Every finding on record at PruittHealth - Augusta

Based on staff interviews, record review, and review of the facility's policy titled Freedom from Patient Abuse, Neglect, Exploitation, Mistreatment and Misappropriation of Property Mission Statement, the facility failed to protect the residents' right to be free from physical and sexual abuse by other residents for two of two residents (R) (R96 and R92) reviewed for abuse out of a total of 31 sampled residents. Actual harm occurred when R96 was physically abused by R64, resulting in R96 receiving a fractured clavicle and head laceration. Additionally, R92 was sexually abused by R93. Findings include: Review of the facility's policy titled, Freedom from Patient Abuse, Neglect Exploitation, Mistreatment and Misappropriation of Property Mission Statement, revised 11/15/2024, noted, It is the mission of [Corporation name] and its affiliated providers (collectively, the Organization) actively to preserve each patient's right to be free from abuse, neglect, exploitation, mistreatment, and misappropriation of patient property. The Organization recognizes that every patient has the right to be free from verbal, sexual, physical, and mental abuse, corporal punishment, and involuntary seclusion. The purpose of our abuse prohibition procedures is to assure that our partners are doing all that is within our control to create a standard of intolerance and to prevent any occurrences of any form of patient abuse, neglect, exploitation, mistreatment, and misappropriation of property. 1. Review of R96'sFace Sheet, located in the electronic medical record (EMR) under the Profile tab, revealed R96 was admitted to the facility on [DATE] with diagnoses that included adult failure to thrive, unsteadiness on feet, visual hallucinations, restlessness and agitation, and vascular dementia. Review of R96's Annual Minimum Data Set (MDS), with an assessment reference date (ARD) of 8/28/2024 and located under the Resident Assessment Instrument (RAI) tab of the EMR, revealed R96 had a Brief Interview for Mental Status (BIMS) score of three out of 15, which indicated R96 was severely cognitively impaired. R96 was identified to wander about the facility, in and out of rooms and the halls. Review of R64'sFace Sheet, located in the EMR under the Profile tab, revealed R64 was admitted to the facility on [DATE] with diagnoses that included cerebral infarction, vascular dementia with agitation, restlessness, and agitation. Review of R64's Annual MDS, with an ARD of 5/23/2025 and located under the RAI tab of the EMR, revealed R64 had a BIMS score of three out of 15, which indicated R64 was severely cognitively impaired. Review of the facility investigation, provided by the Administrator, revealed on 6/21/2024, R64 was heard by a staff nurse to be yelling, Didn't I tell you to stay out of my room? As the nurse was responding, R64 was observed to grab R96 and throw R96 to the floor. Review of an After Visit Summary from the emergency room (ER), dated 6/21/2024, revealed diagnoses of closed, displaced fracture of acromial end of right clavicle, laceration of scalp, and abrasion of right knee. Review of R64's Progress Notes revealed a note dated 6/21/2024 at 6:01 pm of Writer was in Nursing office when she heard a big thump in the hallway. When going into hallway writer heard resident say 'He was in my room. I told him not to go into my room. Hospice nurse stated that he saw resident pick up the other resident and throw him to the floor. The other resident was laying on floor with blood to right side of head and saying his shoulder hurts. Administrator was called. Dr. [Doctor] was called. Dr. said to print 10-13 paper [process of initiating an involuntary mental health evaluation] to send resident out. Resident sister was called, no answer. Message left. Administrator said to call Police. Police called and was in building. Sister was in building, resident finally left with sister. Sister is to transport resident to [local Hospital] . Further review of R64's Progress Notes revealed a note dated 5/19/2024 at 3:20 pm of Writer and several other staff heard loud cussing and a loud noise coming from down Hall 2, went to this resident room where the loud cussing was coming from we all observed another resident lying on floor writer and staff removed resident out room of this resident who continued to be aggressive and cussing resident other resident was taken to his room but this resident when to other hall to the other resident room still cussing and threatening to harm resident. Administrator made aware of status advised to call this resident sister to come to Nursing facility to talk to resident, RP [Responsible Party] called and is on her way to facility resident is in his room at this time will continue to monitor . Review of R64's EMR revealed no further incidents of abuse between R64 and R96 or any other resident. Observations during the survey, from 6/23/2025 through 6/26/2025, revealed no concerns related to abuse. During an interview on 6/24/2025 at 10:18 am, the Administrator stated she could not find any other information to indicate what measures were taken to keep the two residents separated, as she was not employed in the facility at that time, and she found nothing in the previous Administrator's files. The Administrator confirmed all staff received abuse training yearly and as needed. The Administrator confirmed there had been no incidents of abuse involving R96 during her employment at the facility. During an interview on 6/26/2025 at 9:47 am, the Director of Nurses (DON) stated, I just started in December of 2024. I can't answer what was put in place at that time. During an interview on 6/26/2025 at 10:21 am, the Social Service Director (SSD) stated, I wasn't here at that time, I don't know what happened. [R64] has not had any behaviors since I've been here. 2. Review of R92's Quarterly MDS, with an ARD of 12/24/2024 and located in the RAI tab of the EMR, revealed an admission date of 9/15/2015, that R92 had a BIMS score of five out of 15, which indicated her cognition was severely impaired, and had diagnoses of Alzheimer's disease, glaucoma, and vascular dementia. Review of R92's Care Plan, dated 7/30/2019 and located in the EMR under the RAI tab, revealed, Self-care deficit Activities of Daily Living related to: impaired mobility, hx [history] of muscle contractures, vision impairment, incontinent of B/B [bowel/bladder]. Resident requires mostly ext.[extensive] to total assistance/ [R92] has a specialty chair (name). An intervention included, Total assist with the Hoyer lift with appropriate number of staff members. Review of R92's Care Plan, dated 3/16/2020 and located in the EMR under the RAI tab, revealed R92 was at risk for alteration in psychosocial well-being related to a diagnosis of dementia. Interventions included, . Provide calm and safe environment to allow resident to express feelings related to situational stressor . Review of the facility investigation, dated 1/13/2024 and provided by the facility, revealed 1/13/2024 5:52 am Resident roommate alerted staff that another resident was in her room touching her roommate under the sheets, She hollered at man to get out of their room. Man asked resident 'who is you?' Man pulled his pants up and headed into the hallway, Resident [R92] skin assessment clear with no injuries noted, POA [Power Of Attorney] notified, no response, writer left message, Administrator notified, DON notified, Police notified (case #[number]\, MD [physician] notified, Rx [order] send out for further evaluation and treatment, Writer interviewed resident. Resident [R92] was asleep and does not remember the incident. Sending resident [R92] out to hospital for further evaluation via ambulance by stretcher . Review of R93's admission MDS, with an ARD date of 11/28/2023 and located in the RAI tab of the EMR, revealed an admission date of 11/21/2023, that R93 had a BIMS score of 12 out of 15, which indicated his cognition was moderately impaired, and had diagnoses of schizophrenia, apraxia following cerebral infarction, and Parkinson's disease. Review of R93's Care Plan, dated 8/8/2022 and located in the EMR under the RAI tab, revealed Mood State: [R93] is at risk for having signs and symptoms of mood distress as evidenced by verbalizing feeling down, depressed, or hopeless. 1/13/24: inappropriate touching of others. An intervention included, . Observe and report any changes in mental status, mood, behavior caused by situational stressor . Review of the facility investigation, dated 1/13/2024 and provided by the facility, revealed, . 7/13/2024 5:59 am Resident [R93] alert and oriented to person and place, no pain noted, writer was alerted by screaming resident in [room number], [R93] was in resident room with pants down sitting in chair, he was touching 22A [R92] inappropriately with covers pulled back, 228 [roommate] yelled at resident to 'get out of my room,', He responded 'Who is you?' [R93] pulled up his pants and exited to hallway, Nurse [name] was escorting resident in hallway and asking which way to go, Writer came out of office where I was charting, Writer saw that this was her resident so I escorted him back to his bed. He then got into his wheelchair and came back into the hallway looking into room from in the hallway. Family [name] was notified, did not answer, left message to call facility regarding resident behavior, MD aware, DON aware, Administrator aware, on coming staff aware that resident was placed on 1 on 1 monitoring, Police made aware case #[number], statements from staff collected . Resident touched another resident inappropriately while she was in her bed resting. Roommate caught him in the act. Yelled at resident and he pulled up his pants and exited the room into the hallway . Review of the clinical records for R92 and R93 revealed no further incidents. R93 was discharged from the facility following the incident and did not return. Observations during the survey, from 6/23/2025 through 6/26/2025, revealed no concerns related to abuse. During an interview on 6/24/2025 at 11:45 am, the Administrator stated she was not working at the facility at the time of the incident and stated abuse training is provided to staff annually. The Administrator stated she provided everything she could find for the investigation. During an interview on 6/25/2025 at 3:01 pm, R92's roommate was asked if she remembered a male resident about 1.5 years ago coming into her room, going over to her roommate's bed, and being inappropriate to her roommate. The roommate stated, Yes, just barely. The roommate stated she yelled for the nurse to get the male resident out of her room. The roommate stated she vaguely remembers the incident, and it only occurred once. During a telephone interview on 6/25/2025 at 3:08 pm, Licensed Practical Nurse (LPN)10 stated R93 went into R92's room, pulled his pants down, and put his hand in R92's brief. LPN10 stated R92 was not aware, as she had advanced dementia and did not respond. LPN10 went on to say the roommate woke up and saw R93 in her room and yelled for him to get out. LPN10 stated R93 was placed under constant surveillance until a more appropriate placement could be found two weeks later, and no other incident occurred.

