 8:30 a.m. of the facility medication room refrigerator revealed an opened and undated vial of Tuberculin solution. Interview on 8/5/25 at approximately 8:30 a.m. with Staff A confirmed the above findings.Review on 8/6/25 of the facility policy titled, Labeling and Dating of Multi-Dose Vials in Long-Term Care, Undated revealed: . 1. Labeling Upon First Use, Upon first access (puncture) of a multi-dose vial, staff must immediately label the vial with: Date opened, Discard date . Review on 8/6/25 of the manufacturer's' instructions for Tuberculin Purified Protein Derivative, Tubersol, undated, revealed . A vial of Tubersol which has been entered and in use for 30 days should be discarded . Review on 8/6/25 of the facility policy titled, Preparation of Medications in Long-Term Care, Revision Date 2008 revealed: . 4. One Resident at a Time Rule, Only prepare medications for one resident at a time to prevent cross-contamination and medication errors.

Based on observation, interview, and record review, it was determined that the facility failed to implement policies and procedures for infection control during medication administration. (Resident identifiers are #12, #20, #25 and #4.)Findings include:Observation on 8/5/25 at from approximately 8:45 a.m. until 9:05 a.m. with Staff A (Licensed Practical Nurse) during medication administration revealed the following: At approximately 8:45 a.m., Staff A prepared and administered medications to Resident #12. Staff A did not perform hand hygiene before or after Resident #12's medication administration. At approximately 8:50 a.m., Staff A prepared and administered medications to Resident #20. Staff A did not perform hand hygiene before or after Resident #20's medication administration. Immediately following, Staff A assisted Resident #25 with positioning in his/her wheelchair. Staff A did not perform hand hygiene before or after assisting Resident #25 with positioning in his/her wheelchair. At approximately 8:55 a.m., Staff A took Resident #4's breakfast tray from the kitchen to his/her room and assisted Resident #4 with their meal set up and bed positioning. Staff A did not perform hand hygiene before or after setting up Resident #4's breakfast tray and bed positioning. At approximately 8:55 a.m., Staff A prepared and administered medications to Resident #25. Staff A did not perform hand hygiene before or after Resident #25's medication administration. Interview on 8/5/25 at approximately 9:10 a.m. with Staff A confirmed the above findings. Review on 8/6/25 of the facility policy titled, Infection Control During Medication Administration, Revision Date 2020, revealed . 1. A. When to Perform Hand Hygiene: Before preparing or administering any medication . Before accessing a medication cart or entering a resident's room, After direct contact with the resident, their immediate environment, . Between residents .

Based on interview and record review, it was determined that the facility failed to develop and implement a comprehensive infection control guideline for facility water management that had the potential to effect the facility census of 26 residents who resided at the facility. Findings include: Review on 9/5/24 of the Facility Water Management Program with a revised date of 1/2024 revealed strategies for water management to be annual testing for legionella and weekly flushing of vacant rooms. Further review revealed no description of water flow, schematic, or map of plumbing or identified areas of concern available. Interview on 9/5/24 at approximately 11:00 a.m. with Staff A (Infection Preventionist) revealed he/she was unable to answer questions regarding water management or legionella testing. Interview on 9/5/24 at approximately 1:30 p.m. with Staff G (Administrator Assistant) revealed no logs for flushes or legionella test results available.

