Every finding on record at North Bank Center for Rehabilitation and Healing

Based on observation, interview, and record review, the facility failed to ensure that respiratory care services, including oxygen therapy, were provided in accordance with physician orders, professional standards of practice, and the residents' assessed needs for 5 of 9 sampled residents (Residents #4, #5, #7, #8, and #9). The facility did not ensure oxygen was administered at the ordered flow rate, tubing and humidifiers were dated and maintained, orders were accurately entered and followed, care plans reflected actual respiratory needs, or that equipment was appropriately functioning. This failure had the potential to place residents at risk for inadequate oxygenation, respiratory decline, or other avoidable complications. The findings include: 1. On 8/5/2026 at 10:29 a.m., observation revealed Resident #4's oxygen concentrator positioned on the left side of the bed facing the wall. The flow rate was set at 4 L/min via nasal cannula. The oxygen tubing was not dated, and the humidifier bottle was empty. A portable oxygen tank located behind the wheelchair was set at 0.25 L/min, with the gauge in the red zone indicating an empty tank; the nasal cannula tubing was on the floor and undated. (Photographic evidence obtained.) When informed of her concentrator setting, the resident stated that 4 L/min was too much due to her COPD. Additional observations on 8/5/2026 at 1:24 p.m. and 4:20 p.m. confirmed the concentrator remained set at 4 L/min.Record review revealed admission on [DATE] with diagnoses including cerebral infarction, diabetes mellitus II, neuromuscular dysfunctional bladder, adult failure to thrive, and muscle weakness. Physician orders included continuous oxygen at 2 L/min via nasal cannula every shift for COPD; tubing/cannula change weekly and PRN; and positioning interventions.The 5 day MDS dated [DATE] recorded a BIMS (Brief Interview for Mental Status) score of 15/15, indicating intact cognition, and documented continuous oxygen therapy.Care plan review identified a focus on oxygen therapy related to ineffective gas exchange/COPD, with goals to prevent signs of poor oxygen absorption. Tasks included administering oxygen per MD order, medication administration, and monitoring effectiveness.2. On 8/5/2026 at 4:15 p.m., observation revealed Resident #5 awake in bed with the nasal cannula resting on her chin. The oxygen concentrator was set at 3 L/min. The humidifier bottle was dated 8/1/26; oxygen tubing was not dated. (Photographic evidence obtained.)Record review showed admission on [DATE] with recent readmission on [DATE]. Diagnoses included encephalopathy, intracerebral hemorrhage, COPD, acute respiratory failure with hypoxia, hemiplegia, vascular dementia, epilepsy, and dependence on supplemental oxygen.Physician orders included oxygen at 2 L/min PRN for oxygen saturation <90%, and monitoring oxygen saturation every shift.Quarterly MDS dated [DATE] documented a BIMS score of 3/15, indicating impaired cognition, and showed no oxygen therapy listed.3. On 8/5/2026 at 2:41 p.m., Resident #7 was observed sitting up in bed with no oxygen therapy in use. When interviewed, the resident stated he did not need oxygen therapy and had not used it since admission, despite being aware of an order. He denied respiratory concerns.Record review showed admission on [DATE] with diagnoses including polyneuropathy, COPD, PVD, emphysema, AAA without rupture, and nicotine dependence.Physician orders included:- Oxygen at 2 L/min PRN for SOB;- Tubing/cannula changes weekly and PRN;- Continuous oxygen at 2 L/min via nasal cannula every shift for COPD/SOB.The 5 day MDS dated [DATE] documented a BIMS score of 13, indicating intact cognition, and listed continuous oxygen therapy.Review of the care plan revealed the resident was not care planned for oxygen therapy.4. On 8/5/2026 at 3:38 p.m., Resident #8's oxygen concentrator was observed next to the resident's bed facing the room entrance. The nasal cannula was unbagged, unlabeled, and coiled on top of the concentrator. The resident confirmed the concentrator belonged to her and stated she used oxygen at night and PRN during the day, but was unsure of her correct setting.Record review showed admission on [DATE] with multiple cardiac, respiratory, and neurologic diagnoses.Physician orders revealed no oxygen therapy orders for Resident #8.The 5 day MDS dated [DATE] indicated a BIMS score of 15, cognitively intact, and documented no special treatments, including no oxygen therapy.Care plan review identified a focus on COPD related to smoking, with tasks including elevating the head of the bed, monitoring for respiratory insufficiency, and administering oxygen per MD orders.5. On 8/5/2026 at 3:33 p.m., Resident #9 was observed receiving oxygen at 2.5 L/min via nasal cannula with no signs of distress. At 5:40 p.m., the oxygen concentrator remained set at 2.5 L/min.Record review documented admission on [DATE] with diagnoses including COPD, emphysema, rheumatoid arthritis, hypotension, chronic respiratory failure, dementia with behavioral disturbance, and vertigo.Quarterly MDS dated [DATE] recorded a BIMS score of 12, intact cognition, and listed oxygen therapy.Physician orders included tubing/cannula changes weekly, and oxygen at 3 L/min continuous for COPD, along with daily vitals and nasal cannula padding.On 8/5/2026 at 5:44 p.m., an interview and room tour was conducted with Employee G (LPN). She stated nurses check oxygen settings for accuracy and aides perform vital signs. In Resident #7's room, she stated he previously received continuous oxygen and was supposed to be changed to PRN but the order had not been received. In Resident #9's room, oxygen was set at 3 L/min; she stated the resident preferred 2.5 L/min.On 8/5/2026 at 5:57 p.m., a tour was conducted with Employee D (LPN Unit Manager). Resident #8's concentrator had uncovered, undated tubing; the Unit Manager confirmed tubing was not dated and stated new tubing was needed. She was unable to locate an oxygen order for Resident #8 in the EMAR. She confirmed Resident #4's oxygen order was for 2 L/min. In Resident #4's room, the concentrator was flashing red; the manager confirmed the setting was 4 L/min and stated it should have been 2 L/min.The facility provided a list of residents receiving continuous oxygen therapy: Residents #4, #7, and #9. Residents #5 and #8 were not included.Review of the facility's Nursing - Oxygen Administration policy revealed procedures requiring initiating oxygen at the prescribed rate, ensuring proper flow, and dating tubing and humidifier bottles. Documentation requirements included date/time, concentration, flow rate, route, and oxygen saturation.Review of the Resident Assessment Instrument Comprehensive Care Plan (effective [DATE]) showed requirements for quarterly care plan review, updates based on condition changes, and revisions following new assessments.

Based on observations, staff interviews, and a review of facility documentation, the facility failed to 1) Follow proper environmental cleaning and disinfection protocols for a resident shared bathroom (room [ROOM NUMBER]) for three consecutive days, 2) Properly dispose of used razors left accessible in two resident rooms (rooms [ROOM NUMBERS]), 3) Properly clean and disinfect identified feces in a resident bathroom shower (room [ROOM NUMBER]), 4) Use appropriate infection control practices by staff failing to don appropriate personal protective equipment (PPE) and practice proper hand hygiene when administering medication through a gastrostomy tube (g-tube - feeding tube) for one of seven residents with g-tubes receiving medication. The facility did not meet the standard for providing and maintaining a safe, sanitary environment to prevent the development and transmission of communicable diseases with the potential for increased infection risks for residents and staff. The findings include:1. On 9/22/2025 at 12:18 PM, a tour was conducted on the second-floor unit, where resident room [ROOM NUMBER], housing two residents with a shared bathroom, was observed with the shower curtain rod and clear plastic shower curtain still attached and brown-colored debris lying underneath the toilet and against the wall with additional brown debris on the lower toilet bowl and on the vertical pipe connected to the flushing assembly behind the toilet. Brown-colored debris was smeared along the shower wall and door frame. (Photographic evidence obtained) On 9/24/2025 at 11:48 PM, a second observation of room [ROOM NUMBER]'s bathroom revealed no changes from the previous observation. The shower curtain rod with the shower curtain and brown debris was untouched and the brown-colored matter/debris was still located in the same areas. (Photographic evidence obtained).On 9/24/2025 at 1:20 PM, the Assigned Housekeeper A confirmed that she received training on proper resident room cleaning, to include appropriate disinfection and sanitizing protocols to decrease the spread of germs. She was accompanied, along with the Housekeeping Director, to room [ROOM NUMBER] where they observed the shower rod, with the attached curtain lying on the floor. The Housekeeping Director immediately reached for the shower rod and tried to hang the rod back in the shower, before being informed of the brown debris located on the shower curtain, and the shower walls. The Housekeeping Director reported all housekeeping staff had received the required training on proper cleaning and disinfecting of biohazard materials and confirmed this room was missed for several days. On 09/25/2025 at 12:34 PM, an interview was conducted with the Infection Preventionist, Assistant Director of Nursing/Registered Nurse (RN), who reported she provided all the new hire training with assistance from the staff educator for infection control activities within the facility including proper use of PPE, contact precaution signs, proper hand hygiene, bloodborne pathogens, and handling biohazards. She further reported ongoing education was offered several times per year, as needed and during skills fairs. Environment expectations were explained as: If any brown substance of any kind is found in the bathroom, we assume that's biological fluids, so we call housekeeping or grab a glove and disinfectant wipe and clean it, but we don't walk away or wait and leave something like that. She was shown the pictures from room [ROOM NUMBER] and was asked if that should have been left in that condition for three days. She replied, No. That fell through so many staff and should've been caught immediately. She stated her expectation for all staff was to support the infection control program by preventing the spread of infection.On 09/25/2025 at 1:10 AM, an interview was conducted with the Risk Manager, Staff Educator, RN, who reported she oversaw the Risk Management Program to include accidents, incidents and quality assurance including Performance Improvement Plans (PIPS), in addition to providing in-service training to staff. She further reported completing guardian angel room rounds daily and confirmed that she was assigned to visit room [ROOM NUMBER] daily. She reported visiting room [ROOM NUMBER] every day this week and denied seeing the bathroom with the shower rod down and in the condition it was found in, but that was not acceptable infection control practices and given the location, she confirmed the brown debris was feces.A review of the facility's policy and procedure titled Skilled Nursing: Environmental Services-Safe Environment (undated), read:Page 2, 1. e. Housekeeping and maintenance services will be provided as necessary to maintain a sanitary, orderly and comfortable environment. 3. a. Minimize odors by disposing of soiled linens promptly and reporting lingering odors and bathrooms needing cleaning to housekeeping Department. (Copy obtained)A review of the facility's policy and procedure titled Infection Control Plan (revised December 2023), stated: An infection prevention and control program (IPCP) is established and maintained to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of communicable diseases and infections.Policy Interpretation and Implementation stated: 3. The IPCP is a facility-wide effort involving all disciplines and individuals and is an integral part of the quality assurance and performance improvement program. (Copy obtained) 2. On 9/22/2025 at 11:46 AM during a tour of the 200-hall unit, used and uncovered disposable razors were observed on the vanity sink in rooms [ROOM NUMBERS]. (Photographic evidence obtained)On 9/23/2025 at 9:30 AM, a second observation was made where used, uncovered disposable razors were observed lying on the vanity sink in rooms [ROOM NUMBERS]. (Photographic evidence obtained)On 9/25/2025 at 12:00 PM, a staff interview was conducted with Certified Nursing Assistant (CNA) F, who reported that she made rounds on her assigned residents every two hours, and if she saw things in the rooms that shouldn't be there because they (residents) could get hurt or items could spread germs, she would remove them. When asked if razors were permitted, she replied, No, razors should be with the nurses, and we have to ask for them. If we see them, we should remove the razor, give it to the nurse and report it.On 9/25/2025 at 12:34 PM, an interview was conducted with the Assistant Director of Nursing and the Infection Preventionist/Registered Nurse (RN), who reported that expectations for CNAs, Nursing and housekeeping staff to maintain a safe environment included Absolutely no sharps at the bedside, or left behind in the rooms to include razors, lancets or nail clippers. Razors, the CNAs get one, not the whole bag, and the used razors get disposed of in the sharps container but never left in the room, ever. A review of the facility's policy and procedure titled Standards and Guidelines: SG Disposable Resident Care Product Utilization (revised 1/15/2022), read on page 1, 5. Sharps such as needles or lancets are not considered reusable items. These items should be discarded in the Sharps Container after a single use. 6.When the disposable item is no longer needed it should be discarded in the appropriate receptacle. Razors must be discarded in the Sharps Container. (Copy obtained)A review of the facility's policy and procedure titled Sharps Disposal, under Environmental Infection Control with revision date of January 2012, 1. Whoever uses contaminated sharps will discard them immediately or as soon as feasible into designated container. (Copy obtained) 3. On 9/22/2025 at 1:48 PM, a foul, ammonia-like odor was detected in room [ROOM NUMBER] where brown-colored debris was observed on the shower floor of the resident's bathroom.On 9/22/2025 at 1:51 PM, Employee I (Activities Assistant) came into room [ROOM NUMBER] and was asked if she smelled an odor in the room. She stated, yes, and began searching for the source going into the resident's bathroom. She stated, This is where it's coming from, confirming feces on the shower floor in the resident's bathroom.On 09/22/2025 at 1:56 PM, the Director of Nursing (DON) was asked to go to resident room [ROOM NUMBER]. Once there, she was asked if she smelled a foul odor. She stated, Yes. The DON went into the resident's bathroom and confirmed feces on the floor of the shower. A review of the facility's policy and procedure titled Skilled Nursing: Environmental Services-Safe Environment (Undated), read: Page 2, 1. e. Housekeeping and maintenance services will be provided as necessary to maintain a sanitary, orderly and comfortable environment. 3. a. Minimize odors by disposing of soiled linens promptly and reporting lingering odors and bathrooms needing cleaning to housekeeping Department. (Copy obtained)4. On 09/23/2025 at 10:31 AM, an interview was conducted with the Director of Nursing (DON), who reported her expectations for passing medications to residents under Enhanced Barrier Precautions was, They are expected to wear the PPE, gown and gloves, when giving meds via g-tube and to wash their hands before and after.On 09/24/2025 at 12:16 PM, RN G was observed administering medication to a resident on Enhanced Barrier Precautions (EBP) via g-tube with gloves on. No gown was worn. After administration of medication, she removed her gloves and repositioned the g-tube before washing her hands.On 09/24/2025 at 12:40 PM during medication pass, RN J was observed touching medication capsules without wearing gloves.On 09/25/2025 at 12:34 PM, an interview was conducted with the Infection Preventionist, Assistant Director of Nursing, RN, who reported that her expectation for Enhanced Barrier Precautions (EBP) was for staff to have gloves on their hands and a gown on. We want them in a gown and gloves in high-contact activities for enhanced barrier precautions, especially g-tubes, gloves when administering medications, no bare hands to g-tube or Foley (urinary catheter) areas and hopefully washing hands. She confirmed that 30 residents in the facility were on Enhanced Barrier Precautions and agreed that the staff infection control practices needed to improve.A review of the facility's policy and procedure titled Infection Control Plan (revised December 2023), read on page 13. 9, a. The facility has established policies and procedures regarding infection prevention and control among employees, contractors, vendors, visitors, and volunteers including . page 14. c. Those with potential direct exposure to blood or body fluids are trained in and required to use appropriate precautions and personal protective equipment. (Copy obtained)