Based on observation, staff interviews, record review, and review of the facility's policy titled Pressure Injury Prevention Program, the facility failed to monitor for changes and intervene when a pressure ulcer worsened for one of six residents (R) (R9) reviewed for pressure ulcers out of a total sample of 33. R9 was first identified with a pressure ulcer on 3/21/2025. There was no documented monitoring of the pressure ulcer from 3/21/2025 until 3/31/2025, when the pressure ulcer was noted to have worsened from excoriation to an unstageable pressure ulcer requiring debridement. This caused R9 actual harm when she was subsequently found to have a wound infection and osteomyelitis (infection in the bone). Findings include: Review of the facility's policy titled, Pressure Injury Prevention Program, dated 3/18/2021, revealed, . pressure injury prevention includes assessing for the risk of development. A risk assessment should be performed on admission, at regular intervals, and when the resident experiences a significant change in condition. Risk factors for pressure injury development include mobility, continence, medications, cognitive status, nutrition, history of pressure injury, and impaired blood flow. Residents identified at risk must have interventions implemented to mitigate risk factors. Any resident who is identified with a 'Braden Scale for Predicting Pressure Score Risk' score of 18 or below should be placed on the 'Pressure Injury Prevention Program.' The 'Pressure Injury Prevention Program' consists of the following bundles . Those bundles included interventions of . monitor the skin of all at risk residents daily during ADL's [activities of daily living] and report any abnormal findings to the Charge Nurse . Minimize Pressure through turning and positioning, therapeutic support surface assessment, therapeutic seating surface assessment, and tissue tolerance assessment . Review of R9's Face Sheet, located under the Face Sheet tab of the electronic medical record (EMR), revealed the resident was admitted to the facility on [DATE] with diagnoses that included abnormal weight loss, type 2 diabetes mellitus, thyroid disorder, anemia, and anxiety. Review of R9's Care Plan, dated 5/26/2023 and located under the Resident Assessment Instrument (RAI) tab of the EMR, revealed, . [R9] is at risk for skin breakdown/pressure injury D/T [due to] immobility . Interventions included to assist with incontinent care as needed. There was no intervention to assist with repositioning. Review of R9's Annual Minimum Data Set (MDS), located under the RAI tab and with an assessment reference date (ARD) of 3/7/2025, revealed R9 had a Brief Interview for Mental Status (BIMS) score 12 out of 15, which indicated the resident was cognitively intact. It was recorded that R9 was dependent on staff for toileting hygiene and bathing/showering, and required partial to moderate assistance with bed mobility. It was recorded that R9 was always incontinent of bowel and bladder, was at risk for pressure ulcers, and did not have any pressure ulcers. Review of R9's Braden Scale for Predicting Pressure Ulcer Risk, dated 3/7/2025 and located under the Assessment tab of the EMR, revealed R9 scored 17, which indicated the resident was at mild risk for developing a pressure ulcer. Review of R9's Progress Notes, dated 3/21/2025 at 5:52 am and located in the EMR under the Progress Notes tab, revealed, the resident's skin was warm and dry to touch, and she had a formed bowel movement. There was no documentation of any wound on her sacrum. Review of R9's Progress Notes, dated 3/21/2025 at 6:57 am and located in the EMR under the Progress Notes tab, recorded, . During incontinent care, it is discovered that the identified impairment to [R9] sacrum has worsened. Protective clean dry dressing applied and is intact. Nsg [nursing] will continue with close status monitoring . Review of R9's Situation, Background, Assessment, Review (SBAR) completed on 3/21/2025 and located in the Progress Notes tab of the EMR, revealed the Situation was excoriation (scraping or rubbing off the skin, resulting in an abrasion or raw area) to the sacrum. Documentation included, . resident scratches her backside. The Background described R9's medical condition and vital signs. The Assessment documented under skin evaluation that R9 had a wound. The description was . granulated [a type of connective tissue that forms on the surface of a healing wound] tissue to sacrum . The appearance was . wound noted to sacral area with granulated tissue 3 areas approx. [approximately] ½ to 1 inch . It was recorded that the primary care clinician was notified at 7:17 am with orders to clean and dress wound start wound care. Review of R9's Physician Orders, dated 3/21/2025 and located under the Orders tab of the EMR, revealed a treatment order for zinc oxide (a topical cream used to treat excoriation) to the excoriated area. Review of R9's Medication Administration Records (MARs), dated 3/21/2025 through 3/31/2025 and provided by the facility, revealed that the zinc oxide was applied as ordered. Review of R9's Progress Notes, Medication Administration Records, Treatment Administration Records, and Wound Management tabs of the EMR revealed no documented evidence of any measurements, descriptions, or monitoring of R9's excoriation after 3/21/2025 until 3/31/2025. There was no documented evidence of any treatment other than zinc oxide. Review of R9's Progress Notes, dated 3/21/2025 through 3/31/2025, revealed the resident had been diagnosed with an ileus (a painful obstruction of the ileum or other part of the intestines). Review of R9's Wound Management tab of the EMR, dated 3/31/2025, revealed she had an acquired sacral pressure ulcer. It was documented that the pressure ulcer measured 4 centimeters (cm) long by (x) 8cm wide x 0.1cm deep. It was considered unstageable due to the eschar (dead tissue covering the wound). Review of R9's Progress Note, dated 4/3/2025 at 8:35 am, and located under the Progress Notes tab of the EMR, revealed, . Wound care ordered. Wound to sacrum stable. Wound bed necrotic and intact tissue. Surrounding skin intact. No S/S [signs or symptoms] of infection noted . Review of R9's Progress Note, dated 4/3/2025 at 5:34 pm and located under the Progress Notes tab of the EMR, revealed, . [R9] was seen by the QSM [Quality Surgical Management] nurse practitioner. A new order noted to do a wound culture of sacral wound. Culture was done and ready for lab [laboratory] pickup . Review of a wound management note, dated 4/3/2025 and electronically signed at 7:52 pm by the Wound Nurse Practitioner (WNP), revealed that she educated R9 on the wound status, offloading, and repositioning frequently, and R9 verbalized understanding. Sharp debridement was completed to remove necrotic tissue. It was recorded that R9's status was discussed with her Primary Care Practitioner (PCP), along with wound status, wound treatment, and possible osteomyelitis. It was recorded that the WNP measured the wound, and it was 4cm x 8cm x 2cm and had a moderate amount of purulent (thick pus-like fluid that comes from a wound or infection) drainage that had an odor to it. Review of a Wound Management note, dated 4/7/2025 at 2:56 pm, written by the QSM, and provided by the facility, revealed the wound to the sacrum was declining, the wound bed had black necrotic tissue, surrounding skin was thin and dry, and there was a moderate amount of serosanguinous (thin watery) drainage. It was recorded that a low-air-loss bed was ordered, 18 days after the first documented evidence of R9's pressure ulcer. Review of R9's Care Plan, located under the RAI tab of the EMR, revealed an update on 4/7/2025 of . Resident refuses to be repositioned in bed. Resident refuses a wedge to help with positioning . Review of R9's Progress Note, dated 4/9/2025 at 4:42 pm and located under the Progress Notes tab of the EMR, revealed, . Wound culture obtained from sacral wound . At 4:51 pm, it was recorded, . sacral wound declining. Wound bed yellow and black necrotic tissue. Surrounding skin macerated (broken down and soft skin from prolonged exposure to moisture . Review of a Wound Management note, dated 4/10/2025 at 10:00 am, written by the QSM, and provided by the facility, revealed R9's sacral pressure ulcer measured 6cm x 8.5cm x 2.5 cm. The QSM classified the wound as a clinical stage 4 (severe, deep wound that extends through the skin and into the underlying muscle, tendon, or bone) with the tissue depth showing bone. It was recorded that the wound was a larger volume with a persistent odor and movable, nonviable, and fluctuant yellow/black tissue. It was recorded that the skin around the wound was denuded toward the left buttock, and there were concerns for osteomyelitis due to the appearance and the depth now to the bone. The possibility of R9 having osteomyelitis was discussed with her PCP, and initiation of antibiotics was recommended while awaiting the results of the wound culture. Review of R9's Progress Note, dated 4/13/2025 at 9:00 pm and located under the Progress Notes tab of the EMR, revealed, . Remains on ABT (antibiotic therapy) . for cellulitis of the buttocks . Review of R9's Progress Note, dated 4/17/2025 at 2:43 pm and located under the Progress Notes tab of the ERM, revealed, . Per QSM, resident will need a PICC [peripheral inserted central catheter] line. DX [diagnosis]: Osteomyelitis of vertebra, sacral and sacrococcygeal region . order placed with IV [intravenous] team for placement of line . Continued review revealed a Progress Note dated 5/22/25 at 12:36 pm by R9's PCP recorded, .[R9] is a chronically ill . Agreed with discontinuing IV antibiotics. Discussed R9's current and chronic conditions to include . sacral osteomyelitis . R/P [representative] states she does not want aggressive care measures for patient. Discussed Advance Directives and Hospice with R/P. R/P states she wishes to sign Pt [resident] up for Hospice . Hospice contacted and informed of consultation . During an observation on 6/25/2025 at 1:00 pm, R9 was noted to have a large sacral wound. The tissue was red, and no drainage was noted. The sacral bone was visible. During an interview on 6/26/2025, the Director of Nursing (DON) revealed she was aware R9 had a large sacral PU that was facility-acquired. When asked about what treatment and interventions had been put in place when R9's sacral PU had been discovered, the DON stated R9's PCP was called. The DON was asked why there was no order for treatments other than zinc oxide, as the pressure ulcer worsened, and why there was no measurement or monitoring between 3/21/2025 and 3/31/2025. She stated she was not aware that no treatment had been ordered for that time frame. The DON stated that the staff should have followed the pressure ulcer prevention program guidelines. The DON stated there was no root cause analysis completed to determine why R9's PU had deteriorated significantly in a short period of time. The DON stated she was unsure how the osteomyelitis had developed. She further stated she did not know when the resident's low-air-loss mattress had been placed on her bed. The DON stated interventions prior to her developing the sacral pressure ulcer included turning and repositioning every two hours and as needed, and providing prompt incontinence care. The DON confirmed there was no documented evidence that the resident had been turned and repositioned every two hours. She stated there was no place in the electronic medical record for the documentation to have been completed.