Based on observation, record review, and interview, it was determined that the facility failed to determine clinical appropriateness of self-administration of medications for 2 of 4 residents reviewed for choices in a final sample of 13 residents (Resident Identifiers are #19 and #22). Findings include: Resident #19 Observation on 9/5/24 at approximately 8:30 a.m. in Resident #19's room revealed 5 pills in a small coaster on Resident #19's tray table. Interview on 9/5/24 at approximately 8:30 a.m. with Resident #19 revealed that the pills were his/her morning medications and that the nurse leaves the pills for him/her to take everyday. Resident #19 stated that this is done at his/her request to take the medications at his/her own pace. Review on 9/5/24 of Resident #19's medical record revealed that there was no self-administer of medication assessment or physician's order to self-administer medications. Resident #22 Observation on 9/4/24 at approximately 8:45 a.m. with Staff B (Registered Nurse (RN)) during medication administration revealed that Staff B left a cup of 7 pills that were: 1 Aspirin 81 milligrams (mg) EC (enteracoted), 2 garlic (dietary supplement) 1000 mg, 1 Lutein (eye vitamin) capsule 20 mg, 1 multivitamin with minerals, 1 vitamin D 1000 units, 1 jentadueto (anti-diabetic medication) 2.5mg/500mg, and 1 osteobilflex (joint supplement). Interview on 9/4/24 at approximately 8:45 a.m. with Staff B confirmed the above findings. Staff B stated that Resident #22 was cognitive enough to take medications by themselves. Obsrevation on 9/5/24 at 8:30 a.m. in Resident #22's room revealed a medicine cup of 3 pills. Interview on 9/5/23 at approximately 8:30 a.m with Resident #22 confirmed the above findings. Resident #22 stated that the pills were his/her medications and that the nurse left it for him/her to take on their own. Review on 9/5/24 of Resident #22's medical record revealed that there were no physician's order to self-administer medications and there was no self-administration assessment. Interview on 9/5/24 at 8:50 a.m. with Staff B confirmed the above findings. Interview on 9/5/24 at approximately 1:45 p.m. with Staff A (Director of Nursing) confirmed that Resident #19 and #22 were not assessed for self-administration of medications. Staff A was unable to provide a policy for self-administration of medications. 50163

Based on interview, it was determined that the facility failed to ensure the food service director met minimum qualifications. Findings include: Interview on 9/5/24 at approximately 11:30 a.m. with Staff C (Administrator) revealed that the dietician is part-time and that Staff C was the food service director. Staff C confirmed that he/she had been the food service director for years and had not completed a course of study in food safety and management.

Based on observation, interview, and record review, it was determined that the facility failed to ensure that dishes were sanitized according to manufacturer's instruction for food services safety in the main kitchen. Findings include: Review on 9/4/24 of the facility's 2024 dishwasher temperature logs from August to September revealed that the facility documented one temperature per day. The temperatures ranged between 160 to 176 degrees Fahrenheit. The log did not indicate what an acceptable range would be or if the temperature was taken during wash or rinse cycle. Interview on 9/4/24 at approximately 10:45 a.m. with Staff E (Lead Cook) revealed that the above log temperatures were for wash cycle only. Staff E did not know the acceptable temperatures for wash and rinse cycle. Observation on 9/5/24 at approximately 12:00 p.m. with Staff F (Dietary Aide) of a dishwasher cycle revealed a wash temperature of 150 degrees Fahrenheit and rinse temperature of 174 degrees Fahrenheit. Review on 9/5/24 of manufacturer's instruction label for [NAME] LXe revealed minimum ranges for temperatures were 150 degrees Fahrenheit for wash and 180 degrees Fahrenheit for rinse.

Based on observation, interview, and record review, it was determined that the facility failed to ensure that a resident was assessed and an informed consent was obtained for the use of full-length bed rails for 1 of 1 resident reviewed for restraints in a final sample of 13 residents (Resident Identifier #18). Findings include: Observation on 9/4/24 at approximately 10:00 a.m., 12:00 p.m., 1:00 p.m., and 3:00 p.m. revealed that Resident #18 was in bed with full-length bed rails up on the right and left side of the bed. Review on 9/4/24 of Resident #18's medical record revealed that there was no bed rail assessment and informed consent for the full-length bed rails. Review on 9/4/24 of the facility's policy titled, Bed Rail Consent Form, with no date, revealed that the facility will periodically and annually review and re-evaluate the resident's use of the bed rails. Interview on 9/4/24 at approximately 3:00 p.m. with Staff A (Director of Nursing) confirmed the above findings.

Based on observation, record review, and interview, it was determined that the facility failed to ensure that medications were labeled and stored in accordance with currently accepted professional principles for 1 of 1 medication carts observed and 1 of 4 residents reviewed for choices (Resident Identifier #19). Findings include: Observation on 9/4/24 at approximately 8:20 a.m with Staff B (Registered Nurse) of the facility's medication cart revealed an open Lantus (insulin) vial with no resident identifier with an open date of 8/5/24 and discard date of 9/2/24. Review on 9/4/24 of Lantus manufacturer instructions revealed .Store in-use (opened) LANTUS vials .at room temperature .for up to 28 days . Resident #19 Observation on 9/4/24 at approximately 8:45 a.m. revealed a Refresh eye drops (lubricant eye drops) at Resident #19's bedside table. Interview on 9/4/24 at approximately 8:45 a.m. with Resident #19 confirmed the above observation. Resident #19 stated that the eye drops were stored at bedside. Review on 9/5/24 of the facility policy titled, Medication Storage Procedure, with no date, revealed .Medications will be stored in a locked drawer in the patient's room . Interview on 9/05/24 at 1:30 p.m. with Staff A (Director Of Nursing) confirmed above facility policy.