Based on interviews, record review, and a review of facility policies and procedures, the facility failed to appropriately address one (Resident #72) of one resident reviewed for pressure injury, by failing to provide services to prevent pressure ulcers in accordance with professional standards of practice to meet the resident's physical needs, including assistance with repositioning due to a casted lower left extremity and off-loading measures to prevent pressure injury. The facility failed to update the Matrix for a facility-acquired pressure injury and failed to update the resident's Care Plan and Minimum Data Set assessment (MDS) to include fracture and acquired pressure wound. The findings include:A review of Resident #72's medical record revealed an admission date of 8/29/2025. The resident was documented with a fall in the facility on 8/22/2025 and subsequently began to complain of left ankle pain. An X-ray was performed on the left lower extremity (LLE) that revealed a fracture, and the resident was admitted to the hospital on [DATE]. She returned to the facility on 8/29/2025 with a cast on her LLE. An admission assessment and a skin sweep completed on 8/29/2025 revealed no skin conditions. Subsequent daily skilled charting from 8/29/2025 to 9/1/2025 revealed no new changes to skin integrity. Resident #72's medical diagnoses included multiple sclerosis, displaced spiral fracture of shaft of left tibia, subsequent encounter for closed fracture with routine healing, Type 2 diabetes mellitus with unspecified complications, contracture of right and left knee, other reduced mobility, abnormal posture, need for assistance with personal care, muscle weakness (generalized), other rheumatoid arthritis with rheumatoid factor of unspecified site, vitamin D deficiency, unspecified.A review of the MDS assessment dated [DATE] and the quarterly MDS assessment dated [DATE] revealed a BIMS score of 9 out of 15 possible points, indicating mild to moderate cognitive impairment. Section M of the MDS for both dates documented responses of No to resident has pressure ulcer/injury and No to does resident have one or more unhealed pressure ulcers.A review of Resident #72's active physician's orders revealed the following:9/24/2025 - Enhanced Barrier Precautions (EBP) related to wound.9/15/2025 - Cleanse left buttock with normal saline, pat dry, apply skin prep to surrounding tissue, apply Honey hydrogel sheet and cover with bordered gauze dressing every shift for Stage 3 pressure Injury and as needed If soiled or removed9/4/2025 - 9/15/2025 - Cleanse left buttock with soap and water, pat dry, apply Zinc oxide and leave open to air every shift for deep tissue injury and as needed If soiled or removed, 8/29/2025: No wound or skin orders for left buttock8/29/2025 - Patient to have extended leg rest while up in wheelchair to promote posture and comfort as indicated.7/30/2024 - 8/29/2025 - Patient to use donut pillow when in bed to aid in pressure relief on buttocks. A review of the Interdisciplinary Plan of Care (Start Date 8/11/2025, Completed 8/22/2025, Target Completion 9/17/2025), revealed: The resident has potential for pressure ulcer development r/t (related to) incontinence and decrease in mobility. Date Initiated: 04/05/2023 Created on: 04/05/2023 Revision on: 04/08/2024. The resident will have intact skin, free of redness, blisters or discoloration by/through review date. Date Initiated: 04/05/2023 Created on: 04/05/2023 Revision on: 08/22/2025 Target Date: 09/25/2025 Administer medications as ordered. Monitor/document for side effects and effectiveness. Date Initiated: 04/15/2024 Created on: 04/15/2024 Administer treatments as ordered and monitor for effectiveness. Date Initiated: 04/15/2024 Created on: 04/15/2024 Avoid positioning the resident on boney prominences. Date Initiated: 04/15/2024 Created on: 04/15/2024 Revision on: 04/15/2024 Follow facility policies/protocols for the prevention/treatment of skin breakdown. Date Initiated: 04/05/2023 Created on: 04/05/2023 Low air loss mattress Date Initiated: 04/15/2024 Created on: 04/15/2024 Monitor nutritional status. Serve diet as ordered, monitor intake and record. Date Initiated: 04/05/2023 Created on: 04/05/2023* The resident has potential for pressure ulcer development r/t incontinence and decrease in mobility. Date Initiated: 04/05/2023 Created on: 04/05/2023 Revision on: 04/08/2024 Resident is to have a donut cushion while in bed to relieve pressure q shift (every shift) Date Initiated: 07/30/2024 Created on: 07/30/2024 Weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue and exudate Date Initiated: 04/05/2023 Created on: 04/05/2023.A review of relevant Progress Notes/Investigative Reports revealed:9/4/2025 Social Services Note: Late Entry: Note Text: The IDT (interdisciplinary team) convened to review and discuss the patient's recent fall on 8/22/2025. The patient has a primary diagnosis of Multiple Sclerosis, with secondary diagnoses of muscle weakness and contracture of left knee. The patient is alert and oriented x3 (person, place, time). The care plan has been updated as follows: Call don't fall sign. A skin assessment, vital signs, and range of motion (ROM) evaluation were completed. Staff reinforced the importance of adhering to the prescribed interventions, and the patient verbalized understanding.8/29/2025 IDT Note: [Resident #72] has rheumatoid arthritis and contractures, as well as her bed high off the ground, which is care planned for as non-compliance and has been educated. Her x-ray showed a fracture but did not specify acute but has multiple fractures that are consistent with rheumatoid arthritis. That is not adverse, especially with her decision to have her bed up high and transfer attributed to having to be lowered to the floor. Interventions were in place for her safety and to reduce falls risk.8/29/2025- 9/1/2025 Electronic Medical Record (EMR) Daily Skilled Charting documented the following:8/29/2025 - 9/1/2025 - No new changes to skin integrity noted.8/29/2025 - Nursing Admission/readmission Screening: No skin conditions noted8/29/2025 - Weekly Skin Sweep: Skin not impaired, no conditions noted.8/29/2025 - Nursing Note: Resident transported on stretcher via Ambulance Services and readmitted to room [ROOM NUMBER]A. Resident accompanied by two attendants. Hospital 8/27/2025 - 8/29/2025.8/26/2025 Nursing Note: Late Entry: Patient with c/o (complaint of) pain in left ankle, swelling noted and some bruising. placed call to ARNP (Advanced Registered Nurse Practitioner) - received verbal order for left ankle X-ray 3 view - order placed.8/25/2025 IDT Note Text: IDT Members met this AM to discuss the patient/fall. Resident was observed on the floor on 8/22/25. Fall risk assessment completed. Interventions initiated and/or reinforced to reduce risk of future falls. These include CALL DONT FALL SIGN. Updated care plan to reflect fall risk and new interventions. Resident verbalized understanding and agreed to call for assistance. Will continue to monitor closely and reassess as needed.8/22/2025: EMR - Fall documented, no complaints of pain or discomfort.On 9/22/2025 at 11:30 AM, Resident #72 was observed sitting up in bed playing cards. The resident was alert and oriented. She stated she had a fall in the facility a couple of weeks ago and was sent to the hospital. She gestured toward her cast and said she was not able to get up right now. She said she had a problem with pain at her tailbone and that she had a wound on her buttock. On 9/23/2025 at 11:25 AM, Resident #72 was observed sitting up in bed with a deck of cards in her hand. Her hair was noted to be clean and in a braid. She voiced no concerns or complaints during this visit other than her tailbone continued to hurt. She inquired about long she would have to have the cast on.On 9/24/2025 at 1:30 PM, Resident #72 was observed sitting halfway up in bed. She was awake and alert. She stated she had not been out of bed since she returned from the hospital. She was asked if she was receiving care for a wound and she answered, Yes, they changed it this morning. It stings some when they put the new bandage on.On 9/25/2025 at 11:08 AM, Certified Nursing Assistant (CNA) D stated a resident requiring assistance with positioning was turned and repositioned every two hours and as needed. The CNA stated at that time, the resident would be changed if incontinent. Showers were scheduled for three times per week and as needed or per resident preference. CNA D stated CNAs filled out skin sheets or logged any skin conditions in the EMR when they were noticed. She further stated she verbally reported to the nurse when any skin issues were noticed.On 9/25/2025 at 11:24 AM, the Third Floor Unit Manager was asked what admission assessments must be completed for a new resident. She stated, Skin, pain, nursing admission assessments. The assessments that automatically populate and will have a date to show you which ones to do - fall risk. She also stated a head-to-toe skin assessment was done on admission and if any skin issues were found, they would be documented immediately. She stated an order for a wound consultation should also be done and to call the doctor to let them know.On 9/25/2025 at 11:45 AM, the Wound Care Nurse was asked how she was notified of a skin condition. She replied, The nurse will usually tell me. If it's a new admission, the nurses do an admission assessment and then me and the wound care nurse practitioner (WCNP) do a second skin assessment. Every new admission gets a second assessment on each one. Any areas of concern are usually looked at the same day. She stated she rounded with the WCNP typically twice a week on Mondays and Thursdays and they saw the ones on the wound report, the ones that we follow and new admissions. If they have something, we add them onto the wound report. When she was asked about Resident #72 specifically, and how she determined whether the wound was facility-acquired or was present on admission, she replied that the resident was first seen on 9/4/2025 for a new admission skin assessment. A DTI (deep tissue injury) was identified on the resident's left buttock. Usually, when we do a new admission assessment, we put present on admission if there is any wound. If the nurse puts it on the admission assessment, and we knew she didn't have anything prior to her hospitalization, we said present on admission. She was then asked to show the documentation that this wound was present on admission and not facility acquired. She stated, The nurse did not put anything in the admission assessment regarding a skin condition. She was asked if she could pull up anything in the EMR regarding seeing any skin condition on this resident prior to 9/4/2025. In the conference room with the survey team present, she was unable to find any documentation to support that Resident #72 had any skin condition on admission. She was asked to provide the policy and procedure for reporting skin conditions as well as the wound policy. (Copy obtained) The Wound Nurse was asked to provide weekly wound reports for the last four weeks. The report was provided at 12:23 PM. On the report for 9/1/2025 through 9/4/2025, Resident # 72 was seen for a left buttock pressure ulcer/injury DTI on 9/4/2025. It was recorded that the resident's admission date was 8/29/2025 and that the wound was acquired on 8/29/2025.On 9/25/2025 at 12:18 PM, a voicemail was left for the Nurse Practitioner. The call was returned, and she confirmed that she was in the facility on September 1 and September 4, 2025. She stated they did skin sweeps on all admissions and if there was an existing wound it would be listed in the chart, and the wound nurse would let her know. When she was asked why she stated the wound was present on admission she replied, Because I was told by the wound care nurse. I'm not there every day and I rely on what they tell me.

Based on observations, record review, resident and staff interviews, and a review of facility documentation, the facility failed to adequately maintain a safe environment. Disposable razors were improperly disposed of and were left accessible in resident rooms at the vanity sinks for two (Residents #44 and #24) of two residents reviewed for accident hazards from a total survey sample of 31 residents.The findings include:1) Resident #44, was observed in his room on 9/22/2025 at 11:46 PM. He was seated in his wheelchair at the foot of his bed, dressed in day clothing and watching television. When greeted, he smiled without verbal acknowledgement and continued watching television. A vanity sink was in the hallway leading to a resident shared bathroom, where a single disposable razor was observed lying on the vanity sink. (Photographic evidence obtained)On 9/23/2025 at 9:30 AM, a second observation was made, and a single disposable razor was observed lying on the vanity sink. (Photographic evidence obtained)A record review revealed that Resident #44 was admitted to the facility on [DATE] with diagnoses including unspecified dementia, anemia, adult failure to thrive, dysphagia, and repeated falls.A quarterly Minimum Data Set (MDS) assessment, dated 7/14/2025, revealed that the resident was documented with unclear speech and a Brief Interview for Mental Status (BIMS) score of 04/15 indicated severe cognitive impairment. A wheelchair was used for mobility.A review of active Care Plans in place included that the resident was at risk for falls related to weakness (created 12/6/2024). The goal was not to sustain serious injury through the next review with a target date 10/15/2025, and interventions included: Resident needs a safe environment, call light in reach, and frequent rounding (last revised on 7/29/2025). A review of the resident's active physician's orders revealed:Trazodone HCI (hydrochloride) oral tablet 50 mg (milligrams), give 50 mg by mouth two times a day for depressionHydrocodone-Acetaminophen oral tablet 5-325 mg, give one tablet by mouth every 8 hours for pain. 2) Resident #24 was observed on 9/22/2025 at 2:03 PM, sitting up in her wheelchair at her bedside table, dressed in day clothing, with a blanket resting over her lower extremities. When greeted, she smiled and reported having recently been admitted to the facility and was planning to return home soon. A vanity sink was located on the wall just before her bed, with a yellow-colored hygiene basin that contained a single disposable razor. (Photographic evidence obtained) On 9/23/2025 at 8:59 AM, a second observation was made of a yellow-colored hygiene basin with a single disposable razor on her vanity sink. A record review revealed that Resident #24 was admitted to the facility on [DATE] with diagnoses including speech and language deficits following a cerebral infarction, encephalopathy, dysphagia, unspecified convulsions, nontraumatic intracranial hemorrhage, and type 2 diabetes mellitus.A review of an admission MDS assessment, dated 9/2/2025, revealed a BIMS score of 13/15 indicating intact cognition. The resident was documented with upper extremity impairment on one side; she required partial to moderate assistance from staff for showering and bathing, partial to moderate assistance from staff to complete personal hygiene, and she used a wheelchair for mobility.A review of active Care Plans in place included: Resident has an ADL (activities of daily living) self-care performance deficit related to generalized weakness, CVA (cerebrovascular accident - stroke), initiated 9/3/2025, with a goal to improve her current level of function in ADLs through the next review with a target date of 11/11/2025. Interventions included: Praise all efforts at self-care and allow sufficient time for dressing and undressing.A review of the resident's active physician's orders included Aripiprazole Oral Tablet 10 mg via G-tube (gastrostomy tube - feeding tube) one time a day for psychosis, and Amantadine HCI (hydrochloride) Oral Tablet 100 mg one time a day via G-tube for seizures. On 9/25/2025 at 12:00 PM, a staff interview was conducted with Certified Nursing Assistant (CNA) F, who reported that she rounded on her assigned residents every two hours, and if she saw things in the resident rooms that shouldn't be there, she would remove them, because they could get hurt. These items included safety pins, lancets, clutter and hazards in the walkways. When she was asked if razors were permitted, she replied, No, razors should be with the nurses, and we have to ask for them. If we see them, we should remove the razor, give it to the nurse and report it.On 9/25/2025 at 12:34 PM, an interview was conducted with the Assistant Director of Nursing and the Infection Preventionist/Registered Nurse (RN), who reported that expectations for CNAs, Nursing and housekeeping staff to maintain a safe environment included Absolutely no sharps at the bedside, or left behind in the rooms to include razors, lancets or nail clippers. Razors, the CNAs get one, not the whole bag, and the used razors get disposed of in the sharps container but never left in the room, ever. On 9/25/2025 at 1:10 PM, an interview was conducted with the Risk Manager and Staff Educator/Registered Nurse (RN), who reported she was in charge of overseeing accidents, incidents, quality assurance and she served as the abuse coordinator. She reported that her expectation during staff room rounds, and department head guardian angel rounds was for staff to check for hazards, and items left behind in the environment that had the potential to cause harm. A review of the facility's policy and procedure titled Standards and Guidelines: SG Disposable Resident Care Product Utilization (revision date 1/15/2022), read on page 1, 5: Sharps such as needles or lancets are not considered reusable items. These items should be discarded in the Sharps Container after a single use. 6.When the disposable item is no longer needed, it should be discarded in the appropriate receptacle. Razors must be discarded in the Sharps Container. (Copy obtained)