Based on record review and staff interviews, the facility failed to ensure that a Registered Nurse (RN) was on duty for at least eight consecutive hours a day, seven days a week. The failure created the potential for a negative impact on residents' quality of care and had the potential to affect 84 of 84 residents who resided at the facility. Findings include: Review of the Payroll Based Journal (PBJ) report, submitted by the facility, noted four days of non-coverage of Registered Nurses during the second quarter of 2025. The dates were identified as 2/8/2025 (Saturday), 2/9/2025 (Sunday), 3/15/2025 (Saturday), and 3/16/2025 (Sunday). Review of the staffing records, provided by the Staffing Coordinator (SC), revealed there was no RN coverage on the four identified dates as required. During an interview on 6/26/2025 at 9:31 am, both the SC and the Director of Nursing (DON) confirmed that there was no RN scheduled on the specified dates. The DON stated, I will come in when we don't have someone to be in the building. I'm sure I was here. The DON acknowledged, at the time of the interview, that the DON is permitted to work as the Charge Nurse only when the facility census is under sixty. The facility census was consistently over 80. During an interview on 6/26/2025 at 8:39 pm, the Administrator acknowledged the four days of no RN coverage.

Based on staff interviews, record review, and review of the facility's policy titled Infection Prevention and Control Plan, the facility failed to have an effective antibiotic stewardship program. This had the potential to result in residents receiving unnecessary antibiotics, increase the risk of multi-drug-resistant organisms (MDROs), and could adversely affect 84 of 84 residents who resided at the facility Findings include: Review of the facility's policy titled Infection Prevention and Control Plan, revised 6/21/2024, revealed the Facility Administrator and Director of Health Service are responsible for supporting the Infection Preventionist . The Infection Preventionist is responsible for directing all infection control activities and assessing, developing, implementing, monitoring, evaluating and managing the Infection Prevention and Control Program . The section for antibiotic stewardship included, . Monitor antibiotic susceptibility results to detect clinically significant antibiotic resistant bacteria . Monitor appropriate and inappropriate antibiotic utilization in the facility . Implement antibiotic stewardship policy, guidelines, and the algorithms to improve antibiotic utilization . Continuous education all partners/providers regarding antibiotic stewardship policy and program expectations . Evaluation of policy and program outcomes to ensure antibiotic stewardship program improvement . Review of the facility's infection control documentation for March 2025 and April 2025 revealed a list for each unit of which residents received antibiotics. The list for each unit included the resident's name, infection site/symptoms/diagnosis, treatment/intervention, start date, stop date, and a place to document if it had met McGeer's criteria (standardized definitions used in healthcare to classify and categorize infections). There were no comments about whether the infections had met any of McGeer's criteria. Review of March 2025 Monthly Healthcare Associated Infection Summary Report, provided by the facility, revealed the antibiotic therapy rate was 59.91 percent. This was calculated from the rate of antibiotic days of therapy (DOT) per 1,000 resident days. The monthly DOT was 162 x 1000 and then divided by the total monthly resident days of 2704. The antibiotic utilization ratio was 0.059. There were 19 new antibiotics started. Review of April 2025 Monthly Healthcare Associated Infection Summary Report, provided by the facility, revealed the antibiotic therapy rate was 102.13 percent. This was calculated from the rate of antibiotic days of therapy (DOT) per 1,000 resident days. The monthly DOT was 273 x 1000 and then divided by the total monthly resident days of 2673. The antibiotic utilization ratio was 0.102. There were 28 new antibiotics started. During an interview on 6/25/2025 at 2:30 pm, the Infection Preventionist (IP) stated she had just taken over the infection control program in January 2025. She stated she had just followed what the other IP had done. She stated that she was unsure of how to track and trend infections on each unit. She stated she had not ensured the infections being treated with antibiotics had met any of McGeer's criteria. She stated there is a place in the physician order section of the Electronic Medical Record where McGeer's criteria have been met, but that did not show up until the order for the antibiotic had been entered. During an interview on 6/26/2025 at 1:04 pm, the Administrator, Director of Nursing, and the IP agreed that the Antibiotic Stewardship Program had not been fully implemented. They stated the infection rates were discussed in the Quality Improvement (QI) meetings; however, the QI members had not discussed whether the infection rate was acceptable or not.

Based on observations and staff interviews, the facility failed to ensure a safe, clean, homelike environment on two of three units (Unit 1 and Unit 2). Specifically, there was a strong urine smell on Unit 1 and 10 rooms on Unit 1 and Unit 2 (Rooms 1, 2, 4, 9, 13, 20, 21, 23, 25, and 26) with damaged drawer fronts. The deficient practice had the potential to place the residents residing in the rooms at risk of living in a non-homelike environment and had the potential to place the residents at risk of injury related to the damaged drawer fronts. Findings include: 1. During an observation of Unit 1 on 6/23/2025 at 11:45 am, a strong smell of urine was noted. This smell was in the entire hallway, and it was stronger by Rooms 2, 7, 9, and 10, with the strongest smell coming from room [ROOM NUMBER]. Observations on 6/23/2025, at 1:00 pm, 3:00 pm, and 4:45 pm of Unit 1 Hall, revealed that the strong smell of urine continued. There were no times when the smell had decreased in intensity. During an observation on 6/24/2025, at 9:00 am on the Unit 1 Hall, the strong smell of urine was present. The smell was also in the front lobby, which was adjacent to Unit 1 Hall. Observations on 6/24/2025, at 11:20 am, 1:15 pm, 2:25 pm, and 4:00 pm on the Unit 1 Hall, revealed that the strong smell of urine continued. During an interview on 6/25/2025 at 9:30 am, the Environmental Services Manager revealed he was aware of the smell in the hallway and stated they had stripped and cleaned the floors in the rooms, but the smell always came back. He stated he was aware which rooms had the strongest urine smell that came into the hallway. He further stated that the rooms were supposed to be deep cleaned once a month, and that the beds, mattresses, floors, and resident furniture were also cleaned. He stated he had a list of when the rooms were to be cleaned; however, there was no documentation of when these rooms were cleaned. Review of the facility's procedure for completion of a deep clean for a resident room included pulling all furniture out to clean underneath and behind, and damp mopping the floors with a cleaner. This procedure did not address correcting any odors. 2. During an observation on 6/25/2025 at 10:00 am, Rooms 1, 2, 4, 9, 13, 20, 21, 23, 25, and 26 on Units 1 and 2 were noted to have damage to the fronts of the drawers located under the closet doors. There were two closets in each of the above rooms. The damage ranged from the wood veneer being partially peeled off to the edges of some drawers having rough, gouged wood. During an interview on 6/26/2025 at 3:00 pm, the Maintenance Director stated she was aware of the damage to the drawer fronts. She confirmed the drawer fronts could cause injury to the residents. During an interview on 6/26/2025 at 4:30 pm, the Administrator stated she was aware of the odors and damaged drawer fronts. She stated she had not been able to address it yet, as she had only been the facility's Administrator for approximately six months and had a lot of items to attend to.