Based on interview and record review, it was determined that the facility failed to ensure that the facility assessment determined the amount of time required to fulfill the role of the designated Infection Preventionist (IP). Findings include: Review on 9/5/24 of the facility's facility assessment with a review date of 6/2024 revealed no determination for the amount of time required to fulfill the role of the IP. Interview on 9/5/24 at approximately 1:00 p.m. with Staff A (Director of Nursing) revealed that he/she was the designated IP at the facility. Staff A stated that he/she spends 1 hour a week dedicated to the facility's Infection Prevention and Control Program (IPCP).

Based on interview and record review, it was determined that the facility failed to ensure a resident was offered or provided education on the risks and benefits of the Pneumococcal vaccination for 1 of 5 residents reviewed for Pneumococcal vaccination (Resident Identifier is #11). Findings include: Review on 8/15/23 of Resident #11's medical record revealed they had admitted to the facility on [DATE]. Further review of Resident #11's medical record revealed that the Pneumococcal vaccination was documented as refused on the immunization and screening record. There was no evidence in Resident #11 medical record that they had received education about the Pneumococcal vaccination. Interview on 8/16/23 at approximately 2:43 p.m. with Staff A (Director of Nursing) confirmed the above finding.

Based on interview and record review, it was determined that the facility failed to ensure that residents were provided with a private space for a resident group to meet on a regular basis for a facility census of 25 residents (Resident identifiers are #17, #20, #21, and #25). Findings include: Review on 8/16/23 of the 3 previous months of Resident Council meeting minutes revealed the following: May 2023 - last month's follow up: planted herbs and flower seeds for the garden. New: Everyone is looking forward to watching the garden grow. Excited for live music later this month. June 2023 - last month's follow up: None. New: Everyone is looking forward to eating fresh vegetables from our garden. Looking forward to the town parade next month. July 2023 - last month follow up: parade got canceled due to rain. New: All are happy and enjoying the sun porch in the nice weather. Would like to have a monthly auction again. Interview on 8/16/23 at approximately 9:50 a.m. with Resident #17, Resident #20, Resident #21, and Resident #25 during a Resident Group Meeting revealed that they were not aware they were part of the Resident Council group and they were not aware the coffee hour was a Resident Council group meeting. The Resident Council group also were not aware that they could elect a President for the Resident Council. Interview on 8/17/23 at approximately 9:17 a.m. with Staff A (Director of Nursing) revealed that there is no set day for the Resident Council meeting. It is done at the morning coffee hour on days when people who want to come can attend. Review on 8/17/23 of facility policy titled Resident Council Policy revised on 9/22, revealed .The facility must take reasonable steps, with the approval of the resident council, to make residents and family members aware of upcoming meetings in a timely manner .The facility must provide a designated staff person who is approved by the resident council and the facility to provide assistance and respond to written requests from the resident council .

Based on interview and record review, it was determined that the facility failed to ensure the activities program was directed by a qualified professional for a facility census of 25 residents. Findings include: Review on 8/15/23 of the facility's key personal listing revealed that Staff A (Director of Nursing) was also listed as the Activities Director. Interview on 8/15/23 at approximately 1:16 p.m. with Staff C (Human Resources) could not provide proof of the required qualifications for the Activities Director position for Staff A. Interview on 8/16/23 at approximately 11:32 a.m. with Staff B (Administrator) revealed that Staff A does not meet the required qualifications to be the Activities Director. Review on 8/17/23 of the facility's Activities Director Responsibilities revealed . Supervising, conducting or designating responsibility for a needs assessments to ascertain physical, cognitive and emotional abilities. Determine individual interests and expectations regarding leisure time . Developing an activities program that is both sufficiently diverse and sensitive to our occupants' requirements .