Based on observations, interviews, record review, and a review of the facility policies and procedures, the facility failed to ensure that residents who needed oxygen therapy received it as ordered for one (Resident #34) of 15 residents receiving oxygen therapy in a total survey sample of 31 residents. The findings include:On 09/22/2025 at 1:01 PM, Resident #34 was observed lying in bed on a low air-loss pressure-relieving mattress wearing her nasal cannula. The oxygen flow rate on the concentrator next to her bed was set at 2-2.5 liters per minute (L/min). It was not within arm's reach of the resident. Another observation of the oxygen concentrator setting at 3:57 PM revealed it was again set at 2-2.5 L/min. (Photographic evidence obtained) On 09/23/2025 at 11:05 AM, Resident #34 was observed lying in bed on a low air-loss pressure-relieving mattress covered with her blanket and wearing her nasal cannula. The oxygen flow rate on the concentrator next to her bed was set at 2L/min. (Photographic evidence obtained)On 09/24/2025 at 1:42 PM, Resident #34 was observed lying in bed on a low air-loss pressure-relieving mattress with her nasal cannula resting on her top lip. When asked if she was wearing her nasal cannula, she replied, It slips out sometimes. The oxygen flow rate on the concentrator next to her bed was set at 2L/min. (Photographic evidence obtained)A review of Resident #34's active oxygen orders revealed:Oxygen at 3 L/min via nasal cannula as needed for oxygen saturation if below 90% every shift for Shortness of Breath (SOB) (1/13/2025).Other active orders included ProAir HFA (hydrofluoroalkane) Inhalation Aerosol Solution 108 (90 Base) Micrograms (MCG) per Actuation (Albuterol Sulfate) 2 puffs, inhale orally every 4 hours as needed for SOB and wheezing (12/4/2024), andHead of bed elevated per resident's request to prevent shortness of breath while lying flat every shift (12/4/2024).Further review of the medical record revealed that Resident #34 was admitted to the facility on [DATE] with an initial admission date on 8/18/2023. Primary diagnoses included: anxiety disorder, unspecified and shortness of breath.A review of the Quarterly minimum data set (MDS) assessment, dated 7/24/2025, revealed documentation of no shortness of breath and no oxygen therapy. Resident #34 had a Brief Interview for Mental Status (BIMS) score of 12 out of 15 possible points, indicating moderately impaired cognition. The resident was dependent for eating, and toilet transfers were not attempted.A review of the active Care Plan focus and goals included:[Resident #34] received oxygen therapy as needed for shortness of breath. Interventions included oxygen at 2 L/min via nasal cannula inhalation as needed to keep saturations above 90. (Copy obtained)The resident's Medication Administration Record (MAR) for September 2025 revealed no documentation for oxygen at 3 L/min via nasal cannula as needed for oxygen saturation if below 90% every shift for SOB. Documentation was missing for the order: Head of bed elevated per resident's request to prevent shortness of breath while lying flat every shift on 9/4, 9/5, 9/9, 9/11, and 9/15. (Copy obtained)On 09/24/2025 at 1:50 PM, Registered Nurse (RN) G was accompanied to Resident #34's bedside where she confirmed that the resident's oxygen flow rate setting was set at 2L/min. RN G returned to her computer and confirmed that Resident #34's oxygen order was for a flow rate of 3 L/min. RN G stated nurses provided ongoing monitoring of residents' oxygen therapy and ensured residents on oxygen therapy received the correct oxygen order. Correct oxygen settings were identified by checking the physician's orders. Nursing and the Unit Manager were responsible for changing the residents' oxygen tubing weekly. Correct settings were communicated from one staff person to another in shift reports. When RN G was asked if the resident changed her own oxygen flow rate, RN G replied, No. Sometimes she takes it off and says she doesn't want to wear it. She is on it most of the time and we monitor her saturations.On 9/24/2025 at 2:30 PM, the Director of Nursing confirmed that correct oxygen settings were identified by checking the physician's orders.A review of the facility's policy and procedure titled Nursing - Oxygen Administration (undated), revealed:Purpose: The purpose of this procedure is to provide guidelines for oxygen administration. Procedure: . 11. Adjust the delivery device so that it is comfortable to the resident and the proper flow of oxygen is being administered. (Copy obtained)

Based on observations, interviews, and facility policy and procedure review, the facility failed to provide a safe, sanitary, and comfortable environment for residents, by failing to ensure that one (Resident #61) of four residents with personal refrigerators had an internal refrigerator thermometer and refrigerator temperatures were monitored to ensure safety. This had the potential to place Resident #61 at risk for infection, which could result in illness and potential functional decline.The findings include:On 09/22/2025 at 1:25 PM, Resident #61's personal refrigerator was observed with no internal thermometer.During a second observation on 09/23/2025 at 10:57 AM, Resident #61's personal refrigerator was observed to have no internal thermometer.On 09/24/2025 at 1:47 PM, no internal thermometer was observed in Resident #61's personal refrigerator. (Photographic Evidence Obtained)On 09/24/2025 at 1:55 PM, Registered Nurse (RN) G reported that the Unit Manager was responsible for monitoring resident refrigerators. The night nurse logged resident refrigerator temperatures.On 09/24/2025 at 3:15 PM, the Director of Nursing (DON) confirmed that the Assistant Director of Nursing (ADON) was responsible for monitoring, cleaning, and logging temperatures of resident personal refrigerators. She stated the Unit Manager on the 3rd floor was new and was still training. If issues with residents' personal refrigerators were identified during angel rounds, it was reported in the morning meetings.A review of the facility's policy and procedure titled Cleaning and Sanitation of Refrigerators and Freezers on Units (dated 3/20190, revealed:Policy: The facility recognizes the importance of ensuring that all foods are held at a safe temperature in order to ensure the safety of its residents. All refrigerators on the units will be monitored for correct temperatures and cleaned weekly. Procedure: the following procedure will be followed for refrigerators and freezers in the unit pantries. a. Each refrigerator and freezer will be equipped with a thermometer. (Copy obtained)

Based on observations, record reviews, and staff interviews, the facility failed to ensure a medication error rate of 5% or less based on four errors out of 27 opportunities for error, resulting in an error rate of 14.81% and involving three (Residents #66, #61, and #53) of seven residents observed during medication administration. Failure to administer medications correctly as ordered could result to side effects with serious harm to the residents. The findings include: During medication administration observation on 10/10/23 at 11:33 am, Licensed Practical Nurse (LPN) A was observed conducting point-of-care blood glucose testing for Resident #66. She obtained the resident's blood glucose level of 182 milligrams/deciliter (mg/dl). She reviewed the medication administration record (MAR) and stated the resident required four units of Novolog insulin per sliding scale. She obtained the multi-dose vial of Novolog and withdrew five units. As she was about to administer the medication, she was asked to clarify the dosage again and she confirmed she had drawn up five units in error. She pushed one unit off the syringe, then administered the remaining four units of insulin in the resident's right upper arm. A review of Resident #66's October 2023 MAR, revealed that the resident had orders for Novolog 100 units/milliliter administered per sliding scaled before meals. A review of the sliding scale revealed that 182 mg/dl required four units. (Copy obtained) On 10/10/23 at 11:56 am, LPN B was observed conducting point-of-care blood glucose testing for Resident #61. She obtained the resident's blood glucose level of 279 mg/dl. She then reviewed the October 2023 MAR and stated the resident needed four units of Lispro insulin. She obtained the Lispro Kwik Pen and dialed insulin to six units. After performing hand hygiene and donning gloves, she asked the resident where he would like the insulin administered. Resident #61 said, abdomen and lifted his shirt. LPN B then asked the resident, What section of the abdomen? As she was about to administer the medication, she was asked to clarify the dosage again. She said, Six units. She was asked to review the physician's order. She walked to the cart that was parked outside the door and said, Oh, it was supposed to be four units. She dialed the pen back to four units. She was asked how to prime the insulin pen to remove bubbles. She said, Add two more units. She could not appropriately explain how to prime the insulin pen. (Copy of the October MAR obtained) In an interview on 10/10/23 at 12:23 pm, the Director of Nursing (DON) was asked to explain the protocol for priming an insulin pen. She said, The nurse should push out two units of insulin then dial the pen to the appropriate setting per sliding scale. When asked if the nurses were trained to do that, she replied yes. She added that the facility conducted nursing competencies upon hire and annually thereafter, and they reviewed insulin administration at that time. Another medication administration observation was made on 10/11/23 at 9:50 am. LPN C was observed preparing medications for Resident #53. She obtained two tablets of Gabapentin 300 mg (milligrams), Gemeda 75 mg, and Potassium Chloride Extended Release (ER) 20 milliequivalents (meq). LPN C opened the Gabapentin capsules in a separate cup. She then obtained the remaining two medications and poured them in a pill crusher pouch and crushed them. She mixed the powered mixture in apple sauce and administered it to the resident who was seated in the dining room area. The nurse checked off the MAR as having administered the resident's medication. When she was asked to review the MAR, she confirmed that she had not administered either the Cholecalciferol (Vitamin D3) 125 micrograms (mcg) or the Cyanocobalamin (B12) 1000 mcg, but had checked them off as having been administered. (Copy obtained) She checked her medication cart and stated she did not have the right dosage of Vitamin D3 the cart. According to Mayo Clinic.org (https://www.mayoclinic.org/drugs-supplements/potassium-citrate-oral-route/proper-use/drg-20074773, accessed on 10/12/23 at 10:00 am), extended-release tablets should not be broken, crushed, chewed, or sucked because in doing so, they may cause irritation to the mouth or throat. A review of the facility's guideline titled Insulin Administration using an insulin Pen (undated), revealed how to use steps which included, but not limited to: 7. Wipe the tip of the pen where the needle will attach with an alcohol swab or cotton ball moistened with alcohol. 8. Remove the protective pull tab from the needle and screw it into the pen until snug (but not too tight). 9. Remove both the plastic outer cap and inner needle cap. 10. Look at the dose window and turn the dosage knob to 2 units. 11. Holding the pen with the needle pointing upwards, press the button until at least a drop of insulin appears. This will prime the needle and remove air from the needle. Repeat this step if needed unit a drop appears. 12. Dial the number of units ordered. A review of the facility's policy and procedure titled Administering Medication (revised April 2019), revealed: Medications are administered in a safe and timely manner, and as prescribed. The policy interpretation and implementation indicated: 4. Medications are administered in accordance with presciber orders, including any required time frame. 10. The individual administering the medication checks the label three (3) times to verify the right resident, right medication, right dosage, right time, and right method (route) of medication before giving the medication. 21. If a drug is withheld, refused, or given at a time other than the scheduled time, the individual administering the medication shall initial and circle the MAR space provided for that drug and dose.