3. During an observation on 6/25/2025 at 8:30 am of R49's incontinent care, Certified Nurse Aide (CNA)1 failed to wash her hands after she discarded the dirty brief and dirty gloves prior to donning clean gloves to apply the clean brief. During an observation on 6/25/2025 at 10:40 am of R192's incontinent care, CNA7 failed to wash her hands after she discarded the dirty brief and dirty gloves prior to donning clean gloves to apply the clean brief. During an observation on 6/25/2025 at 11:03 am of R54's incontinent care, CNA2 failed to wash her hands after she discarded the dirty brief and dirty gloves prior to donning clean gloves to apply the clean brief. During an interview on 6/25/2025 at 11:15 am, when asked when she would change gloves during the incontinent care process, CNA2 stated that she would change gloves and wash her hands if the resident had a bowel movement. CNA2 stated that she did not recall being trained to change gloves during the incontinent care process. During an interview on 6/26/2025 at 9:50 am, CNA7 stated that she realized that she should have changed gloves and washed her hands prior to applying the clean brief, but she was nervous. During an interview on 6/26/2025 at 2:50 pm, the Director of Nursing (DON) stated that her expectation going forward regarding handwashing practices during care is that staff will be immediately in-serviced and leadership will conduct rounds and audits to ensure the training is effective. Based on observations, staff interviews, record review, and review of the facility's policies titled Infection Prevention and Control Plan and Handwashing, the facility failed to fully develop the infection control program to track and trend infections, maintain one of one laundry folding table in a cleanable manner, provide incontinent care in a manner to prevent cross contamination for three of three sampled residents (R) (R49, R54 and R192) observed during incontinent care out of a total sample of 31. These failures had the potential to cause increased infections in the facility and affect the 84 residents residing in the facility. Findings include: Review of the facility's policy titled Infection Prevention and Control Plan, revised 6/21/2024, revealed the Facility Administrator and Director of Health Service are responsible for supporting the Infection Preventionist . The Infection Preventionist is responsible for directing all infection control activities and assessing, developing, implementing, monitoring, evaluating and managing the Infection Prevention and Control Program. Review of the facility's policy titled Handwashing, dated 10/9/2023, indicated, . Procedure When to perform Hand Hygiene: After contact with blood, body fluids, excretions, mucus membranes, non-intact skin or wound dressings; after any contact with objects/medical equipment on the vicinity of the patient; If your hands move from a contaminated body site to a clean body site; and after removing gloves . 1. Review of the March 2025 and April 2025 Partner Infection Log Form for each unit revealed the resident's name, infection site, symptoms, diagnosis, treatment, interventions, and the start and stop dates. In the comments section, it was to have whether it had met McGeer's criteria or if it was a healthcare-associated infection; however, there was no documentation. There was a map of the facility with each infection noted with a color marked for each type of infection, and a separate map for which residents had enhanced barrier precautions or another type of infection precautions. During an interview on 6/25/2025 at 2:30 pm, the Infection Preventionist (IP) revealed she had just taken over the infection control program in January 2025. She stated she had just followed what the other IP had done. She stated that she was unsure of how to track and trend infections on each unit and how this related to preventing the spread of infections, or if staff education was needed. During an interview on 6/26/2025 at 1:04 pm, the Administrator, Director of Nursing, and the IP agreed that the Infection Control program had not been fully implemented to prevent further infections. 2. During an observation and interview on 6/25/2025 at 10:30 am, on the clean side of the laundry room, the folding table was noted to be wood that had unfinished areas. The table was not attached to the wall behind it, so it tilted in a V shape. There was an approximately four-inch hole in the wall, and several areas were exposed through the drywall paper, revealing the gypsum. The Environmental Services Manager and the Laundry Aide revealed the table had been attached to the wall, but the supports had broken. The Laundry Aide stated it had been that way for at least six months to a year. Both agreed that the table was not a cleanable surface and the clean laundry could be hung up against the wall. During an interview on 6/25/2025 at 12:15 pm, the Maintenance Supervisor revealed she was unaware the laundry table and wall were in that condition. She stated she was still working on fixing things in the year she was at the facility.

Based on observations, staff interviews, facility document review, and review of the facility policy titled Pest Control: Dietary Services, the facility failed to have an effective pest control program for the facility's only kitchen. This deficient practice had the potential to place the 84 residents residing in the facility at risk for adverse health effects and a diminished quality of life. Findings include: Review of the facility's policy titled Pest Control: Dietary Services, revised 4/11/2016, revealed, . It is the policy of [facility name] that the Dietary Department is free of rodents and insects at all times to help ensure food is prepared and served in a sanitary environment . Review of the facility's pest control receipts, dated 1/06/2025 through 6/21/2025, provided by the facility revealed: On 1/6/2025: Target Pest: cockroaches, locations insecticide was applied included break room- interior, front door- introduction point, laundry/housekeeping- interior, rear door- introduction point, side door- introduction point. On 2/10/2025: Target Pest: cockroaches, locations insecticide was applied included Patient/Guest Rooms- interior, additional details: room [ROOM NUMBER] nightstand and under sink, rear door- introduction point, side door- introduction point. On 3/6/2025: Target Pest: cockroaches, locations insecticide was applied included the break room- interior, front door- introduction point, rear door- introduction point, side door- introduction point, laundry/housekeeping- interior. On 4/8/2025: Target Pest: cockroaches, locations insecticide was applied included the break room- interior, front door- introduction point, rear door- introduction point, side door- introduction point. On 5/1/2025, the only target pest was bedbugs. On 6/4/2025: Target Pest: cockroaches, locations insecticide was applied included the break room- interior, front door- introduction point, laundry/housekeeping- interior, rear door- introduction point, side door- introduction point. On 6/21/2025: Target Pest: cockroaches, location insecticide was applied included front door- introduction point and kitchen area- interior; Findings- grease build up in/out/by under kitchen grill and fryers. Please Clean. During an observation on 6/24/2025 at 2:57 pm, two roaches were observed on the kitchen floor when entering the kitchen from the back door. One roach was alive and Dietary Aide (DA)3 confirmed the insects were roaches and proceeded to sweep it up. A second roach was observed on the floor near the tray line. The Dietary Manager (DM) confirmed the roach. During an observation on 6/25/2025 at 11:57 am, a dead roach was observed on the floor behind the ice machine. During an interview on 6/25/2025 at 4:11 pm, the Maintenance Director was asked about roaches in the kitchen. The MD confirmed there were roaches in the kitchen partly due to lack of cleanliness as well as with issues from the pest control company's technician not always treating the kitchen. The Maintenance Director stated she complained to the pest control company, and they have since changed the technician.