Based on interview and record review, it determined that the facility failed to have a Director of Nursing serving on a full time basis for a facility census of 25 residents. Findings include: Review on 8/15/23 of the facility's key personal listing revealed that Staff A (Director of Nursing) was also listed as the Infection Preventionist, Activities Director, Social Services, and Minimum Data Set Nurse. Interview on 8/16/23 at approximately 10:41 a.m. with Staff A confirmed the above findings. Staff A could not identify how many hours per week were dedicated to each of the above-mentioned roles. Review on 8/18/23 of the facility's Payroll Based Journal (PBJ) Individual Daily Staffing [NAME] report for the time period of 6/16/23 - 6/30/23, revealed that there were no hours submitted for the following job codes: Director of Nursing, Director of Social Services, Registered Nurse with Administrative Duties or Therapeutic Recreational Specialist.

Based on interview and record review, it was determined that the facility failed to conduct and document a facility-wide assessment to determine what resources are necessary to care for its residents competently during day-to-day operations. The facility also failed to review and update the assessment by the required individuals, as necessary, and at least annually. Finding includes: Review on 8/17/23 of the facility assessment, dated May 2023, revealed that the facility's assessment did not indicate the care required by the resident population considering the types of diseases, conditions, physical and cognitive disabilities, overall acuity, and other pertinent facts that are present within that population. Further review revealed that the medical director was not involved in completing the assessment. Interview on 8/17/23 at 11:14 a.m. with Staff B (Administrator) confirmed the facility's assessment was incomplete.

Based on interview and record review, it was determined that the facility failed to submit to the Centers for Medicare & Medicaid Services (CMS) accurate direct care staffing information for Registered Nurse hours for 10 of 92 days reviewed for Fiscal Quarter 2 (1/1/23 - 3/31/23) and direct care staffing information for the period of 6/16/23 - 6/30/23. Findings include: Fiscal Quarter 2 (1/1/23 - 3/31/23) Review on 8/15/23 of the Payroll Based Journal (PBJ) Staffing Data [NAME] report for Fiscal Year Quarter 2, 2023 revealed that the facility failed to have Licensed Nursing coverage 24 hours a day on the following dates 1/17/23, 1/31/23, 2/7/23, 2/8/23, 2/9/23, 2/14/23, 2/21/23, 2/22/23, 2/28/23 and 3/7/23. Review on 8/16/23 of the facility's monthly staffing schedule for January 2023 through March 2023 revealed that there was licensed nursing coverage on the above dates. Interview on 8/17/23 at 9:42 a.m. with Staff C (Business Office Manager) stated that the administrative assistant inputs the hours manually for the facility every quarter for the PBJ submission. Staff B stated that they do not verify the actual hours worked with the hours submitted for PBJ. Review on 8/17/23 of the facility's PBJ Staffing [NAME] Report, Individual Daily Staffing Report for the time period of June 16, 2023 - June 30, 2023 revealed hours for the following job codes: Certified Nurse Aide, Licensed Practical/Vocational Nurse, Registered Nurse and Licensed Practical Nurse with administrative duties. Review also revealed that there were no hours submitted for the following job codes: Administrator, Director of Nursing, Medical Director, Physician Services, Therapeutic Services, Social Services, Mental Health Services, Pharmacy Services, and Dietary Services Interview on 8/17/23 at 9:45 a.m. with Staff B revealed that they only submit Licensed Nursing staff hours (Registered Nurse, Licensed Practical Nurse, and Licensed Nursing Assistant) for PBJ. Staff B stated that they don't submit any hours for Direct Care Staff, Physical Therapist, Occupational Therapist, Speech Therapist, Medical Director, Podiatrist, Nurse Practitioner, Activity Staff, Dietary Staff, Dietician, Director of Nursing, Director of Social Services, and Registered Nurse with administrative duties. Interview on 8/17/23 at 10:21 a.m. with Staff C (Administrator) confirmed the above findings.