Based on observation, interview, and a review of the facility's policies and procedures, the facility failed to maintain an infection prevention and control program designed to provide a safe and sanitary environment to help prevent the development and transmission of communicable diseases and infections during point-of-care testing for two (Residents #66 and #61) of two residents observed during point-of-care testing, out of seven residents observed during medication administration. Failure to adhere to infection control standards during point-of-care testing poses a risk to residents of acquiring communicable diseases. The findings include: On 10/10/23 at 11:33 am, Licensed Practical Nurse (LPN) A was observed conducting blood glucose testing for Resident# 66. She obtained a glucometer from a bag and placed it on the nurses' cart without a barrier. She obtained a lancet, alcohol wipes and a test trip, and placed them in a medication cup. She took the supplies to the resident's room and placed the glucometer on the resident's sink without a barrier as she performed hand hygiene. She went to the bedside and placed all of the supplies on a paper towel as she donned clean gloves. She cleaned the resident's right thumb and released the thumb after cleaning it to place the test trip in the glucometer. The resident's hand was contracted and was against his chest. The cleaned finger was touching the resident's gown. After placing the test trip in the glucometer, LPN A pricked the resident's finger and obtained a blood glucose reading of 182 milligrams per deciliter (mg/dl). She picked up all of the supplies and discarded them appropriately. She placed the used/soiled glucometer on the nurses' cart, doffed the gloves and performed hand hygiene, then she donned clean gloves and cleaned the glucometer with a Sani Wipe for two minutes. She did not allow it to air dry before placing it back in the bag. She stated each resident had their own glucometer. She also stated the facility had two glucometers in each medication cart that were shared between multiple residents. When asked if she cleaned the glucometer before use, she replied, We always put it back in the bag when its cleaned, so I assumed it was clean. I did not see any dirt on it either. LPN A confirmed that she did not use the barrier for the glucometer, and did not ensure that the blood collection site remained clean after cleaning it and before obtaining the blood sample. When asked how long the glucometer should be cleaned, she reviewed the Sani Wipe container and said three minutes. Another observation was made on 10/10/23 at 11:56 am. LPN B was observed conducting blood glucose testing for Resident #61. She obtained a glucometer from a bag in the medication cart. She got two lancets and three alcohol wipes and placed them in a medication cup. She took the glucometer bag with test strips, the glucometer and the other supplies that were in the medication cup to the resident's room and placed them on the resident's bedside table without a barrier. She performed hand hygiene and donned clean gloves. She pricked the resident's right middle finger and obtained a blood glucose reading of 279 mg/dl. She picked up the remaining alcohol wipes, the lancet, and the used/soiled glucometer and placed them on the medication cart. She discarded the used lancet and test trips, doffed the gloves, and performed hand hygiene. She then picked up the used/soiled glucometer with her bare hands, obtained Sani Wipes, cleaned the glucometer, and placed it on a medication cup to air dry. She then reviewed the October 2023 Medication Administration Record (MAR) and began preparing the insulin to administer without first performing hand hygiene. After administering the insulin, LPN A stated the glucometer was ready to be stored. She stated she forgot the glucometer bag in the resident's room and went to get it. When she was asked about the leftover supplies that were brought back from the resident's room and placed on the nurse's cart in a medication cup, she said, These are still clean. I did not use them. I will use them on my next resident. When she was asked if she had taken those items into Resident #61's room, she confirmed that she had, stating, Yes, but they are still clean. She was then asked about the glucometer bag that was left in the resident's room. She said she had always taken the bag to the resident's room because it held the test strips. She confirmed that the the glucometer was a shared glucometer used for more than one resident. A review of the facility's policy and procedure titled Blood Sampling - Capillary (Finger Sticks) (Revised September 2014), revealed: The purpose of this procedure is to guide the safe handling of capillary - blood sampling devices to prevent transmission of bloodborne diseases to residents and employees. The General Guideline included te following: Always ensure that blood glucose meters intended for reuse are cleaned and disinfected between residents' uses. Lancets and platforms must always be changed after use on each resident. Steps in the procedure were outlined as follows: 1. Wash hands. 2. Don gloves. 3. Place blood glucose monitoring device on clean field. 4. Place a new lancet and disposable platform on the spring-loaded finger-stick device. 5. Wipe the area to be lanced with an alcohol pledget. 6. Obtain the blood sample following the manufacturer's instructions for the device. 7. Discard lancet and platform into the sharps container. 8. Following the manufacturer's instructions, clean and disinfect reusable equipment, parts and/or devices after each use. 9. Wash hands. 11. Replace blood glucose monitoring device in storage area after cleaning. A review of the facility's policy and procedure titled Infection Prevention and Control Program (Revised October 2018), revealed: An infection control program is established and maintained to provide a safe, sanitary, and comfortable environment, and to help prevent the development and transmission of communicable diseases and infections. The Policy interpretation and implementation, Section 11 - Prevention of Infection - indicated that the important facets of infection prevention included: 1. Identifying possible infection or potential complication of existing infection. 2. Instituting measures to avoid complication or dissemination. 3. Educating staff and ensuring that they adhere to proper techniques and procedures. The policy further indicated that those with potential direct exposure to blood and body fluids are trained in and required to use appropriate precautions and personal protective equipment.

Based on observations, staff and resident interviews, medical record review, and facility policy review, the facility failed to ensure that four (Residents #29, #30, #70, and #54) of 31 residents sampled, received necessary services to maintain grooming and personal hygiene. Residents #29, #30, and #70 did not receive appropriate nail care. Resident #54's facial hair was overgrown, and his mustache was growing past his upper lip and into his mouth. The findings include: 1. On 10/09/23 at 11:45 am, Resident #29 was observed lying in bed awake. Her fingernails were observed to be elongated with purple polish only remaining at the tip of each nail and brown debris observed under each nail. She was asked how she preferred to wear her nails and she stated she did not like them to be long. They used to have girls that would come around and trim them, clean them, and polish them, but they don't have them here anymore. She was asked if she could remember who used to keep her nails clean, trimmed and polished. She stated, It was the girls from Activities, but they have new people now and they don't do nails. On 10/10/23 at 11:18 am, Resident #29 was observed lying in bed awake. Her fingernails were elongated with brown debris underneath. The nail tips were observed with grown-out purple nail polish. Resident #29 was asked for permission to photograph her fingernails. She agreed and photographs were taken. (Two photographs obtained, one of each hand.) On 10/11/23 at 12:50 pm, in an interview with Certified Nursing Assistant (CNA) F, she was asked who was responsible for caring for residents' fingernails. She stated, We keep them clean and trimmed, but if they are a diabetic, then the nurse takes care of them. She was asked when fingernail care was provided to the residents. She stated, It's when they need it. We check on shower days, but we can clean and trim them anytime they need it done. On 10/12/23 at 9:40 am, in an interview with Licensed Practical Nurse (LPN) D, she was asked who provided fingernail cleaning and trimming for the residents. She stated, Any CNAs, nurses or myself, and activity staff can also help with that. She was asked how often residents' fingernails were cleaned and trimmed. She stated, On shower days and as needed. On 10/12/23 at 9:50 am, LPN D was asked to observe Resident #29's fingernails. When she was asked if the resident's fingernails were trimmed and clean, she replied, No, they are pretty long and there is debris under her nails. She was asked why the resident had remnants of purple nail polish on the tip of each nail. The resident stated, Oh my, that polish is still showing? LPN D stated the Activities department assisted with polishing nails. The resident stated, No one has been in to polish my nails in over four months. On 10/12/23 at 12:50 pm, in an interview with CNA G, she was asked who provided fingernail care for residents. She stated, Whenever I see them long, I'll do it. The Activities staff will do the manicure and polish. She was asked if she was caring for Residents #29 and #30 today. She stated yes. She was asked if she had cleaned and trimmed their fingernails recently. She stated, I try to do the best I can with their nails. A medical record review for Resident #29 revealed diagnoses including type 2 diabetes and legal blindness. A review of the resident's quarterly Minimum Data Set (MDS) assessment, dated 7/21/23, revealed that Resident #29 required extensive assistance of one person for personal hygiene. No behaviors, including refusal/rejection of care were indicated. A review of the person-centered Care Plan revealed: Focus: (6/5/23) Resident has an (ADL) Activities of Daily Living Self-Care Performance Deficit; Goal: Resident will have ADL needs met through the review date; Interventions: Check nail length and trim and clean on bath day and as necessary. Resident requires assistance by staff with personal hygiene. Focus: (6/5/23) Resident has Potential/Actual Impairment to Skin Integrity; Goal: Resident will maintain or develop clean and intact skin by the review date; Intervention: Avoid scratching and keep hands from excessive moisture; keep fingernails short. 2. On 10/09/23 at 11:30 am, Resident #30 was observed lying in bed awake. Her fingernails on both hands were observed to be elongated with brown debris under each nail. The resident was asked at what length she preferred her nails. She stated, I want them trimmed and cleaned. I don't want them polished but I want them trimmed and clean. On 10/10/23 at 11:20 am, Resident #30 was observed lying in bed awake. Her fingernails were elongated with brown debris observed under each nail. She was asked for permission to photograph her hands. She agreed and photographs were taken. (Photographic evidence obtained) On 10/10/23 at 11:30 am, Licensed Practical Nurse (LPN)/Unit Manager D entered the room. Resident #30 asked LPN D to apply her arm splints. LPN D placed a splint on the resident's left hand/arm. The resident asked, What about my hand? LPN D stated, I can put a washcloth in your hand to keep it from closing. While placing the washcloth in the resident's hand, dead skin was observed to flake off of the resident's palm. The resident stated, No one washes my hands, that's why I've got all that dead skin. LPN D stated, They should be washing your hands twice a day. Resident #30 stated, Well they don't. That's dirt. I need soap and water. On 10/11/23 at 8:45 am, Resident #30 was observed lying in bed awake, watching TV. Her fingernails remained elongated with brown debris underneath. A medical record review for Resident #30 revealed diagnoses including unspecified dementia. A review of her quarterly Minimum Data Set (MDS) assessment, dated 8/2/23, revealed that Resident #30 required extensive assistance of one person for personal hygiene. No behaviors, including refusal/rejection of care were indicated. A review of the person-centered Care Plan for Resident #30 revealed: Focus (7/14/23) Resident has an ADL Self-Care Performance Deficit; Goal: (revised 9/16/23) Resident will demonstrate the appropriate use of adaptive device to increase ability through review date; Interventions: (revised 7/28/23) bathing/showering: Check nail length and trim and clean on bath day and as necessary. Report changes to the nurse. Focus: (7/14/23) Resident has Potential/Actual Impairment to Skin Integrity; Goal: Resident will maintain or develop clean and intact skin by the review date; Intervention: Avoid scratching and keep hands from excessive moisture; keep fingernails short. 48947 3. On 10/9/23 at 11:53 am, Resident #70 was observed lying in bed awake. He was nonverbal but smiled and nodded his head. His fingernails were elongated on each finger. He was scratching at his upper arms. On 10/10/23 at 10:55 am, Resident #70 was observed lying in bed awake. His fingernails on both hands remained elongated. On 10/10/23 at 11:35 am, a telephone interview was conducted with Resident #70's spouse. The spouse was asked about the resident's care at the facility. She stated, I've asked them to take care of his fingernails, it has been quite a while, and I haven't been able to check up on it again. I trim them sometimes when I come, but I can't get up there as much as I'd like to. On 10/11/23 at 9:08 am, Resident #70 was observed in bed. His fingernails remained elongated. On 10/12/23 at 11:15 am, LPN D was asked who was responsible for residents' fingernail cleaning and trimming. She stated, Everyone is responsible for nail care, the nurses, the CNAs, and myself. LPN D was asked when fingernail care was provided. She stated, Nail care is done on shower days and as needed. A review of the medical record for Resident #70 revealed diagnoses including encephalopathy and unspecified dementia. A review of the resident's Care Plan, dated 9/13/23, revealed a focus area, goal, and interventions which indicated that Resident #70 had an ADL Self-Care Deficit related to dementia, impaired balance, and limited mobility. Interventions included checking nail length, trimming and cleaning the nails on shower days and as necessary. Staff were to report any changes to the nurse. A review of the annual Minimum Data Set (MDS) assessment, with a reference date of 8/11/23, revealed that Resident #70 had a Brief Interview for Mental Status (BIMS) score of 00 of 15 possible points, indicating severe cognitive impairment. Resident #70 was also documented as requiring extensive one-person physical assistance for personal hygiene. Rejection of care behaviors were not documented as having been exhibited. 4. On 10/9/23 at 11:57 am, Resident #54 was observed in bed with overgrown facial hair. His mustache was grown past his upper lip and was in his mouth, and his beard was covering both of his cheeks as well as his neck. When he was asked how he preferred to keep his facial hair, he stated he did not like it this long, but I don't have any money for the barber shop. On 10/10/23 at 11:00 am, Resident #54 was observed in bed talking on the phone. His facial hair was in the same condition was was previously observed on 10/9/23 at 11:57 am. On 10/11/23 at 9:00 am, Resident #54 was observed in bed. His facial hair was in the same condition was was previously observed on 10/9/23 at 11:57 am and on 10/10/23 at 11:00 am. He stated he was going to request a shave today. On 10/12/23 at 1:00 pm, Resident #54 was observed sitting up in bed awake. His facial hair was in the same condition as was observed on 10/9, 10/10 and 10/11. He was asked if anyone had been in to shave him. He stated, I've asked and they are too busy. I asked last night on the evening shift but she never came back. He stated he preferred to be clean shaven, but I don't have any money for the barber. A review of the medical record for Resident #54, revealed a person centered Care Pplan dated 9/26/23 with a focus area for Activities of Daily Living (ADL) Self-Care Performance Deficit related to decreased mobility with interventions to include, but not limited to: Personal Hygiene: The resident requires (extensive assistance) by (1) staff member with personal hygiene, and has contractures of both hands. A review of the quarterly Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 7/16/23, revealed that Resident #54 had a BIMS score of 12 out of 15 possible points, indicating moderate cognitive impairment. Resident #54 was also documented as requiring extensive one-person physical assistance with personal hygiene. Rejection of care behaviors were not documented as having been exhibited. A review of the facility's policy titled Restorative Nursing - ADLs Assistance (Bathing, Dressing, Grooming - Undated) revealed: The facility will provide restorative programming to assist residents in attaining and maintaining the highest practicable level of function . A resident will be eligible for restorative ADL programming if he/she demonstrates interest in improving or participating in self-performance of activities of daily living and requires skill practice and/or training in dressing, bathing, or grooming. Procedure: 1. c) Grooming: May include maintaining personal hygiene, planning the task, gathering supplies, combing hair, washing face and hands, brushing teeth, shaving, applying deodorant, applying make up, trimming nails, or use of adaptive equipment. In an interview with the Administrator on 10/11/23 at 8:10 am, she was asked if the facility had any other policies pertaining to ADLs and/or grooming. She stated no, this was their only policy.

Based on observation, interview, and record review, the facility failed to assist one (Resident #28) of one resident reviewed for dental care, from a total sample of 31 residents, in obtaining routine and/or 24-hour emergency dental care. Failure to provide dental care could result in pain/discomfort, tooth loss, and infection. The findings include: On 10/09/23 at 12:11 pm, Resident #28 stated her teeth were falling off. She was observed trying to hold her tooth on the lower jaw and feeling it with her tongue. She stated she had problems chewing food because her teeth are all falling off. She stated she recently had one tooth fall off and was not sure of whether or not there were pieces of the tooth left in her mouth. She said she was not receiving dental care at the facility. She denied pain and stated she had learned to deal with it. I will make it. In an interview on 10/10/23 at 11:45 am, the resident's power of attorney (POA)/Daughter stated she visited the resident often and at unexpected times. Most of the time she was not notified about the resident's care. She added, I was not notified of Mom's broken glasses until I came in today. She revealed the broken glasses arm. When she was asked about Resident #28's dental services, she stated the resident had partial dentures, but they had been lost at the previous nursing home. She added that she tried to schedule an appointment for new ones, but the resident's dentist stated the resident had very tender gums and it would be painful trying to fit new ones. When she was asked if the resident was receiving additional services at the facility she said no. She was not aware of whether or not her mother had any dental issues or if anyone was checking her for that. She also mentioned that her mother stated she was having a hard time chewing her meals, but she the daughter not know if the facility had changed the resident's diet texture to make chewing easier. A review of the medical record revealed that Resident #28 was admitted to the facility on [DATE] with diagnoses including chronic kidney disease - stage three; vascular dementia, polyneuropathy, and acute angle-closure glaucoma. A review of the diet order dated 4/26/23, revealed a regular textured diet and thin consistency liquids. A review of the quarterly Minimum Data Set (MDS) assessment, with an assessment reference date (ARD) of 8/20/23, revealed that the resident had a Brief Interview for Mental Status (BIMS) score of 4 out of 15 possible points, indicating severe cognitive impairment. She required limited assistance for bed mobility, transfers, and toilet use, and supervision for eating. There were no swallowing or dental concerns identified. There was no care plan addressing the resident's dental status. In an interview with the Social Services Director (SSD) on 10/12/23 at 12:04 pm, she stated she placed Resident #28 on the list for a dental consultation upon admission. Upon initial evaluation, the dental company would then decide whether to continue with services or not. When she was asked about Resident #28's dental status, she confirmed the resident was not receiving dental services at the facility. She stated Resident #28 had not been accepted by the dental company affiliated with the facility due to her insurance (Medicaid pending upon admission). The SSD added that the facility changed dental providers around June 2023. She said the new company sent consent forms to the resident's representative and had not heard back yet. She was unable to produce confirmation of the consent form having been sent to the resident's representative. She was then asked about Resident #28's health coverage. She provided paperwork which indicated that Resident #28's Medicaid was approved on 8/18/23. A review of the facility's policy and procedure titled Dental Services (undated), revealed: The facility will assist residents in obtaining both routine and 24-hour emergency dental care. For Medicaid residents, the facility will provide all emergency dental services and those routine dental services to the extent covered under the Medicaid state plan. The facility will inform the resident of the deduction for the incurred medical expenses available under the Medicaid state plan and assist the resident in applying for the deduction. If any resident is unable to pay for the dental services, the facility should attempt to find alternative funding sources or delivery systems so that the resident may receive the services needed to meet their dental needs to maintain his/her highest practicable level of well being.