Based on staff interviews, record review, and review of the facility's policy titled Patient Discharges and Transfers, the facility failed to provide written notification of a facility-initiated transfer to the resident/responsible party (RP) for one of two residents (R) (R72) reviewed for hospitalization out of a total sample of 31. The failure had the potential to affect the residents and/or their representative concerning the residents' appeal rights. Findings include: Review of the facility's policy titled, Patient Discharges and Transfers, dated 3/24/2015, revealed, . When infusion therapy services are discontinued or transferred, the patient will meet [facility name] Pharmacy Services criteria for discharge or transfer. The policy did not address providing written notice to a resident or their representative when transferred to the hospital. Review of R72's Annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) date of 3/18/2025, and located in the Resident Assessment Instrument (RAI) tab of the electronic medical report (EMR), revealed an admission date of 3/26/2024, a Brief Interview for Mental Status (BIMS) score of 10 out of 15, which indicated R72's cognition was moderately impaired, and diagnoses of cirrhosis, hypertension, and other seizures. Review of R72's admission Packet, dated 3/26/2024 and located in the EMR under the Resident Document tab, revealed, . B. Hospital Transfers. In the event that a physician orders the Resident to be transferred to a hospital, the Facility agrees to make arrangements for the transfer. Any charges associated with the transfer shall be the responsibility of the Resident. The Facility will not charge the Resident past the day that the Resident is transferred unless the Resident wishes to reserve the bed for when the Resident returns, in accordance with the Facility's bed hold policy . Review of R72's Progress Note, dated 1/08/2025 and located in the EMR under the Progress Note tab, revealed, Resident monitored throughout shift for stated/noted changes in condition. Resident noted with disorientation. Complaints of headache. Noted weakness. Away from the normal alert and oriented baseline. Received orders to send to ER [emergency room] for eval [evaluation]. Emergency transport was initiated. Resident transferred out to [hospital name]. Resident's [family member], [name] was made aware. Phone number to hospital was provided. NP [nurse practitioner] [name] aware . Review of R72's Transfer Form, dated 1/08/2025 and provided by the facility, revealed no documentation that a written notice was provided, and the form did not include appeals information. Review of R72's Transfer Form, dated 1/08/2025 and located in the EMR under the Observation tab, revealed no documentation that a written notice was provided to R72 or R72's representative, and the form did not include appeals information. Review of R72's Progress Note, dated 1/10/2025 and located in the EMR under the Progress Note tab, revealed, . Resident returned from [name] hospital today. During an interview on 6/25/2025 at 11:10 am, the Social Services Director (SSD) was asked about R72's written transfer notice to the hospital on 1/8/2025. The SSD stated she just started doing the transfer notices, and she was not sure if she did R72's notice for his 1/8/2025 hospital transfer. The SSD was also asked if the ombudsman was notified of R72's transfer to the hospital on 1/8/2025. The SSD stated she did not inform the Ombudsman if residents go out to the hospital, only for other transfers. The SSD stated she did not know to notify the ombudsman of hospital transfers. During a follow-up interview on 6/26/2025 at 6:10 pm, the SSD confirmed R72's representative and R72 only received a telephone call as the notice, and not a written notice, when R72 was transferred to the hospital on 1/8/2025.

Based on observation, interview, and record review, the facility failed to review and revise the comprehensive care plans for four of four residents (Resident) 96, R27, R35, and R9) out of a total sample of 31. The failure placed the residents at risk for unmet care needs and their inability to meet their maximum practicable level of functioning. Findings include: Review of the facility's policy titled, Care Plans, revised [DATE], noted, . The comprehensive person-centered care plan is developed to include measurable goals and timeframes to meet a patient/resident's medical, nursing and psychosocial needs, the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental and psychosocial needs that are identified in the comprehensive assessment . 1. Review of R96's Face Sheet, located in the electronic medical record (EMR) under the Profile tab, identified R96 was admitted to the facility on [DATE] with diagnoses that included adult failure to thrive, unsteadiness on feet, visual hallucinations, restlessness and agitation, and vascular dementia. Review of R96's annual Minimum Data Set (MDS), located in the EMR under the RAI tab and with an assessment reference date (ARD) of [DATE], revealed R96 had a Brief Interview for Mental Status (BIMS) score of three out of 15, which indicated R96 was severely cognitively impaired. Review of the facility investigation, provided by the Administer, revealed R96 was identified to have had two altercations with another resident, R64, as a result of R96's wandering. On [DATE], R64 screamed at R96 for being in his room. On [DATE], R64 physically assaulted R96 for wandering in his room causing injuries. Review of R96's comprehensive care plan, located under the RAI tab in the EMR and last updated [DATE], revealed R96 had . episodes of wandering on hall and in/out other residents' rooms . The goal read, Will not harm others. The intervention was identified as Remove from others room. Despite the two incidents between R96 and R64 with R96 suffering injuries, no care plan revisions were made for the protection of harm for R96. In an interview on [DATE] at 10:24 AM, the Social Services Director (SSD) confirmed that a care plan was not updated to address the incidents between R96 and R64 and keeping both free from injuries. 2. Record review of R27's Face Sheet, located in the EMR under the Profile tab, identified R27 was admitted to the facility on [DATE] with diagnoses that included congestive heart failure, hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting left dominant side, and depression. Review of R27's quarterly MDS, located under the RAI tab and with an ARD of [DATE], revealed R27 had a BIMS score of 15 out of 15, which indicated R27 was cognitively intact. In an interview on [DATE] at 10:33 AM, R27 stated, I want to tell you, my family have been alcoholics. They [staff] search my room. They took my vodka, but it was empty. I hadn't touched the gin yet. It doesn't seem right, they take my alcohol and want to kick me out. Review of R27's Progress Notes, located in the EMR under the Progress Notes tab, revealed on [DATE], [DATE], and [DATE], R27's room was searched for alcohol. On [DATE], R27 was informed that he would be given a notice of discharge if he continued to have alcohol in his room. Review of a psychiatric evaluation, dated [DATE] and located under the Documents tab in the EMR, noted that the evaluation was requested for the resident drinking in the facility. The evaluation read, . Unclear if his alcohol use is a problem in the facility or for his health. He is not motivated to stop. If it is a problem for his health I would consider putting him on naltrexone [used to treat opioid and alcohol addiction] 50 mg [milligrams] . Review of the Patient at Risk (PAR) note, located under the Progress Notes tab in the EMR and dated [DATE], noted, PAR/ WEEK 3 [R27] was discussed in par for behaviors. He has not shown any new behaviors this week. He was seen by [Psychiatrist] on [DATE] for behaviors. [Psychiatrist] recommended 50mg Naltrexone. We will continue to follow for another week than discharge him from PAR. The notation was entered by the SSD. Review of the comprehensive care plan, located under the RAI tab in the EMR and last updated [DATE], revealed R27 had no problems, goals, or interventions listed regarding his alcohol use, if there is a plan to discourage use, plan for medication interventions, psychiatric services, or potential discharge because of having alcohol in the facility. During an interview on [DATE] at 10:24 AM, the SSD said she was present during the room searches with R27. The SSD said she told R27 about the potential to be discharged . The SSD confirmed she had not updated R27's care plan to address the resident's alcohol use and plan to discontinue use in order to stay in the facility or if he is to be discharged how that would be managed. 3. Review of R35's Face Sheet, located in the EMR under the Profile tab, revealed R35 was admitted on [DATE] with diagnoses that included unspecified dementia, moderate, with other behavioral disturbance; lack of coordination; frequent falls; unsteady on feet; and cognitive communication deficit. Review of R35's quarterly MDS, located in the EMR under the RAI tab and with an ARD of [DATE], revealed R35 had a BIMS score of six out of 15, indicating R35 was severely cognitively impaired. In an interview on [DATE] at 8:15 AM, Certified Nursing Assistant (CNA3) confirmed that R35 was in a relationship with another resident. CNA3 stated, We just got told last week, so they moved the roommate out so they could have relations in the room, privately. Review of R35's comprehensive care plan, located under the RAI tab in the EMR and last updated [DATE], revealed R35 had no problems, goals, or interventions listed regarding her relationship with another resident specific to consent, safety, or privacy. During an interview on [DATE] at 10:24 AM, the SSD said she was aware of the resident's relationship and confirmed that a care plan had not been updated to address the resident's ability to consent, respect privacy, or safety measures if needed. 4. Review of R9's Face Sheet, located under the Face Sheet tab of the EMR, revealed R9was admitted to the facility on [DATE] with diagnoses that included type 2 diabetes, abnormal weight loss, and anxiety. During an interview on [DATE] at 12:15 PM, Licensed Practical Nurse (LPN) 3 revealed R9's daughter had died, and she had a decline after that. LPN3 stated R9 had lost weight and did not get out of bed anymore. Review R9's significant change in status MDS, with an ARD of [DATE] and located under the RAI tab of the EMR, revealed R9 had a BIMS score of 8 out of 15, which indicated the resident was moderately cognitively impaired. Review of R9's Care Plan, last revised [DATE] and located under the RAI tab of the EMR, revealed no problem, goal, or interventions related to the death of the resident's daughter and her response to that loss. Review of R9's Progress Notes, found in the EMR under the Progress Notes tab, revealed the only documentation of her daughter's death was that she went to the funeral on [DATE]. During an interview on [DATE] at 1:50 PM, MDS Coordinator (MDSC) 1 and MDSC2 confirmed R9's care plan had not been updated when her daughter had died to ensure she had received interventions to support her grief.