Based on observation and interview, it was determined that the facility failed to ensure the posted daily nurse staffing data included the current date and actual hours worked per shift in 2 out of 2 days of nurse staffing data observed, and failed to retain the daily nurse staffing data for a minimum of 18 months. Findings include: Observation on 9/7/22 at approximately 8:30 a.m. revealed that the daily nurse staffing data had no current date and actual hours worked per shift. Observation on 9/8/22 at approximately 8:30 a.m. revealed that the daily nurse staffing data had no current date and actual hours worked per shift. Interview on 9/8/22 at 10:45 a.m. with Staff B (Executive Director) confirmed the above findings. Interview on 9/8/22 at 1:00 p.m. with Staff A (Director of Nursing) revealed that the facility was unable to produce any daily posting of nursing staff data. Staff A stated that the staffing level did not change and that the posting remained posted daily without change.

Based on interview, record and policy review, it was determined that the facility failed to investigate injuries of unknown source for 3 out of 5 residents reviewed for abuse in a sample survey of 24 residents reviewed. (Resident identifiers are #8, #23, and #24.) Findings include: Resident #8 Review on 8/16/21 of Resident #8's medical record revealed that Resident #8 has a Brief Interview for Mental Status (BIMS) was a 8. Review on 8/16/21 of Resident #8's skin condition reports revealed the following: 2/29/21 Resident #8 had a skin tear with a flap and bleeding a small amount to right forearm. The skin tear measured 1.5 centimeters (cm) length, 1.0 cm width, and depth 0.1 cm. 6/11/21 Resident #8 had a bruise to his/her left inner thigh. The bruise measured 2 cm in length, 2.6 cm. in width and was described as dark purple bruise on the skin condition report. 7/23/21 Resident #8 had a bruise to his/her left forearm. The bruise measured 14 cm in length, 6.8 cm in width and was described as dark purple bruise on the skin condition report. Interview on 8/18/21 at approximately 8:15 a.m. with Staff B (Director of Nurses) revealed that he/she did not know the orgins of the above tear and bruises and that there was no investigations into the how the injuries above occurred. Staff B also revealed that these injuries were not reported to the State Survey Agency. Resident #23 Review on 8/16/21 of Resident #23's medical record revealed that Resident #23 had a BIMS of 3. Review on 8/16/21 of Resident #23's skin condition reports revealed the following: 5/14/21 Resident #23 had a skin tear to right upper arm. The skin tear measured 1.5 cm in length, 0.9 cm in width, and superficial in depth. 6/1/21 Resident #23 had a skin tear with flap to his/her left lower shin. The skin tear measured 1.7 cm. in length, 1.5 cm in width and depth was measured as UTD (unable to determine). 6/4/21 Resident #23 had a bruise to right hip. The bruise measured 10 cm in length and 2.5 cm. in width. The bruise was described as deep purple bruise. Interview on 8/18/21 at approximately 9:30 a.m. with Staff B revealed that that he/she did not know the orgins of the above injuries and that there was no investigations into the how the injuries above occurred. Staff B also confirmed that these injuries were not reported to State Survey Agency. Resident #24 Review on 8/16/21 of Resident #24's medical record revealed that Resident had a BIMS of 2. Review on 8/16/21 of Resident #24's skin condition reports revealed the following: 5/31/21 Resident #24 had a skin tear (shaped half moon) to his/her left shin. The skin tear measured 6 cm. in length, 0.1 cm. in width and 0.1 cm. in depth. 6/27/21 Resident #24 had a skin tear on his/her right elbow, half moon skin tear on right elbow with scant bloody drainage. The skin tear measured at 2.7 cm. half moon. Interview on 8/17/21 at approximately 12:00 p.m. with Staff B revealed that he/she did not know the orgins of the above injuries and that there was no investigations into the how the injuries above occurred. Staff B also confirmed that these injuries were not reported to State Survey Agency. Review on 8/18/21 of the facility policy titled, F225: Prevention of Resident Abuse, Revision date of 1/10/08 revealed: It is the policy of Hillsboro House to prohibit mistreatment, neglect, and abuse of residents and misappropriation of resident property. In furtherance of that policy, the facility: . IV. Identifies possible events of resident abuse. It is the responsibility of the administrator to investigate events, such as bruising of residents, occurrences, patterns and trends that may constitute abuse. . 1. Injuries of an unknown source. Injuries should be classified when both of the following conditions are met: A. The source of the injury was not observed by any person or the source of the injury could not be explained by the resident, and B. The injury is suspicious because of the extent of the injury or the location of the injury (e.g. the injury is located in an area not generally vulnerable to trauma) or the number of injuries observed at one particular point in time or the incident of injuries over time. .