Based on staff and resident interviews, medical record review, and facility policy review, the facility failed to ensure that all alleged violations involving injuries of unknown origin were reported immediately, but not later than two hours after the allegation was made, if the events that caused the allegation involved abuse or resulted in serious bodily injury, or not later than 24 hours if the events that caused the allegation did not involve abuse and did not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and Adult Protective Services where state law provides for jurisdiction in Long-Term Care facilities) in accordance with State law through established procedures for one (Resident #1) in a sample of three residents. The findings include: A review of Resident #1's medical record revealed a nursing progress note written on 05/19/2023 at 7:10 a.m., which read: Resident slept good. Alert, oriented and verbally responsive. Around 6:00 a.m., when staff assigned to her were doing B/B (bowel and bladder) incontinent care, writer noticed right lower side of leg with discoloration and also right breast. At 7:00 a.m., informed DON (Director of Nursing)/management and in the building. Dr. (doctor's) answering service called . and waiting for call back. At 7:05 a.m., responsible party informed and thankful to writer. She wants her mother to have a pillow as protection because her mother is leaning to the right side. Give report to incoming nurse. A review of facility grievances revealed that a grievance was filed on 05/19/2023 on behalf of Resident #1 by her daughter. The grievance read: Describe the grievance as provided by resident/individual: Unexplained severe hematoma to R (right) breast, R side of back, R side of arm, R lateral leg from knee to ankle, L (left) upper lower arm, L leg, chest. My mother alleges two people, one white girl and one black man were helping her to the toilet without a lift or sit-to-stand from her wheelchair. My mother can't walk or stand. Describe the grievance as seen/heard by witness: N/A. In an interview with the Administrator on 06/19/2023 at 12:00 p.m., she was asked if she investigated the grievance from 05/19/2023 concerning Resident #1. She stated yes. She was asked whether an Immediate Federal Report and a 5-Day Federal Report for injury of unknown origin were completed. She stated, No, because we know where the injuries came from. She had been transferring with the sit-to-stand mechanical lift and was also on a blood thinner, Eliquis. The bruising came from being transferred when she could no longer bear the weight needed for the sit-to-stand lift. The daughter is who discovered the bruising and she alleged her mom had fallen, but she had not fallen. There was no fall. The bruising was all on her right side, and she leans to her right side in her wheelchair. She had X-rays done which were all negative. All staff were re-educated on the use of mechanical lifts. In a second interview with the Administrator on 06/19/2023 at 2:50 p.m., she was asked if there were any other investigations conducted other than the grievance investigation from 05/19/2023 for Resident #1. She stated no. She was asked when this grievance investigation was concluded. She stated, We notified the daughter on 5/25/23 of the resolution. She was asked to clarify who was caring for Resident #1 when the bruising occurred. She stated, I don't know who was caring for her. The grievance form was based on the daughter's feedback and the resident's feedback. She was asked if staff were attempting to transfer the resident to the toilet without a sit-to-stand device or were they using a transfer device. She stated, I'm not sure. I believe they were using the sit-to-stand device. She stated she did not know when this incident occurred. She did not know which staff were involved. When asked how the bruising was discovered, she stated, She did not have the discoloration a day prior to. The daughter comes in and provides hands-on care and there was no discoloration the day prior. The daughter discovered the bruising. She came in a couple of days after Mother's Day and she brought it to our attention. The daughter notified me personally. She came down to the office and told me and I started the grievance. The staff were already addressing it. The daughter said it supposedly occurred on the 14th. I don't know how or where she got that date from. The Administrator stated she observed the bruising the day it was reported. When asked to describe what she observed, she stated, It was discoloration below her right breast and on her side. There was nothing on the left side. When asked whether the source of the injury was observed by anyone, she stated no. She was asked if the injuries were discovered by another person. She stated, Yes, it was discovered a couple days after using the lift. It took a couple days for the discoloration to show up. She was asked if the source of the injury could be explained by the resident. She stated, No, the resident was not able to really give us what happened. In an interview with Employee A on 06/19/2023 at 3:05 p.m., she was asked when she was first notified about the bruising discovered on Resident #1. She stated May 19, 2023. When asked whether the event was reported to her by staff or family, she replied, By staff. By the floor nurse. She no longer works here. When asked whether she observed the bruises, she replied, At that time, no. When asked when she observed the resident's bruises, she stated, It was either that evening or the next morning. When asked to describe what she observed, she stated, Her breast was bruised from the bottom of her right breast and across the right breast to her side, and a long lateral bruise on the lower part of her right lateral leg. When she was asked what she did when the event was reported to her, she stated, I informed [Administrator] and [Regional Nurse]. I was also the Interim Director of Nursing (IDON) at that time and I wasn't really sure what to do, so I called them. She was asked what their response was. She stated, I think we had to report it to Agency for Health Care Administration (AHCA). I'm not sure if we reported it. As the Risk Manager, I had to do the investigation to interview the staff. Because it was such an odd location, we had to rule out that anything happened. Just to find out how the bruising happened. My thought process was how would she get bruising like that outside of a physical assault. She was asked if the source of the injury was observed by any person. She stated no. She was asked if the injury was discovered by another person. She stated, Yes, by the nurse. She was asked if the source of the injury could be explained by the resident. She stated, No, she wasn't able to say what happened. She was asked if the injury was suspicious because of the extent of the injury or the location of the injury. She stated yes to both. A review of the facility's policy titled Abuse, Neglect, Exploitation, and Misappropriation (undated) revealed: Policy: It is the policy of this facility to take appropriate steps to prevent abuse, neglect, exploitation, misappropriation and the occurrence of an injury of unknown source, and to ensure that all alleged violations of Federal and/or State laws are reported immediately to the Administrator, the Risk Manager, The Social Service Director, and the Director of Nursing. The Abuse Coordinator/Designee shall report any alleged violations of abuse or serious bodily injury immediately but not later than two hours to the Agency for Health Care Administration, the Adult Protective Services, and the local law enforcement if they feel a crime has occurred. If the alleged violation involves neglect, misappropriation of resident property, exploitation, or injuries of an unknown source and involves no serious bodily injury, it must be reported no later than 24 hours. 6. Reporting: Upon initial investigation, where suspicion that Abuse/Neglect/Exploitation may have occurred, the Abuse Coordinator/designee shall immediately report the alleged violation to AHCA (for Federal report), Adult Protective Services, and local law enforcement when appropriate. The Risk Manager/Designee will file the Immediate Federal Report with AHCA and then submit the summary and findings of the investigation with the 5-day Federal Report.

Based on observations, record reviews and interviews, the facility failed to employ staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service. This had the potential to negatively impact all residents who received meals from the kitchen. The findings include: On 12/06/21 at 2:15 PM, observations were made of the low temperature dishwasher while being used by a dietary staff member. The dishwasher was observed at a temperature of 115 °F. Two more wash cycles were observed and the temperature never rose above 118 °F. Dietary Staff Member (DSM) I reported the dishwasher temperature should be 120 to 125° F. She was asked what temperature the dishwasher was at now, and she replied, I don't know, I have to get my glasses. DSM I was asked what the facility's process was at the beginning of washing dishes in the dishwasher. She stated, I let it run one time before I start doing dishes. I check it at the beginning, but I don't log until the end of washing dishes. DSM I retrieved her glasses and looked at the dishwashing machine while it ran. She reported that it reached 118 °F. She was asked what she did if the temperature was low, and she replied that she would log it and then get the supervisor. DSM I was asked to notify the Food Service Director (FSD) about the low dishwasher temperature she just read. The FSD was informed and he ran the machine again himself. It was still under 120°F. At this time the FSD did not give the kitchen staff any instructions or ask them to wait. Before leaving the kitchen, the FSD was asked if he told staff what to do in the dish room regarding cleaning the dishes and he replied, not yet. The December 2021 temperature log for the dishwasher was reviewed on 12/06/21 at 2:30 PM and revealed there was a dishwasher temperature and PPM (parts per million) already filled in for the night shift today, 12/6/21. The FSD was asked about the entries already filled in for today's night shift and he stated, The employee was getting a head of himself. The FSD was asked to check the sanitizer for the three-compartment sink, but he could not find a color key to compare the strip from the sink with it. After several minutes, he went to the office and retrieved a new bottle. On 12/06/21 at 5:00 PM, another visit to kitchen was made. The staff at the three-compartment sink were asked to check the sanitation level, but they could not find test strips or a strip bottle with a color key to test the PPM. They were hand washing dishes at of time of this observation. An interview was conducted with the FSD on 12/7/21 at 5:00 PM. He stated this morning, a representative from the facility's contracted water treatment/purification/cleaning/hygiene company was here and checked the dish machine. He stated the representative told him if the dishwasher temperature was higher then 120 °F, it would neutralize the sanitizer. He reported at the time of the visit, the representative did a couple of things to the dishwasher and it was working properly now. The representative's report was requested for review. It was received the following day, 12/8/21, at 3:00 PM. The report indicated the dishwashing maching should be at 120 to 140 °F during use and it was at 139°F the day of the representative's visit. (Copy obtained) On 12/8/21 at 11:15 AM, the FSD was asked if he had conducted an in-service with kitchen employees regarding the dishwasher. He replied, nothing official. I just had a talk with them. On 12/09/21 at 4:30 PM, the FSD was asked if he had conducted any formal training with the kitchen staff regarding the dishwasher. He replied no. He was asked to clarify the appropriate temperature the dishwasher should reach when running. He stated the dishwasher should be between 120 to 140°F. He said he was going with the representative's recommendations. He stated, Yes, I know I said the temperature should be no more than 120° F, but I am just going to go with our [contractor's] report. It was pointed out that the log's temperature ranges for a high temperature machine did not match the machine recommendations or the poster on the wall, and the FSD agreed it was confusing. (Copy of logs obtained) The FSD demonstrated the dishwasher again on this day. He had to run it four (4) times to get the temperature up over 120 °F for the wash cycle. 2. Cook K was observed obtaining food temperatures on 12/08/21 at 11:34 AM. She said the facility fortified a portion of the mash potatoes with a concentrated whey protein powder ([MEDICATION(S)]). She was asked how much she added to the food and she replied, I put 15 scoops in mash potatoes, 1 scoop for every person that is on fortified potatoes. An interview was conducted with the Certified Dietary Manager (CDM) on 12/09/21 at 2:15 PM. She reported that the facility did fortify foods with packets of [MEDICATION(S)]. She reported she believed only 4 to 5 residents were on fortified foods. She stated the recipe was 1 packet of [MEDICATION(S)] added to a 1/2 cup of mashed potatoes. At 2:39 PM on 12/09/21, the FSD stated he was acting as the cook today and at lunch service he put six scoops of [MEDICATION(S)] in the mashed potatoes. He stated, It was because it is what he saw the cook do. During this interaction between the CDM and FSD, the CDM told the FSD that it should be 1 packet of [MEDICATION(S)] for 1/2 cup of mashed potatoes, and that he should be using [MEDICATION(S)] not [MEDICATION(S)]. The FSD was asked what training the kitchen staff had recevied related to dishwashing duties, and he replied, none. When asked about new employee training he stated, New employees learn from shadowing other staff members. A review of the facility's policy titled Sanitization revealed, Dishwashing machines must be operated using the following specifications: Low temperature dishwasher wash temperature 120° F and final rinse with 50 parts per million (PPM) hypochlorite for at least 10 seconds. (copy obtained) A review of the facility's policy titled Dishwashing Machine Use revealed, Food service staff required to operate the dishwashing machine will be trained in all steps of dishwashing machine use by the supervisor or a designee proficient in all aspects of proper use and sanitation. (Copy obtained)

Based on record review and interview, the facility failed to monitor behaviors for one (Resident #31) of ten residents investigated for unnecessary medications, from a total of 29 residents in the sample. The findings include: A review of Resident #31's medical record revealed he was admitted to facility on 11/24/20 and was readmitted on [DATE]. His diagnoses included occlusion and stenosis of left carotid artery, cerebral infarction, hemipelgia, [CONDITION(S)] of liver, dementia with behaviors, unspecified dementia without behaviors, adult failure to thrive, repeated falls, [CONDITION(S)] disease, and hypertension. Resident #31 was care planned for combative behaviors with interventions that included psychology evaluations and medications as needed. He also was care planned for potential for discomfort and side effects related to the use of [CONDITION(S)] medications for Alzheimer's disease with interventions that included evaluate behaviors, administer medications and observe for adverse effects of medications. A review of the resident's Physician's Order Sheets for December 2021 revealed they included current orders for [MEDICATION(S)] two times a day for behavior and psychological symptoms of dementia, and [MEDICATION(S)] three times a day for anxiety. A review of the Medication Administration Record (MAR) for December 2021 revealed that no behaviors were being monitored in relation to the administration of [MEDICATION(S)]. An interview was conducted with Licensed Practical Nurse (LPN) H on 12/09/21 at 3:16 PM. She was asked if a resident was receiving [MEDICATION(S)] or [MEDICATION(S)] whether they should be monitored for behaviors. LPN H replied, Yes. She was asked whether behaviors were being monitored for Resident #31's [MEDICATION(S)] medication, and she replied, No, [MEDICATION(S)] was started on 11/22/21. I'm not sure why they didn't put behavior monitoring on for that medication. The facility's policy and procedure for [CONDITION(S)] medication administration was requested but was not received during the course of the survey.