Based on observations, staff interviews, and record review, the facility failed to investigate the underlying issue for significant weight loss and assess the resident for goals and interventions for weight loss for one of three residents (R) (R82) reviewed for nutritional status out of a total sample of 31. This deficient practice had the potential to place R82 at risk of unmet nutritional needs. Findings include: Review of R82's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) date of 5/12/2025, located in the Resident Assessment Instrument (RAI) tab of the Electronic Medical Record (EMR), revealed an admission date of 2/12/2025, had a Brief Interview for Mental Status (BIMS) score of seven out of 15, indicating her cognition was severely impaired, weighed 207 pounds, was prescribed a therapeutic diet, and had diagnoses of unspecified fracture of lower end of left tibia, sequela, schizophrenia, unspecified, and muscle weakness. Review of R82's Orders, dated 2/12/2025, and located in the EMR under the Order tab, revealed R82 was to receive a NAS [No Added Salt] Special Instructions: Regular diet. Review of R82's Nutrition Assessment, dated 2/25/2025 and located in the EMR under the Observation tab, revealed, Weight (Lbs [pounds]): 205# [pounds] . FX [fracture] tibia . Goals: Adequate intake . Review of R82's Weights, located in the EMR under the Vitals tab, revealed on 4/03/2025, R82 weighed 207 pounds (lbs.) and on 5/2/2025, the resident weighed 197 lbs. This represented a 4.83 percent (10 lbs.) weight loss in one month. Review of R82's Meal Intake, dated 5/17/2025 through 5/31/2025 and located under the Vitals tab of the EMR, revealed that on 5/17/2025, R82's meal intake was 76-100%. There was no documentation of meal intakes from 5/18/2025 to 5/23/2025. Review of R82's Care Plan, dated 5/23/2025 and located in the EMR under the RAI tab, revealed, . [R82] is at nutrition and/ or hydration risk as evidenced by . Consumes less than 75% of food and/ or fluids at most meals. Initiated for PAR [Patient At Risk] for weight loss . The goal included, . [R82] weight will remain at +/- [plus/minus] lbs [pounds] of current weight through next review . Approaches included, . Provide diet as ordered (see current physician orders) . Therapeutic diet NAS Regular . ST [speech therapy] to evaluate and treat . Weight and monitor results . On admission x4 weeks . Observe for s/s [signs/symptoms] of dehydration and report to nurse . Review of R82's Nursing Note, dated 5/23/2025, and located in the EMR under the Progress Note tab, revealed, PAR note week 3. Resident had a 14 LB weight loss in a week. Last week in PAR, ice cream with lunch and dinner added to meal tray. Will get an order for Ensure Plus daily. Will continue to monitor. Review of R82's Orders, dated 5/23/2025 and located under the Orders tab of the EMR, revealed an order for Ensure Plus High Protein (food supplemt [sic], lactose-reduced) liquid; 0.08 gram-1.5kcal/mL; amt: Drink 1 Ensure; oral Special Instructions: Drink1 Ensure Plus daily . Review of R82's Meal Intake, dated 5/24/2025 through 5/29/2025 and located under the Vitals tab of the EMR, revealed no documentation of meal intake percentages. Review of R82's Nursing Note, dated 5/29/2025 and located in the EMR under the Progress Note tab, revealed, . PAR Note/Weights week 4. Resident was discussed in the PAR meeting today. Resident's last weight was 185lb this week weights 181lb. Care plan assessed. Resident will be discharged from the weight program. MD and RP are aware . Review of R82's Meal Intake, dated 5/30/2025 through 6/3/2025 and located under the Vitals tab of the EMR, revealed no documentation of meal intake percentages. Review of R82's Weights, dated 6/3/2025 and located under the Vitals tab of the EMR, revealed R82 weighed 181 lbs. This represented a 12.56 percent (26 lbs.) weight loss in two months. Review of R82's Meal Intake, dated 6/4/2025 through 6/9/2025, revealed no documentation of meal intake percentages. Review of R82's Dietary Note, dated 6/9/2025 and located in the EMR under the Progress Note tab, revealed, . Reviewed wt [weight] 181# 6/3/3025 BMI [body mass index] 33.1=obesity IBW [ideal body weight] range 102- -131# ABW [adjusted body weight] 148# Lost 8.1% past 32 days. Receives NAS meal plan with Ensure x 1 per day to add 250 cal [calories] and 9 gm [grams] protein. Intake 76-100%. Continue up and plan of care . Review of R82's Meal Intake, dated 6/10/2025 through 6/24/2025, revealed no documentation of meal intake percentages. During an observation and interview on 6/24/2025 at 12:50 pm, R82 was sitting on the side of her bed, wearing a brace on her left leg, and with her lunch tray untouched. Her meal included fried chicken, rice, spinach, fruit, and a beverage. R82 stated she had completed therapy this morning, and she could not eat because she was in pain. R82's meal intake was 0 percent. During an interview on 6/24/2025 at 1:15 pm, the Medical Doctor (MD) stated they were unaware of R82's weight loss. During an observation and interview on 6/25/2025 at 8:35 am, R82 was in her room sitting on her bed with her breakfast tray untouched. Her meal included pancakes, egg omelet, grits, sausage patty, and a beverage. R82 stated she was not going to eat it. R82 stated she was aware she was losing weight and was doing it on purpose. R82 stated she drinks a nutritional supplement and takes vitamins. R82 stated she will sometimes eat small amounts of the facility food and will buy her own snacks. R82 was asked if she had told anyone about her desire to lose weight, and she stated, It's nobody's business. R82 was asked if anyone had asked her about her weight loss, and R82 stated, No. During an interview on 6/25/2025 at 5:39 pm, the Director of Nursing (DON) was asked if she was aware of R82's significant weight loss in June 2025. The DON stated she would have to look at the record. The DON was asked if they had a nutrition committee. She stated that they had a PAR [Patient At Risk], but she was unsure if R82 was discussed. During an interview on 6/26/2025 at 9:05 am, R82 was asked if she received ice cream on her lunch and dinner tray. R82 stated, Sometimes, but not this week. R82 was asked if she liked ice cream, and she said, Yes. During a follow-up interview on 6/26/2025 at 9:13 am, the DON was asked again about R82's significant weight loss and why her meal intake was not documented in the EMR between 5/17/2025 and 6/25/2025, which was the timeframe of when R82 had her biggest weight loss. The DON stated she did not know, but the Dietary Manager (DM) was at the PAR meetings, and she informed the Registered Dietitian (RD) of concerns. The DON was asked if she was aware of R82 stating she wanted to lose weight to be more mobile. The DON stated, Yes. She stated that they had discussed her eating snacks rather than her facility food, which was more nutritious. The DON was asked why there was no documentation or a care plan with goals addressing R82's desire to lose weight. The DON stated they communicate that with dietary. During a telephone interview on 6/26/2025 at 10:33 am, the RD was asked if she was aware of R82's significant weight loss. The RD stated, Yes. She stated she charted on it and added a supplement, and just changed her diet 10 minutes ago as interventions. The RD was asked why R82 was losing weight. She stated, Because [R82] wanted to and she has been cutting back. The RD was asked how she knew this. She stated, By looking at the monthly weights. The RD stated she charted about R82's weight in May and June of 2025. The RD was asked when she became aware that R82 wanted to lose weight. The RD stated, When the nurses told me about one to two hours ago. The RD stated she would discontinue the Ensure. The RD was asked about the ice cream that was charted in the PAR notes when discussing weight loss. She stated the DM would have added it as a food preference, or maybe the PAR committee added it. The RD was asked if she was aware of the incomplete meal intake documentation. She stated, Yes. She stated she referenced it if they record it. The RD confirmed that the meal intake was not always documented, and it was an issue. The RD stated she relied on the documentation to see if the resident is eating enough, and it's very helpful to know that to determine the best interventions. During an interview on 6/26/2025 at 4:16 pm, the DM was asked why R82 had no ice cream on her lunch tray on the days of the survey. The DM stated it was because R82's ice cream was upon request, and she just changed the meal ticket to reflect this.