Based on interview, record and policy review, it was determined that the facility failed to investigate injuries of unknown source for 3 out of 5 residents reviewed for abuse in a sample survey of 24 residents reviewed. (Resident identifiers are #8, #23, and #24.) Findings include: Resident #8 Review on 8/16/21 of Resident #8's medical record revealed that Resident #8 has a Brief Interview for Mental Status (BIMS) was a 8. Review on 8/16/21 of Resident #8's skin condition reports revealed the following: On 2/29/21 Resident #8 had a skin tear with a flap and bleeding a small amount to right forearm. On 6/11/21,Resident #8 had a bruise to his/her left inner thigh. On 7/23/21, Resident #8 had a bruise to his/her left forearm. Interview on 8/18/21 at approximately 8:15 a.m. with Staff B (Director of Nurses) revealed that he/she did not know the orgins of the above injuries and there was no investigations into the how the injuries above occurred. Resident #23 Review on 8/16/21 of Resident #23's medical record revealed that Resident #23 had a BIMS of 3. Review on 8/16/21 of Resident #23's skin condition reports revealed the following: On 5/14/21, Resident #23 had a skin tear to right upper arm. On 6/1/21, Resident #23 had a skin tear with flap to his/her left lower shin. On 6/4/21, Resident #23 had a bruise to right hip. Interview on 8/18/21 at approximately 9:30 a.m. with Staff B revealed that he/she did not know the orgins of the above injuries and there was no investigations into the how the injuries above occurred. Resident #24 Review on 8/16/21 of Resident #24's medical record revealed that Resident had a BIMS of 2. Review on 8/16/21 of Resident #24's skin condition reports revealed the following: On 5/31/21, Resident #24 had a skin tear (shaped half moon) to his/her left shin. On 6/27/21, Resident #24 had a skin tear on his/her right elbow, half moon skin tear on right elbow with scant bloody drainage. Interview on 8/17/21 at approximately 12:00 p.m. with Staff B revealed that he/she did not know the orgins of the above injuries and there was no investigations into the how the injuries above occurred. Review on 8/18/21 of the facility policy titled, F225: Prevention of Resident Abuse, Revision date of 1/10/08 revealed: It is the policy of Hillsboro House to prohibit mistreatment, neglect, and abuse of residents and misappropriation of resident property. In furtherance of that policy, the facility: . IV. Identifies possible events of resident abuse. It is the responsibility of the administrator to investigate events, such as bruising of residents, occurrences, patterns and trends that may constitute abuse. . 1. Injuries of an unknown source. Injuries should be classified when both of the following conditions are met: A. The source of the injury was not observed by any person or the source of the injury could not be explained by the resident, and B. The injury is suspicious because of the extent of the injury or the location of the injury (e.g. the injury is located in an area not generally vulnerable to trauma) or the number of injuries observed at one particular point in time or the incident of injuries over time. . Cross reference F609: Reporting of Alleged Violations

Based on record review and interview, it was determined that the facility failed to employ, at least on a part time basis, an Infection Preventionist that completed specialized training in infection prevention and control Findings include: Review on 8/18/21 at approximately 8:30 a.m. of the CDC (Centers for Disease Control and Prevention) Infection Preventionist training certificates for Staff B (Director of Nursing) revealed that he/she had completed 7 out of 23 modules. Staff B was no able to provide any other specialized training in infection prevention and control. Interview on 8/18/21 at approximately 8:30 a.m. with Staff B (Director of Nursing) confirmed they had started the CDC Infection Preventionist training in January 2020, but was unable to provide any documentation to show completion of the training.