Based on observations, interviews, and record reviews, the facility failed to fully develop and/or implement a comprehensive person-centered care plan for one (Resident #71) of a total sample of twenty-nine residents. Specifically, Resident #71's care plans did not address medication administration on [CONDITION(S)] days, and the facility was not implementing her care plan for the provision of oxygen as per her physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] The findings include: During an interview with Resident #71 on 12/06/21 at 12:00 p.m., she stated she received [CONDITION(S)] away from the facility on Tuesdays, Thursdays, and Saturdays. Resident #71 reported she was not on oxygen, however, an oxygen tank was observed sitting in the corner of her room, not in use. A review of Resident #71's medical record revealed an admitted [DATE], and a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . She had a Brief Interview for Mental Status (BIMS) score of 15 out of a possible 15 points, indicating intact cognition, and she required extensive assistance with Activities of Daily Living (ADLs). A review of Resident #71's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . This order was discontinued on 12/09/21and a new order was written for supplemental oxygen at 2 liters per minute as needed. (Copies obtained) A review of Resident #71's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident #71's Care Plans revealed no care plans addressing Resident #71's oxygen therapy or medication administration on [CONDITION(S)] days. An interview was conducted with Certified Nursing Assistant (CNA) F on 12/08/21 at 2:15 p.m. When asked what type of [CONDITION(S)] care/services training she had received, CNA F stated, No [CONDITION(S)] training. I get her dressed, make sure she eats, and have her ready for [CONDITION(S)] on time. When asked what type of training she'd received related to respiratory interventions, CNA F stated, The nurse handles all that. I just moisture her nose if it is sore. She is on oxygen. Lately, she hasn't been on it. An interview was conducted with Registered Nurse (RN) E on 12/09/21 at 12:53 p.m. When asked what type of [CONDITION(S)] care/services training he had received, RN E stated, no [CONDITION(S)] training. He confirmed that the resident was receiving hemodialysis three times per week. When asked about the resident's medication administration, RN E stated, [Resident #71] accepts her medications with no problem. If it's at a time she is gone, we can't give her medication. Yesterday, she left at 6:00 a.m., so we could not give her the 8:00 a.m. medication; we just left them here. If the time is past, we just don't give it. By the time she is back something else is due. When asked whether Resident #71 was currently receiving oxygen, RN E stated, Yes, the [CONDITION(S)] center has the orders. Another interview was conducted on 12/09/21 at 4:35 p.m. with Resident #71. She reported she was not receiving oxygen at the [CONDITION(S)] center. She stated, They give it to me if I need it. When asked whether she was receiving oxygen here at the facility, Resident #71 responded, no. During the interview, an oxygen tank was observed sitting in corner, not in use. (Photographic evidence obtained) An interview was conducted with the Director of Nursing (DON) on 12/09/21 at 5:47 p.m. When asked whether she was familiar with Resident #71 and if the resident was on oxygen, the DON replied, Yes, sometimes when she goes to [CONDITION(S)]. The DON stated, Most of the time she is not using it, her saturation goes to 96-97% on room air. When asked why Resident #71 had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Tomorrow the physician comes and will review her chart. When asked why the nurses were signing the MAR for administration of oxygen if they were not administering oxygen to Resident #71, the DON replied, I'll check. When asked how she ensured the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . I will in-service staff to call the physician to change it if she is not using the oxygen. The facility's policy and procedure entitled Care of a Resident with End-Stage [CONDITION(S)] ([CONDITION(S)]) read, The resident's comprehensive care plan will reflect the resident's needs related to [CONDITION(S)]/[CONDITION(S)] care. (Photographic evidence obtained) The facility's policy and procedure for Oxygen Administration instructed staff to verify that there was a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . (Photographic evidence obtained)

Based on observations, interviews, and record review, the facility failed to ensure residents were free of significant medication errors by failing to administer as-needed antihypertensive medications to residents for blood pressures at or above the parameters established by the physician for two (Resident #52 and Resident #22) of two residents reviewed, from a total of 29 residents in the sample. The findings include: 1. A review of the medical record for Resident #52 revealed an initial admitted [DATE]. Her admitting diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] A review of a Significant Change Minimum Data Set (MDS) assessment, dated 10/28/2021, revealed a Brief Interview for Mental Status (BIMS) score of 06 out of a possible 15 points, indicating severely impaired cognition. The assessment did not identify any behaviors or rejection of care and no history of falls. Resident #52 required extensive to total assistance with activities of daily living. A review of Resident #52's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . (Photographic Evidence Obtained) A review of Resident #52's blood pressure flow records for November and December 2021 revealed the following entries: 12/6/2021 7:35 a.m. 162/77 12/5/2021 9:21 a.m. 162/70 12/5/2021 1:56 a.m. 164/83 12/4/2021 11:26 p.m. 172/81 12/4/2021 3:52 a.m. 166/84 12/4/2021 12:18 a.m. 164/70 11/30/2021 9:47 p.m. 173/82 11/29/2021 5:57 p.m. 172/78 11/29/2021 10:07 a.m. 161/69 11/28/2021 10:47 p.m. 165/87 11/27/2021 8:34 p.m. 170/70 11/27/2021 3:55 p.m. 174/76 11/22/2021 10:28 p.m. 188/73 (Photographic Evidence Obtained) A review of the Medication Administration Records (MARs) for November and December 2021 revealed no documented administration of [MEDICATION(S)]. (Photographic Evidence Obtained) On 12/09/2021 at 2:55 p.m., an interview was conducted with Registered Nurse (RN) A. She confirmed that she was assigned to care for Resident #52. She was asked to review Resident #52's blood pressure flow records and medication administration records. She stated she was not aware the resident had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . After reviewing the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the pharmacy consults for October and November 2021 revealed no recommendations identified by the consultant pharmacist for the as-needed [MEDICATION(S)]. 2. A review of the medical record for Resident #22 revealed an initial admitted [DATE]. Her primary medical diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of a quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 09 out of a possible 15 points, indicating moderately impaired cognition. Resident #22 required extensive to total assistance with activities of daily living. A review of Resident #22's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . (Photographic Evidence Obtained) A review of the medical record revealed the resident was transferred to the hospital and returned on 11/6/2021. Resident #22's blood pressure was documented as 181/70 on the admission nursing data collection upon returning from the hospital. A review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . (Photographic Evidence Obtained) A review of Resident #22's blood pressure flow records for December 2021 revealed an entry dated 12/7/2021 at 7:36 p.m. with a blood pressure of 165/69. An entry dated 12/7/2021 at 11:32 p.m. revealed a blood pressure of 174/85. A review of the medication administration records for December 2021 revealed no documented administration of the as-needed [MEDICATION(S)]. (Photographic Evidence Obtained) A provider progress note dated 11/10/2021 directed staff to notify the physician or nurse practitioner for chest pain, shortness of breath, or a systolic blood pressure greater than 160 mmHg or lower than 100 mmHg. A review of the nursing progress notes revealed no documentation to indicate the physician had been notified of the elevated blood pressures on 12/7/2021. (Photographic Evidence Obtained) During an interview on 12/09/2021 at 2:55 p.m. RN A, she was asked to review the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . She reviewed the orders and again acknowledged that if the blood pressure parameters established by the physician had been met, the as-needed [MEDICATION(S)] should have been administered. A review of the pharmacy consults for October and November 2021 revealed no recommendations identified by the consultant pharmacist for the as-needed [MEDICATION(S)]. A review of the facility's medication administration policy titled Administering Medications revealed a directive for staff to administer medications in accordance with the orders. (Photographic Evidence Obtained) According to the American Heart Association (accessed 12/9/2021) at https://www.heart.org/en/health-topics/high-blood-pressure/the-facts-about-high-blood-pressure, high blood pressure (also referred to as HBP, or hypertension) is when your blood pressure, the force of blood flowing through your blood vessels, is consistently too high. When left untreated, the damage that high blood pressure does to your circulatory system is a significant contributing factor to heart attack, stroke and other health threats.

Based on observations, interviews, and record reviews, the facility failed to ensure that residents who required [CONDITION(S)] services received such services, consistent with professional standards of practice, by failing to ensure ongoing communication with the [CONDITION(S)] facility regarding [CONDITION(S)] care and services for one (Resident #71) of two residents receiving hemodialysis from a total sample of twenty-nine residents. The findings include: During an interview with Resident #71 on 12/06/21 at 12:00 p.m., she stated she received [CONDITION(S)] away from facility on Tuesdays, Thursdays, and Saturdays. A review of Resident #71's medical record revealed an admitted [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . She had a Brief Interview for Mental Status (BIMS) score of 15 out of a possible 15 points, indicating intact cognition, and she required extensive assistance with Activities of Daily Living (ADLs). A review of Resident #71's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . An interview was conducted with Registered Nurse (RN) E on 12/09/21 at 12:53 p.m. When asked what type of training he'd received related to [CONDITION(S)] care and services, RN E stated, no [CONDITION(S)] training. RN E confirmed that Resident #71 was receiving hemodialysis three times per week and had an AV fistula (arteriovenous fistula - an abnormal connection between an artery and a vein in which blood flows directly from an artery into a vein) at her left chest. When asked at what point nursing monitored vital signs and weights, RN E stated, Every morning and anytime she receives hypertension medicines. The weight team track and monitor weights and weights are completed at the [CONDITION(S)] clinic. When asked how care was coordinated and communicated between the [CONDITION(S)] staff and the facility nurses, RN E stated, Vital signs are completed before she (Resident #71) leaves. If she has an issue, the [CONDITION(S)] center will notify us. An interview was conducted with the Director of Nursing (DON) on 12/09/21 at 5:47 p.m. When asked about Resident #71's weights and post-[CONDITION(S)] care, the DON stated, The fistula is checked for bruising and bleeding. When asked whether the [CONDITION(S)] Communication forms were created at the facility or the [CONDITION(S)] center, the DON replied, The facility completes the top portion of the form, and the [CONDITION(S)] center completes the bottom of the page. On 12/09/21 at 4:48 p.m., a review of nine [CONDITION(S)] Communication Forms revealed missing information as follows: 10/14/2021 - top portion of form weight and cycles per minute missing, nurse's signature missing (This was the only form available for review for October 2021.) 11/16/2021 - top portion of form weight missing, nurse's signature missing 11/18/2o21 - top portion of form weight missing, nurse's signature missing 11/20/2021 - top portion of form weight missing, room number missing, nurse's signature missing 11/23/2021 - top portion of form weight missing, nurse's signature missing 11/26/2021 - top portion of form weight missing, nurse's signature missing 11/30/2021 - top portion of form weight missing, nurse's signature missing 12/02/2021 - top portion of form weight missing, nurse's signature missing 12/04/2021 - top portion of form weight missing, nurse's signature missing 12/09/2021 - top portion of form weight missing, nurse's signature missing During an interview with the DON on 12/09/21 at 7:20 p.m., only the October 14, 2021 form was available for the month of October. No other October forms were available for review. When asked what the purpose of the [CONDITION(S)] communication forms was, the DON replied, The forms are very important. They have the blood pressures on them. She further stated, If blood pressures are low, Resident #71 can have a code. The facility uses the forms to communicate with the [CONDITION(S)] center on how the resident is doing. The DON reported that the facility initiated the form. The facility's policy and procedure for Care of a Resident with End-Stage [CONDITION(S)] (revised 8/3/2011), stated, Agreements between this facility and the contracted [CONDITION(S)] facility include all aspects of how the resident's care will be managed, including: how information will be exchanged between the facilities. (Photographic evidence obtained)

Based on observations, staff and resident interviews, and medical record review, the facility failed to ensure the call light was within reach for one (Resident #62) of 29 sampled residents, for whom the facility had assessed and developed care plans. This action prevented the resident from requesting help when he needed it, leaving him vulnerable to not having his needs met. The findings include: On December 6th, 2021, at 11:30 AM, Resident #62 was observed sitting on a chair positioned to the right of his bed, watching television. His call bell was not within reach. (Photographic evidence obtained) It was wrapped around the left bed rail on the resident's bed, approximately four feet away from the resident. His water cup was dated 12/05/21. Call bell response time was tested , at which time the call bell was not audible in the room, however an unsampled certified nursing assistant (CNA) entered the room [ROOM NUMBER]-3 minutes later. On December 6th, 2021, at 12:48 PM, Resident #62 was observed sitting in a chair positioned to the right of his bed. His call bell was not within reach. (Photographic evidence obtained) The resident's water cup was observed on top of the bedside table with his room number written on it, but the cup was not dated. Resident #62's empty urinal was also on top of the bedside table. On December 7th, 2021, at 9:26 AM, Resident #62 was observed in his room, dressed and sleeping in a chair. His call bell was observed wrapped around the left upper bed rail, approximately four feet away from him. (Photographic evidence obtained) On December 8th, 2021, at 9:37 AM, Resident #62's call bell was wrapped around the left upper bed rail, approximately four feet away from him. He was sitting in a chair. A cup with fluids dated 12/8/21 was sitting on top of the bedside table. On December 8th, 2021, at 10:13 AM, Resident #62 was observed in his room sitting in a chair. His call bell was wrapped around his left upper bed rail, approximately four feet away from him. On December 9th, 2021, at 9:52 AM, Resident #62 was observed in his room sitting in a chair. His call bell was wrapped around the left upper bed rail, approximately four feet away from him. When asked how he summoned staff when he needed assistance, he replied, I shout. He stated he would like the call bell closer when he was not lying in bed. His urinal was behind the chair he was sitting in. When asked how he accessed his urinal, he stated he had to reach for it. On December 9th, 2021, at 2:31 PM, Licensed Practical Nurse (LPN) G was interviewed regarding call bell positioning and accessibility. She stated call light monitoring was done by both the nurses and CNAs. She further stated call lights must be put where residents can get to them. On December 9th, 2021, at 11:32 AM, a Social Services note dated 12/05/21, indicated Resident #62 would continue with long-term care placement. He was alert and oriented to self and surroundings. His speech was impaired. He required reminders. He was pleasant and cooperative. He interacted with his peers. A review of the nurses' notes dated December 3rd, 2021, revealed that staff assisted Resident #62 with activities of daily living (ADLs). He remained continent of bowel, but was occasionally incontinent of bladder. He transferred from bed to chair with one assist, and he ambulated using a four-wheeled walker. A review of the resident's quarterly Minimum Data Set (MDS) assessment, dated November 3rd, 2021, revealed that Resident #62 had a Brief Interview for Mental Status (BIMS) score of 12 out of a possible 15 points, indicating moderately impaired cognition. (Total possible BIMS score ranges are as follows: 13-15: cognitively intact, 08-12: moderately impaired, and 00-07: severe impairment) He required a one-person assist with transfers/walking in his room and the corridor, locomotion on and off the unit, and for toilet use. His balance was not steady, but he was able to stabilize without staff assistance. His range of motion (ROM) was limited for both lower extremities (BLEs). A walker was used as a mobility device. A review of Resident #62's care plan (CP), dated August 8th, 2020, documented: Focus: Resident has occasional to frequent incontinence at times. Toileting/incontinence management per facility protocol C. Goal: Resident will have reduced episodes of incontinence through next review date (NRD). Interventions included: Functional call light within easy reach and prompt staff response. Do frequent rounds when resident is in his room, as he may not use the call light due to cognitive deficit and physical limitation. Focus: Resident has diagnosis (Dx) of convulsions with reduced safety awareness due to mild cognitive impairment. He requires limited assistance from staff while ambulating. Ambulates with a walker. Goal: Resident will have minimized risk of fall-related injuries through NRD, related to visual deficit through NRD, will have no injuries due to falls and/or seizures through NRD. Interventions include: Functional call light and frequently used items within easy reach and visual field of resident. Prompt staff response. SR (side rails) up x 2 as an enabler for bed mobility PRN (as needed). Keep pathway clear of clutter, environmental hazards and items placed below resident field of vision. Provide environment with adequate lighting, free of glare. On December 9th, 2021, at 6:12 PM, the Administrator was asked for the facility's policy and procedure (P&P) for call lights. The P&P provided at 6:28 PM, stated each resident had a functioning call light at bedside, which relayed an audible tone at the nurses' desk when the resident needed to summons or communicate with a staff member. All new residents would be oriented to the function and proper use of call lights. It was expected that the call light would be answered within a reasonable amount of time. All staff were responsible for answering the call lights and checking on the residents for safety needs. If the responding staff member was not qualified to meet medical needs, they would relay the resident's needs to the nurse or appropriate staff member and respond to the resident accordingly. When residents were in bed, call lights would be secured near the resident for easy access. When residents were out of bed, the call light would be secured to a location near the resident for easy access. If the call light had an identified functional problem, a work order would be written, and maintenance would be notified to inspect and promptly repair the device. In such an event, staff would manually monitor the residents and meet their safety needs.