Based on observations, staff interviews, record review, and review of the facility's policy titled, F-689 Accidents - Water Temperatures, the facility failed to ensure comfortable hot water temperatures were maintained below 110 degrees Fahrenheit (F) for 12 of 40 rooms and for one of two shower rooms. The facility census was 92. Findings include: Review of the facility's policy titled, F-689 Accidents - Water Temperatures dated 1/10/2023 revealed the policy of this facility is to maintain safe water temperatures in resident care areas. Task instructions Number 1 (one) stated: For burn prevention, federal guidelines advise that you keep domestic water temperatures below 120 degrees F, although this temperature can still cause burns if exposure reaches five minutes. Many states have even stricter standards that set maximum temperatures lower than 120 degrees F. Observations during the initial tour on 1/9/2023 beginning at 10:12 am through 2:16 pm revealed, unsafe water temperatures ranging from 113.0 degrees F to 126.5 degrees F were obtained and verified with the Maintenance Director using the facilities calibrated thermometer. room [ROOM NUMBER] (two) - 120.5 degrees F room [ROOM NUMBER] (six) - 118.7 degrees F room [ROOM NUMBER] - 117.3 degrees F room [ROOM NUMBER] - 122.5 degrees F room [ROOM NUMBER] - 120.5 degrees F room [ROOM NUMBER] - 118.4 degrees F room [ROOM NUMBER] - 123 degrees F room [ROOM NUMBER] - 113.0 degrees F (Bathroom Sink) room [ROOM NUMBER] - 117.5 degrees F room [ROOM NUMBER] - 113.1 degrees F room [ROOM NUMBER] - 119.1 degrees F room [ROOM NUMBER] - 118.7 degrees F Station 1 (one) Shower Room - Sink: 123.0 degrees F; Shower Head: 126.5 degrees F. Station 2 (two) Shower Room - Closed Interview on 1/9/2024 at 1:51 pm with the Maintenance Supervisor stated, the hot water temperature should be no more than 110 F. Observation on 1/9/2024 at 4:35 pm with the Maintenance Director revealed, all the above hot water temperatures were rechecked and found to all be below 110 degrees F. Interview on 1/11/2024 at 11:00 pm with the Administrator revealed the policy was to check the water temperatures according to the maintenance schedule. He stated that it was his expectation for staff to ensure that the hot water temperatures remain under 110 degrees F.

Based on observations, staff interviews, record review, and review of facility's policies titled Medication Administration: General Guidelines and Medication Administration: Insulin Injections, the facility failed to ensure the medication error rate was less than five percent (5%). Specifically, two of four nurses observed during medication administration omitted an antihypertensive medication, administered insulin using the wrong technique and administered supplements without a physician's order resulting in an error rate of 11.54 percent . The facility census was 92. Findings include: Review of the facility's policy titled, Medication Administration: General Guidelines dated 4/10/2019, revealed medications are administered as prescribed, in accordance with good nursing principles and practices and only by persons legally authorized to do so. Review of the facility's policy titled, Medication Administration: Insulin Injections dated 10/27/2020, under the Policy Statement revealed, It is the policy of this facility that the procedures outlined in this policy must be followed to aid oxidation and utilization of blood sugar by the tissues and to control the blood sugar levels in resident with diabetes mellitus through the correct administration of insulin. Under the section titled, For insulin pens revealed, 4. Insert the needle under the skin at a 90-degree angle; 5. Press the button on the end of the pen; 6. Count to 10 and remove the pen; 7. Recap the pen. 1. Observation on 1/10/2024 at 8:46 am revealed Licensed Practical Nurse (LPN) administering medications to a resident. She pulled aspirin 81 milligrams (mg), acetaminophen 325 mg tablet, cetirizine 10 mg tablet from floor stock bottles. She then pulled amlodipine 10 mg tablet, citalopram 20 mg tablet and folic acid tablet, that were pre-packaged together from the pharmacy. After preparing the medication for administration, she verified that there was a total of six (6) pills in the medication cup. The nurse then went into the resident's room to administer the medications. The resident took them, and in doing so, the resident dropped two pills. One pill was dropped on the floor and one pill fell between the resident's arm and abdomen. Before leaving the room, the nurse was asked by the surveyor if she was aware that the resident had dropped two medications. She stated she was not. She picked them up and stated that it was the acetaminophen and amlodipine pills. She then went to the cart and pulled another acetaminophen tablet and administered it. She was then asked by the surveyor what the process was for the dropped medication that had been prepacked by the pharmacy, and she stated that all the medications were in packets and the next dose was scheduled for 1/11/2024. She stated that the resident would do without it, because he did not have an extra dose of amlodipine. 2. Observation on 1/10/2024 at 11:36 am revealed LPN BB administering sliding scale insulin to a resident. She entered the room and checked the resident's blood sugar which was 362. She returned to the cart and performed hand hygiene. She prepared the insulin after looking at the order which read, 10 units before meals and eight units of sliding scale insulin. She placed the needle on the pen, and she turned the dial to 18 units. She knocked on the door, entered and informed the resident that she was going to give him insulin. She cleaned the area with an alcohol wipe and administered the insulin until the pen clicked and then removed the pen. Once she returned to the cart, she was asked by this surveyor how long should she have kept the pen at the site before pulling out and away from the site, and she stated that she was not aware that there was any wait time after administering the insulin. 3. Observation on 1/10/2024 at 9:17 am revealed LPN CC administering medication to one resident. She prepared aspirin 81 mg tablet, vitamin D 325 micrograms (mcg)- two tablets, and vitamin B-12, 1000 mg tablet from floor stock bottles. She then prepared valsartan 80mg and amlodipine 10 mg tablet from pre-package pouches from the pharmacy. After preparing the medications, she verified that she had five medications for a total of six pills. Review of records for the residents observed during medication administration revealed there was no physician's order for the resident that was administered vitamin D325 mcg- two tablets. Interview on 1/10/2024 at 11:50 am with LPN CC revealed, when asked by the surveyor to verify the medications for the resident, she was not able to verify that the resident was ordered to receive vitamin D3. She stated that it was there this morning and stated that the resident would not have taken any of his medications if all his medications were not in the pill cup. Interview on 1/10/2024 at 11:55 am with the Director of Health Services revealed when asked by the surveyor about insulin administration, she stated that she was unsure how long after the click, that the pen should be removed. She revealed that she was aware that the pen should not automatically be removed after the click. She was then asked if a resident drops a prescribed medication, what was the process to replace the medication. She stated that the resident would still need to receive it and that the nurse would need to go to the e-kit box and fill out a slip that would notify the pharmacy of the medication removed for a resident. She stated that the residents should never go without their medication. When asked about nurses administering supplements without an order, she stated that the nurses would need to call and inform the physician and get a new order. Interview on 1/10/2024 at 12:25pm with the DHS revealed that the insulin pen should remain in place for six seconds after the click before removing it.

Based on observations, resident and staff interviews, record review, and review of the facility's policy titled Nursing: Patient/Resident Rights, Accommodation of Needs, the facility failed to provide a Geri wheelchair to one of 44 Residents (R) (R39). This failure has the potential for diminished quality of life, and to affect the resident's mental and psychosocial wellbeing. Findings include: Review of the facility's policy titled, Nursing: Patient/Resident Rights, Accommodation of Needs dated 12/1/2023 under section titled A. Call Light System revealed, (5). Respond to request. If an item is not available, or a request is questionable, get assistance from Charge Nurse. Return to patient/resident promptly. Review of R39's medical records revealed, she admitted to the facility with diagnoses that included muscle weakness (generalized), contracture of muscle, right lower leg, contracture of muscle, left lower leg, morbid (severe) obesity due to excess calories, and unsteadiness on feet. Review of R39's Quarterly Minimum Data Set (MDS) dated [DATE] revealed, Section C-Cognitive Patterns revealed she had a Brief Interview for Mental Status (BIMS) score of 15 indicating the resident had intact cognition; Section GG-Functional Abilities and Goals revealed she required assistance with toileting hygiene/lower body dressing, shower/bathing, putting on/taking off footwear and personal hygiene and indicated no use of mobility devices. Review of R39's care plan dated 12/21/2023 revealed an Activities of Daily Living (ADL)s Functional Status/Rehabilitation Potential with the potential for ADL self-care deficit: resident required total assistance with her ADL care needs and she was non-ambulatory. During an observation and interview on 1/9/2024 at 10:41 am with R39 observed in bed stated, her wheelchair had been taken away from her since September 2023. During an observation and interview on 1/10/2024 at 8:45 am, with R39 observed in bed stated, she would like get out from her room and propel around the facility if she had a wheelchair. R39 stated she felt confined to her room. During an interview on 1/11/2024 at 8:40 am with the Administrator, he acknowledged that R39 did not have a wheelchair. He stated that he started with the facility in September 2023 and when he found out that resident did not have a wheelchair he placed an order for a wheelchair with a company. He stated that they were expecting delivery soon and meanwhile they would get a wheelchair from the sister facility. He stated his expectations for staff to provide one on one activities per preference to residents who were not able to attend group activities. During an interview on 1/11/2024 at 9:10 am with the Activity Director, she acknowledged that the resident was not attending resident group activity due to the resident not having a Geri chair. She revealed that she offered the resident word search puzzles in her room in December 2023. She revealed that the Administrator was aware of the Geri chair issues. Cross Reference F679