Based on observation, interview, facility policy and procedure review and record review it was determined that the facility failed to provide necessary treatment to prevent development/progression of a non-pressure ulcer lesion to an unstagable pressure ulcer and failed to assess a pressure ulcer for 1 resident out of a final survey sample of 12 residents. (Resident identifier is #26.) Findings include: Observation on 2/13/19 at approximately 10:30 a.m. in Resident #26's room revealed that Resident #26 was moaning out loud. Interview on 2/13/19 at approximately 10:30 a.m. with Resident #26 revealed that Resident #26 was in pain stating, My butt is burning. Observation on 2/13/19 at approximately 11:00 a.m. of Resident #26's coccyx with Staff D LNA (Licensed Nursing Assistant) revealed that Resident #26 had a duoderm (dressing) applied to area on coccyx. Duoderm had an application date written on it of 2/11/19. Interview on 2/13/19 at approximately 11:15 a.m. with Staff C, RN (Registered Nurse) revealed that the duoderm dressing was due to be changed on 2/15/19. Review on 2/15/19 of Resident #26's (MONTH) treatment record revealed that there was no physicians order for a duoderm to Resident #26's coccyx. February's treatment record revealed that from 2/1/19 through 2/13/19 there had not been any treatment applied to the coccyx area. Interview on 2/15/19 at approximately 9:00 a.m. with Staff A (Director of Nurses) revealed that Resident #26 has had a chronic split to coccyx since admission 2/12/15 and that the split was not pressure. Staff A also revealed that a physician had not seen the area on Resident #26's coccyx since 11/17/15 and that there had been no facility monitoring of the slit area to coccyx since 8/14/18. Observation on 2/15/19 at approximately 10:00 a.m. of Resident #26's coccyx revealed an unstageable pressure ulcer measuring 3.0 cm (centimeter) x 0.5 cm and a depth of 0.5 cm with slough surrounding a black eschar center approximately 0.2 cm x 0.2 cm. Interview on 2/15/19 at approximately 10:00 a.m. with Staff B revealed the following statement, This is the worst I have ever seen it. I think that the duoderm caused more harm than good, it seems to have removed a layer of skin when it was removed. Interview on 2/15/19 at approximately 10:30 a.m. with Staff A revealed, We should have been coding this as unstageable. I think this would be a Stage 4 pressure ulcer. Staff A confirmed the area had black eschar in the center of the wound. When asked if the area to Resident #26's coccyx was being treated, Staff A stated, (pronoun omitted) was care and comfort. Review on 2/15/19 of Resident #26's skin condition tracking report sheets revealed that the last time it was measured and assessed was on 8/14/18. On 8/14/18 the wound measured at 1.0 cm x 0.4 cm (no depth measured.) Description of wound was no change, open slit. The facility had no documentation of when the area on Resident #26's coccyx went from a baseline slit to a pressure ulcer. Review on 2/15/19 of the facility policy and procedure for pressure ulcers, (not titled and not dated) revealed the following: . Pressure ulcer injuries are described as: .Unstageable: Full-thickness loss. The base of the ulcer is covered by slough which can be yellow, tan, gray, green or brown in color and/or eschar which can be tan, brown or black in color in the wound bed Policy: Hillsboro House shall have a system in place that assures assessments are timely and appropriate; interventions are implemented, monitored and revised as appropriate; and changes in condition are recognized, evaluated, reported to the resident's attending practitioner and other healthcare professionals (i.e , wound nurse) as appropriate. Procedure: . Nursing Staff Shall: Observe for infection . Follow practitioner's orders for treatment (if any) of the pressure ulcer (injury), including cleansing and dressing. Monitor the healing process Observe and change dressings as ordered and needed. Monitoring of Pressure Ulcer (Injury) Shall Include: . The pressure ulcer (injury) wound shall be assessed and documented (this is usually performed by a physician, advanced practice nurse, physician assistant, certified wound care specialist.) The assessment will mandate what further treatment, in the judgement of the physician, is necessary and appropriate Documentation: When a physician has ordered treatment for [REDACTED]. Documentation shall include a combination of . Size of the pressure ulcer (length and width) The depth: base of wound to skin in centimeters Exudate: type, amount, color and odor Stage 1-4, Unstageable, Deep Tissue Injury . Tissue type: necrotic, granulation, slough, epithelization Condition of skin around the pressure ulcer (injury) Note any change in the condition or size of the ulcer (injury). Changes shall be documented in the medical record Review on 2/15/19 of the facility policy and procedure for physician orders, (not titled and not dated) revealed the following: Policy: Orders for residential treatment and medications, including the administration of medications, shall be carried out only when given by a qualified physician, surgeon, dentist, podiatrist or other person duly licensed or authorized to prescribe by the state of New Hampshire and who has been approved as a member of the medical staff of this facility. All orders of medication and treatment shall be written into the medical record of the resident and signed by the ordering licensed independent practitioner.