Based on record reviews and interviews, the facility failed to ensure provision of care and treatment in accordance with professional standards of practice, and the comprehensive, person-centered care plan, by failing to properly transfer one (Resident #3) of three residents reviewed for transfers. The findings include: A review of Resident #3's clinical record revealed an [AGE] year-old male admitted to the facility on (MONTH) 15, (YEAR), with [DIAGNOSES REDACTED]. On 12/5/18 at 11:57 AM, an interview was conducted with Resident #3 regarding how he is transferred. He stated that the staff sometimes used the Hoyer lift to transfer him, and sometimes they did not. On 12/5/18 at 12:37 PM, an interview was conducted with Employee A, Certified Nursing Assistant (CNA), regarding how Resident #3 transferred, and she stated he was a one-person assist. He could stand up and bear weight. On 12/5/18 at 12:41 PM, an interview was conducted with Employee C, Licensed Practical Nurse (LPN), regarding how Resident #3 transferred, and she stated, He is a one-person transfer. The CNA transfers him. I don't think he can really stand, so they have to assist him. On 12/5/18 at 12:50 PM, an observation was made of Employee A, CNA, transferring Resident #3 back to bed. She transferred him herself without a second staff member's assistance. Employee C, LPN, was also in the room. Employee A, CNA, placed the resident on the right side of the bed with his left side (flaccid side) next to the bed. He was not wearing a gait belt. She had him reach up and grab the side rail, crossing over with his right hand. She then placed both of her arms around him. He partially stood up out of the chair, and she turned him and placed him on the bed. During the observation of the transfer, Employee A was made aware that the resident had stated the staff sometimes used the lift to transfer him. She confirmed this with the resident, then stated she was unaware that anyone had ever used the lift with him. On 12/5/18 at 1:03 PM, an interview was conducted with Employee A, CNA, regarding Resident #3's transfer back to bed. She was asked how she knew how to position the resident to transfer him back to bed, and she stated, It depends on which way he wants to lay. If he wants to face this way, you put him in over here, and if he wants to lay the other way, you would put him in on the other side of the bed. She was asked whether it mattered that he had left-sided weakness and she replied, No, that does not matter. She was asked whether she could access the care plan to determine whether he required the use of a lift, and she stated, If he needs a lift, the nurses will tell me that, and then I would have to use a lift. On 12/5/18 at 1:08 PM, an interview was conducted with Employee C, LPN, regarding the resident's transfer. She confirmed that the CNA should not have placed the resident's weak side adjacent to the bed. He needed his stronger side there to help him stand up. She further stated she had just re-educated the CNA on how to transfer someone with [MEDICAL CONDITION]. On 12/5/18 at 3:31 PM, an interview was conducted with the Risk Manager regarding the observation of Resident #3's transfer, and she confirmed the resident was transferred inappropriately and should have been transferred on his stronger side, not on his weaker side. On 12/5/18 at 4:19 PM, an interview was conducted via telephone with the therapist regarding education provided to the staff for transfers. He stated he conducted education with all new hires and for each staff member on their anniversary date. He demonstrated and provided staff with a handout. He trained one-on-one with the staff and they provided return demonstration. When he was asked about Resident #3's transfer today, he confirmed he had been made aware of the situation and had to then provide one-on-one education. He stated confirmed that a resident with [MEDICAL CONDITION] should be transferred utilizing their strong side, and if the resident was unable to exert 50% of the effort prior to transferring, they should be assessed for use of a lift. If a staff member was unsure, an assessment for use of a lift should be done. A review of the resident's care plan revealed the following: (Resident #3) has impaired mobility and ability to transfer due to left-sided [MEDICAL CONDITION] from [MEDICAL CONDITION]([MEDICAL CONDITION] - stroke). Intervention: 1-2 person assist with transfers; assess the need for lift equipment during transfers. Employee A, CNA, was unable to identify how to assess the need for lift equipment during transfers, during her interview. A review of the facilty's policy and procedure for transfers revealed the following: Moving a Resident from Bed to a Wheelchair Updated 2013 Guideline Statement: In order to protect the safety and well-being of staff and residents, and to promote quality care, this facility uses appropriate techniques in moving residents from bed to wheelchairs/chairs & vice-versa. Guideline Interpretation and Implementation 3. Preparation: a. Think about the steps before you act, and get help if you need it. If you are not able to support the resident by yourself, you could injure yourself and the resident. b. You may want to put non-skid socks or shoes on the resident's feet if the resident needs to step onto a slippery surface. Explain the steps to the resident. a. Place the wheelchair on the same side as the resident's good leg. b. Park the wheelchair next to the bed, close to you. c. Put the brakes on and move the footrests out of the way. 4. Procedure a. Assist the resident to sitting position on the side of the bed. have a chair in position at a 45 degree angle to bed. b. Apply transfer belt/transfer aides if needed. c. Ensure resident has stable nonskid shoes. Weight-bearing or strong leg forward, weak foot back. d. Spread your feet apart. e. Flex hips and knees, aligning knees with resident's. f. Reach around the chest/waist, and lock your hands around the resident or grasp transfer belt/gait belt from underneath. g. Place resident's outside leg (one farthest from the wheelchair) between your knees for support. Bend your knees and keep your back straight. Maintain stability of resident's weak or paralyzed leg with knee. h. Count to three and slowly stand up. Use your legs to lift. i. At the same time the resident should place his/her hands by his/her sides and help push off the bed if able. j. The resident should help support his/her weight on his/her good leg during the transfer.

Based on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for the hearing needs of one (Resident #33) of thirty-four sampled residents. The findings include: An interview was conducted on 08/20/18 at 11:46 AM with Resident #33, who was admitted to the facility on [DATE]. The resident was alert and oriented. During the interview he stated that the doctor told him his ears were dead, and that he would get hearing aids, but he still hadn't received them. Record review of the most recent quarterly minimum data set (MDS) assessment revealed that the resident had a brief interview for mental status (BIMS) score of six (6) out of a possible 15 points, indicating moderate cognitive impairment, and a need for supervision with most activities of daily living (ADLs). Record review of the comprehensive care plan for Resident #33, dated 2/16/18, revealed that hearing loss was not addressed. The care plan was revised on 5/18/18, and again on 8/17/18. Hearing loss was not addressed in any manner on either of the revisions. During an interview with Employee A, a certified nursing assistant (CNA), on 08/22/18 at 2:35 PM, she stated, He has a little problem with his hearing. He'll turn the good ear toward you for you to talk in. During an interview with Employee B, a licensed practical nurse (LPN), on 08/22/18 at 2:41 PM, he stated, I am familiar with this resident. You just have to talk louder than usual. He usually understands when I'm talking to him, I just have to talk a little louder. During an interview with Employee C, a LPN, on 08/23/18 at 10:16 AM, she stated, He has the hearing thing, you just have to lean in and talk louder to him. During an interview with Employee D, a CNA, on 08/23/18 at 10:23 AM, she stated, He doesn't hear good; you have to yell when you're talking to him. During an interview with the Director of Social Services (SSD) on 08/22/18 at 3:03 PM, the SSD stated, We (the facility) have to take them out for hearing screenings. Record review of ENT (ear, nose and throat physician) consult provided by the Director of Social Services revealed that Resident #33 was seen by an ENT specialist on 7/9/18. His left and right ears were positive for hearing loss. His right ear had cerumen (earwax) impaction. His new [DIAGNOSES REDACTED].). 2. Tinnitus (ringing in the ears) 3. Cerumen, impacted right ear. Additional notes attested that Resident #33 had a [AGE] year history of hearing loss.

Based on observations, record reviews, and staff interviews, the facility failed to ensure the residents' environment (physical surroundings to which the residents have access) remained free of accident hazards (refers to being free of accident hazards which the facility had control over) as evidenced by the failure to maintain hot water temperatures at safe levels. Immediate Jeopardy (IJ) was identified at F323 regarding unsafe hot water temperatures. Immediate Jeopardy (IJ) was identified as beginning on 4/26/16 following the maintenance director's adjustment of the boiler temperatures. The maintenance director started logging temperatures above 115 degrees Fahrenheit (F), but he admitted that his thermometer was not calibrated. He would make additional adjustments and would continue to document elevated temperatures. The maintenance director did not inform the administrator regarding the inconsistent and elevated temperatures in order for the concern to be addressed. During the survey, surveyors recorded elevated temperatures up to 122 degrees F. There was also an interview with Resident #72 on 8/24/16 regarding the hot water. The resident stated that on an unknown date, she received a shower in which the water was too hot and she felt like she could be burned. The resident said she did not want to take more showers due to fear of getting burned. Due to the elevated hot water temperatures, which could cause potential serious skin burns to residents, the unknown root cause for the temperature fluctuations, the breakdown of the system in which administration was not made aware until the survey, and a least one resident ' s fear to use the shower because the water was too hot, it was determined that IJ occurred in the facility. The facility was informed of the IJ on 8/26/16. The facility failed to maintain hot water temperatures at safe temperatures (temperature ranged from 116 to 118F) on April 26, 2016 in 26 out of 75 rooms throughout the facility, including the 3rd floor spa/shower room. The facility failed to maintain hot water temperatures at safe temperatures (temperature ranged from 116 to 118F) on May 10, 2016 in 25 rooms out of 38 on the 3rd floor. On 6/7/2016 and on 6/10/16, the facility failed to maintain hot water temperatures at safe temperatures (temperature ranged from 116 to 118F) in 48 rooms out of 78, and 1 shower room on the 2nd floor (out of 2 showers). On 7/18/2016, the facility failed to maintain hot water temperatures at safe temperatures (temperature ranged from 116 to 118F) in 10 out of 35 rooms. No readings were obtained for the 2nd floor for the month of July 2016. On 8/19/2016, 28 rooms out of 38 and 2 of 4 shower/spa rooms had hot water that was not maintained at safe temperatures (temperature ranged from 116 to 119F) which caused a high likelihood for scalds and serious skin burns for all residents who resided in these rooms, including 31 cognitively impaired residents. Due to the system breakdowns, all of the facility residents were at risk of potential serious harm and injury from hot water not maintained at safe temperatures. The facility census at the time of the survey was 104 and the resident capacity was 120. The facility submitted a credible allegation of compliance on 8/26/16. During the survey, the facility tested and recorded water temperatures in all resident areas using calibrated thermometers; they had their plumber inspect the water system to ensure temperatures came within the acceptable range; maintenance staff were in-serviced on 8/26/16 and a plan was implemented for reporting temperatures that are out of range; water temperatures will be taken twice daily and recorded immediately, all staff were in-serviced or in the process of being in-serviced on the reporting structure and for proper resident supervision & assistance, and residents and families are being informed of the facility ' s awareness and monitoring of the water temperatures. The IJ was removed as of 8/26/16. The severity of this deficiency was lowered from L to F, widespread, no actual harm, with potential for more than minimal harm. The findings include: On 8/22/2016 at 12:17 p.m., a room observation was conducted for Resident #72 in Room #216, and the hot water was noted to be hot to this surveyor 's hands to the point of not being able to keep them under the running hot water. On 8/22/2016 at 12:18 p.m., a water temperature was obtained using a calibrated thermometer for Room #216. The reading was 118 degrees Fahrenheit (F). An observation was conducted on 8/22/2016 at 1:40 p.m. of the water temperature for Room #219, and the water was hot to this surveyor's hands to the point of not being able to keep them under the running hot water. A water temperature was obtained of Room #219's hot water on 08/22/2016 at 1:42 p.m. with a calibrated thermometer. The temperature was 120 degrees F. An observation was conducted on 8/22/2016 at 1:43 p.m. of the water temperature for Room #220, and the water was hot to this surveyor's hands to the point of not being able to keep them under the running hot water. A temperature was obtained at that time with a calibrated thermometer, and the reading was 122 degrees F. A water temperature was obtained of Room #320 s hot water on 08/22/2016 at 1:50 p.m. with a calibrated thermometer. The reading was 118 degrees F. A water temperature was obtained of Room #333's hot water on 08/22/2016 at 1:53 p.m. with a calibrated thermometer. The reading was 120 degrees F. An interview was conducted on 08/22/2016 at 2:01:52 p.m. with Employee C, Maintenance Director, and he was asked how often the facility obtained water temperatures. Employee C replied, I take them every week. We just spent a lot of money on getting reticulates (plumbing lines) for the rooms due to cold temps, but now we have issues with hot water temperatures. Friday (8/19/2016) when I took the temperatures, I got a reading for the hot water temperature of 118 degrees, and at that time I decreased the boilers down 5 degrees. Employee C confirmed that he left for the weekend and did not recheck the temperatures. Employee C informed this surveyor he was planning on taking temperatures this am (8/22/2016), but was not able to do so. Employee C stated, The facility is of old construction, and by the time the water gets down to the end of the hallway it gets colder, so he is constantly adjusting the boilers to make sure the water is in the right temperature range. The Maintenance Director was then asked if he knew the temperature range for hot water and he replied, Yes, it ' s 105 - 115 degrees according to state regulations. On 8/22/016 Employee C was asked to obtain a thermometer to walk with this surveyor and verify the water temperatures for various rooms. He was asked if he was using the thermometer he normally used and was it calibrated, and he replied, Yes. The water temperature was obtained for room #219 at 2:10 p.m. with a reading of 116.9 degrees F. The water temperature was obtained for room #222 at 2:11 p.m. with a reading of 115.7 degrees F. The water temperature was obtained for room #226 at 2:15 p.m. with a reading of 116.9 degrees F. Employee C was asked at this time to obtain water temperatures for all the rooms in the facility. On 08/22/2016 at 3:33 p.m., Employee C returned with a log of the water temperatures obtained for all the rooms in the facility, and temperatures were ranging from 104 -116 degrees F. Employee C informed the surveyor at this time that he made changes to the boiler temperature and was now getting a reading of 110 degrees F. Employee C was asked if he knew what the reason was behind the high water temperatures, and he said no . An interview with Employee C, on 08/23/2016 at 4:05 p.m. confirmed he was rechecking the water temperatures for the facility, and he made another adjustment to the boiler taking it down 4 more degrees F. On 08/23/2016 at 4:18 p.m., Employee C and this surveyor took a tour of the boiler room/water system for the facility. Observations and interview at that time revealed the facility has two boilers, but one domestic holding tank where the water is stored until it goes to the resident rooms and showers. There were no anti-scalding devices installed on the plumbing. A review of the computer which gave the facility a reading of the boilers and the domestic hot water holding tank revealed a reading for boiler #1 of 119 degrees F and for boiler #2 of 120.58 degrees F. The domestic holding tank reading was 105 degrees F. Employee C stated, This morning it was reading 110 degrees, so I took it down to 105 degrees, and I changed pump 6 to automatic instead of run . I hope that makes the temperatures go down. Employee C was asked what the facility had done to correct the concerns with hot water temperatures, and he replied I just keep tweaking the boiler temperatures. Employee C confirmed the boiler temperatures were reading as high as 124-126 degrees F at times, but then when he adjusted it the facility would get cold water temperatures in some of the rooms at the end of the hallways. Resident rooms closest to the holding tank were Rooms 216, 217, 219, 220, 316, 317, 319, 319 and 320. Employee C was asked if any residents had complained to him about their water being too hot and he replied, Yes, a resident (Resident #5) came to me about a month ago and told me his water was too hot, so I came down and adjusted the boiler. Employee C was asked whether he filled out a grievance or completed an incident report for Resident #5, and he replied, No, I just came down and adjusted the temperature. When asked whether he had ever notified the Administrator of the high water temperatures, he replied that he had not. During an interview on 8/23/2016 at 4:35 p.m. with Employee C, he was asked if the facility had ever called a professional company to come and look at the water system since the water had been running too hot. He replied, No, I just have been doing it myself, and I know just as much about the boilers and the system as they do. A review was conducted of the facility's water temperature logs which revealed the following readings: On 4/26/2016, third floor rooms #304 - #306 had temperature readings of 117 degrees F, rooms #310 - #313 had readings between 116 & 117 degrees F, rooms #318 to #325 had readings between 116 and 118 degrees F, and rooms #327 to #333 had readings of 116 - 117 degrees F for a total of 22 out of 37 that were greater than 115 degrees F. The temperatures for the third floor spa and shower rooms were 117 and 118 degrees F. The 2nd floor readings were listed as follows: room #206 was 116 degrees F, rooms #218 to #220 were each 116 degrees F, room #228 was 116.2 degrees F, and room #230 had a reading of 116 degrees F for a total of 7 rooms out of 37 that were greater than 115 degrees F. (photographic evidence obtained). On 5/10/2016, the facility water temperature log revealed the following readings: rooms #306 - #313 read 116 to 118 degrees F, room #315 read 118 degrees F, rooms #317 - #323 were 116 and 118 degrees F, room #326 was 116 degrees F, rooms #328 - #333 were 116 and 117 degrees F, and rooms #336 - #338 had readings of 116 degrees F for a total of 25 rooms out of 37 with hot water temperatures exceeding the range of 105 - 115 degrees F. The second floor water temperatures were not conducted. Readings done on 6/7/2016 for the second floor were listed as the following: rooms #207 - #209 were 116 degrees F, rooms #211 - #116 and #214 - #225 had readings of between 116 -117 degrees F, and rooms #228 - #233 had readings between 116 - 117 degrees F (22 out of 37 rooms were out of range). The shower room on the second floor had a reading of 116 degrees F. Third floor readings were as follows: rooms #306 - #308 were between 116 - 117 degrees F, 110 - 113 degrees F, and between 116 - 118 degrees F. Room #315 was 118 degrees F, rooms #317 - #323 ranged between 117 and 118 degrees F, rooms #325 - #331 ranged between 116 and 117 degrees F, room #333 was 117 degrees F, and room #335 was 116 degrees F (26 rooms out of 37 were out of range). On 07/18/2016, the third floor readings were as follows: rooms # 306 and #307 had readings of 117 degrees F. There were no readings documented for rooms #309 - #311, rooms #312 and #313 were 118 degrees F, and rooms #315 - #320 were between 116 and 118 degrees F (10 out of 35 rooms were out of range). No readings were obtained for the second floor for the month of July. On 08/19/2016, the third floor readings were as follows: rooms #306 - #307 were 118 degrees F, rooms #310 - #313 were between 117 and 118 degrees F, room #315 was 118 degrees F, rooms #317 - #323 were between 116 and 119 degrees F, rooms #325 - #326 were recorded at 116 degrees F, rooms #328 - #333 were between 117 and 118 degrees F, and rooms #336 - #338 were recorded at 116 degrees F (26 rooms out of 37). On the second floor, 22 out of 37 rooms were out of range. West-end showers and shower area sinks on the second floor were 117 degrees F. An interview was conducted on 08/23/2016 at 5:19 p.m. with Employee C. He was asked that after he received a high temperature reading and made adjustments, how soon afterward he would re-check the temperatures. He replied, A few weeks, I guess. Employee C was asked how often he calibrated the thermometer he used, and he replied, I don't; it's digital. He confirmed he thought since it was digital that it was automatically calibrated and accurate. Employee C was asked whether he knew how to calibrate the thermometer, and he replied, No, I have never done that. Employee C was asked that since he made an adjustment on 8/19/2016 at the end of the day, why the facility was still getting high water temperature readings on 8/22/2016. He replied, I don't know. An interview on 08/23/2016 at 5:30 p.m. with the Administrator confirmed that she was not aware that the facility hot water temperatures were out of range since 04/26/2016. The Administrator reviewed the facility temperature log and confirmed that the hot water had been running as high as 118 to 120 degrees F. She stated, I knew the water was cold, but I had no idea it was running hot. The Administrator confirmed she should have been notified and would expect to be notified with any reading less than 105 F or greater than 115 F. An interview on 08/23/2016 at 5:41 p.m. with Employee C confirmed that he was making adjustments and changes to the system since April 2016, and didn't really know why the facility was still getting high and low water temperature readings. Employee C confirmed he didn't document any of the interventions he had conducted, and did not speak with staff or interview residents about whether they had concerns with hot water. He confirmed that he didn't notify the Administrator of the high temperature readings. During an interview on 08/23/2016 at 5:50 p.m., Employee C was asked to calibrate his thermometer so water temperature readings could be obtained. He was not aware of how to calibrate the facility thermometers, and asked for this surveyor to assist him to calibrate the thermometer. An observation was conducted on 08/23/2016 at 6:04 p.m. of the Administrator and Employee C looking up on the computer how to calibrate the facility thermometers. An 08/24/2016 interview was conducted at 9:00 a.m. with an outside plumbing contractor who was called into the facility to investigate why the facility was having hot water temperature concerns. The contractor confirmed he made adjustments to the domestic hot water holding tank and set it to 108 degrees F and tightened the PID (proportional interval derivative) valve and thought that he may have fixed the problem. He was asked if this was the reason for the high hot water readings, and he replied, I can't be certain, but I think it was the faulty valve since we made the adjustment, and the temperatures have been in the right range, so we will see if that's the solution. On 08/24/2016 at 6:24 p.m., an interview was conducted with Resident #72 who was asked if she had any concerns with the water temp in her room. She replied, Oh yes! I had a shower a few weeks ago, and the water was way too hot and it almost burned me! When asked what she did about that, she stated, I was yelling saying it's hot, it's hot turn it off, its burning me! The girl turned it off then. When asked whether anyone from the facility came and checked her water temperature or spoke with her about it, she stated, No, and I'm not taking a shower back there again. I told them they could just do it in the bed and do it for me; I didn't want to be burned again. The resident ' s two sisters where visiting in the room at the time of the interview, and they confirmed the resident complained to them that she was almost burned during the shower due to her water being too hot. This incident occurred in the shower in her room which was scheduled during the day shift. A record review was conducted for Resident #72 which revealed a date of admission of 07/27/2016 with [DIAGNOSES REDACTED]. A review of the Admission Material Data Set (MDS) revealed a Brief Interview for Mental Status score of 14 out of 15 (indicating that she was cognitively intact). She required total assistance for bathing and personal hygiene. Additional record reviews revealed that for the rooms where the water temperatures were elevated, there were 31 cognitively impaired residents. An interview was conducted with Employee H, Certified Nursing Assistant (CNA) on 08/25/2016 at 9:43 a.m., who confirmed that a few weeks ago Resident #72 told her that she got a shower, the water was hot, and she thought she was burned. The employee was asked whether the resident had complained since then when she received a shower, and the CNA replied, No, she won't get back in the shower since then; she gets a bed bath. When the CNA was asked whether she told anyone about the water being too hot, she replied, Yes, I told a maintenance guy. A review was conducted of the facility's grievance log, and no documentation was noted related to Resident #72 ' s complaint of hot water temperatures. On 08/25/2016 at 10:50 a.m., an interview was conducted with Employee S, Maintenance Staff, who confirmed he had been obtaining and documenting hot water temperatures as high as 118 to 120 degrees F for the facility. The employee was asked what happened when he got a reading that was high. He replied, I go back and tell Employee C, and we adjust the boiler a few degrees F, and then we go back and check it. Employee S was asked how soon afterward he rechecked the temperatures, and he replied, We check every month. The employee confirmed the facility did not re-check the temperatures; they waited until the next month when temperatures were due. An interview on 08/26/2016 at 9:45 a.m. with the Director of Nursing (DON) confirmed she wasn't notified by Employee C that the facility water temperatures were running high or by Employee H that Resident #72 complained of hot water temperatures when she received a shower. An interview on 08/26/2016 at 10:36 a.m. with Employee C confirmed he still did not know the root cause of the high water temperatures, but that since the PID valve was tightened and changes were made to the domestic holding tank, the temperatures had been within range. During an interview on 08/26/2016 at 11:07 a.m. with the Administrator and Employee C, the Administrator confirmed that Monday, 08/22/2016, was the first time she was informed that the water temperatures were running high and out of range, and that Employee C was making the adjustments. The Administrator confirmed she called an outside contractor on Tuesday 8/23/2016 to come to the facility and investigate/address the issue. The contractor arrived on 8/24/2016 around 8:00 a.m. On 08/26/2016 at 11:09 a.m., an interview with the outside plumbing contractor confirmed that he made adjustments on the computer, tightened the PID loop, and brought the domestic hot water tank to 107 degrees F. He was asked that since the domestic hot water tank was set at a certain temperature, how the room temperatures were reading higher than the domestic hot water tank. He replied I have no idea why the water is getting hotter as it leaves the tank. It should only vary by 1 degree up or down. It could be the sensor in the domestic holding tank. It's been there for 4 - 5 years, so maybe it's not giving an accurate reading to the computer, and might need to be replaced. The contractor confirmed that at this time the root cause for the elevated hot water temperatures was unknown. He stated that he would change the sensor to see if they would get more accurate readings. On 8/26/16, the facility submitted a credible allegation of compliance which documented the steps taken by the facility. On 8/23/16, facility staff adjusted the domestic water tank to 105 degrees F. Water temperatures were taken throughout the building and were found to be within the acceptable range. Thermometers were calibrated prior to the temperature recordings. The facility notified their A/C & heat contractor who made adjustments to the system. The plumbing contractor was also notified. On 8/24/16, the plumbing contractor adjusted the PID loop and checked the set-point for the domestic hot water. Water temperatures were taken again and were within required limits. Maintenance staff took all room temperatures which were within limits during morning and afternoon readings. On 8/25/16, the plumber visited again to ensure that water temperatures were acceptable in resident rooms. Water temperature were taken in the morning and afternoon and found to be within parameters. On 8/26/16, the water temperatures were again taken in the morning and afternoon and found to be within the required limits. Logs of the temperature readings were provided. The plumbing contractor visited again to check the system. Five housekeeping staff and four maintenance staff were in-serviced on the morning of 8/26/16 regarding the required water temperatures and how to report immediately if temperatures fall outside the acceptable range. Staff were instructed to contact the Maintenance Director or Administrator. Phone numbers were provided for the Maintenance director, Administrator, A/C & Heat contractor and the plumbing contractor. The facility will continue to take water temperatures twice daily and to immediately record each temperature. Training documentation was provided. Forty-eight care staff, including CNAs, nurses, activities, dietary and social services, were in-serviced on 8/26/16 on who to notify if water temperatures felt too hot or too cold. Staff were instructed to test the water first and to not allow residents to touch the water if it was not comfortable when the staff touched the water. Training documentation was provided. The Maintenance Director will provide daily temperature logs to the Administrator. Temperatures will be discussed at the weekly Standard of Care meetings. All temperatures will be reviewed at the Quality Assurance meetings to ensure ongoing compliance. Residents, staff, families and visitors will be requested to report any uncomfortable temperatures so they can be responded to immediately. The IJ was removed on 8/26/16 prior to the survey team's exit from the facility.