Based on observations and staff interviews, the facility failed to provide a safe/clean/comfortable/homelike environment for two rooms on Station one, one room on Station two, and two rooms on Station three. These rooms contained missing hinges from closet doors, missing wood from a closet drawer, stained countertops, a baseboard in disrepair, a stained bathtub with a missing faucet and a dirty fan. The facility census was 92 residents. 1.Observation on 1/9/2024 at 11:27 am of room [ROOM NUMBER] revealed bed 39-A closet door hinge missing and bed 39-B closet's drawer door missing wood. Observation on 1/10/2024 at 9:50 am of room [ROOM NUMBER] revealed bed 39-A closet door hinge missing and bed 39-B closet's drawer door missing wood. Observation on 1/11/2024 at 10:05 am of room [ROOM NUMBER] revealed bed 39-A closet door hinge missing and bed 39-B closet's drawer door missing wood. Observation on 1/11/2024 at 10:25 am of room [ROOM NUMBER] revealed a stained countertop, baseboard in disrepair, and a stained bathtub with a missing faucet. 2. Observation on 1/9/2024 at 11:18 am of room [ROOM NUMBER] and 32, revealed beds 26- A, 26-B, 26-C,26- D, bed 32-A and 32-B hinges on the closet doors were missing preventing the doors from staying closed. Observation on 1/10/2024 at 1:15pm of room [ROOM NUMBER] and 32 revealed beds 26- A, 26-B, 26-C,26- D, bed 32-A and 32-B hinges on the closet doors were missing preventing the doors from staying closed. Observation on 1/11/2024 at 10:20 am of room [ROOM NUMBER] and 32 revealed beds 26- A, 26-B, 26-C,26- D, bed 32-A and 32-B hinges on the closet doors were missing preventing the doors from staying closed. During a tour of the facility on 1/11/2024 at 10:35 am, an interview was conducted with the Maintenance Director (MD), he confirmed damaged and missing hinges from closet doors, the missing wood from a closet drawer, stained countertops, a baseboard in disrepair, and stained bathtub with a missing faucet. The MD stated the conditions of the rooms were unacceptable and needed attention of repairs and removal of damaged unrepairable items. The MD mentioned he would immediately correct and address the damaged items in each room. 3. Observation on 1/9/2024 at 10:35am of room [ROOM NUMBER] revealed the resident in bed 12 A fan was covered with dust and blowing towards the resident's face. Interview on 1/10/2024 at 11:43 am with Housekeeper DD revealed that she was unsure who cleaned the personal fans of residents but stated that she would wipe down the back of the fan. She verified that the blades and the front of the fan was dirty/dusty. Interview on 1/10/2024 at 12:01 pm with the ESM stated that the cleaning of the residents' fans was a joint effort and housekeeping would clean the outside and if the blades were dirty then that would be completed by the maintenance department. Observation on 1/11/2024 at 11:50 am with the Environmental Services Manager (ESM) revealed the fan in room [ROOM NUMBER]A had not been cleaned and continued to be dirty. The ESM then removed the fan and took it out of the room to clean the dust off the fan. 47946 49138

Based on staff interview, record review, review of the facility's policy titled, MDS Assessment Accuracy and review of the Resident Assessment Instrument (RAI) Manual 3.0 User's Manual, the facility failed to document the discharge status for three of 42 Residents (R) (, R101, R104, and R106) who discharged from the facility. Findings include: Review of the facility's policy titled, MDS Assessment Accuracy, dated 12/6/2022, Policy Statement revealed the following: It is the policy of this healthcare center that each Minimum Data Set (MDS) reflects the acuity and the medical status of each patient/resident in accordance with acceptable professional standards and practices. Review of the Resident Assessment Instrument (RAI) Manual 3.0 User's Manual, version 1.18.11, dated October 1, 2023, revealed the following in Section A2105 Discharge Status, Item Rationale: This item documents the location to which the resident is being discharged at the time of discharge. Knowing the setting to which the individual was discharged helps to inform discharge planning, Demographic and outcome information. Review of R101's Minimum Data Set (MDS) Discharge Assessment-return anticipated dated 4/11/2023, Section A Identification Information under Section A2105 Discharge Status revealed there was no discharge status/location documented. Review of R104's MDS Discharge Assessment-return not anticipated, Section A Identification Information, dated 9/18/2023, Section A Identification Information under Section A2105 Discharge Status revealed there was no discharge status/location documented. Review of R106's MDS Discharge Assessment-return not anticipated, Section A Identification Information, dated 9/29/2023, Section A Identification Information under Section A2105 Discharge Status revealed there was no discharge status/location documented. Interview on 1/10/2024 at 3:20 pm, with the MDS Coordinator, she stated the MDS assessments should be completed quarterly and thoroughly. She confirmed the omission of the discharge status for R101, R104, and R106 and stated it should have been included in the Discharge Assessments. 46579

Based on observations, resident and staff interviews, record review, and review of the facility's policy titled Activities Program, the facility failed to ensure an ongoing program of activities based on activity preference assessments for one of 44 Residents (R) (R39). This failure has the potential to decrease the resident's quality of life and psychosocial wellbeing related to the ability not to participate in group activity and socialize with other residents within the facility. Findings include: Review of the facility's policy titled, Activities Program under Procedure revealed, 3. There shall be at least one different structured recreational activity provided daily each week that shall accommodate residents needs/interest/capabilities as indicated in the care plan. Review of Resident Face Sheet for R39 revealed, she admitted to the facility with diagnoses that included muscle weakness (generalized), contracture of muscle, right lower leg, contracture of muscle, left lower leg, morbid (severe) obesity due to excess calories, and unsteadiness on feet. Review of R39's Annual Minimum Data Set (MDS) dated [DATE] revealed, Section C-Cognitive Patterns revealed she had a Brief Interview for Mental Status (BIMS) score of 15 indicating the resident had intact cognition, Section F: Preferences for Customary Routine and Activities-Interview for Activities Preference included but not limited to, it was very important for resident to do things with groups of people, do her favorite activities, and to go outside to get fresh air when weather was good. Review of R39's care plan dated 12/21/2023 revealed an Activities care plan with the potential for social isolation and low activity participation to the resident's choice; Resident does enjoy family visits and conversing with roommates; Goal included, resident will choose and participate in activities of choice: Independent Activities ,1:1 Visitation/ Small groups activities; Approach included welcome resident/patient to the facility and introduce activities staff members. During an observation and interview on 1/9/2024 at 10:41 am with R39 in bed, stated her wheelchair had been taken away from her since September 2023 and she was not able to attend group activities. During an interview on 1/10/2024 at 8:45 am with R39, she was observed in bed and revealed that she would like to get away from her room and propel within the facility if she had a wheelchair. R39 revealed she was confined to her room and had not received one on one activities from staff since October 2023. Review of the Activity Progress Note from January 2023 to January 9, 2024, revealed the last one on one room visit provided to R39 was on 7/28/2023 at 12:14 pm consisting of a word search book and social talking with the last quarterly observation completed on 9/5/2023 at 2:59 pm. During an interview on 1/11/2024 at 8:40 am with the Administrator, he acknowledged that R39 did not have a wheelchair. He stated that he started with the facility in September 2023 and when he found out that resident did not have a wheelchair he placed an order for a wheelchair with a company. He stated that he got a response from the company to redo the order in a certain way, which he did. He stated that they were expecting delivery soon and meanwhile they would get a wheelchair from the sister facility. He stated his expectations for staff was to accommodate the needs of residents. During an interview on 1/11/2024 at 9:10 am with the Activity Director, she acknowledged that R39 was not attending group activity due to resident not having a Geri chair. She revealed that she had offered resident word search puzzle in her room December 2023. She revealed that the Administrator was aware of the Geri chair issues. Cross Reference F558

Based on observations, staff and resident interviews, record review and review of the facility's policy titled, Oxygen Administration, the facility failed to ensure that one of 44 sampled Residents (R) (R73), received oxygen per physician's orders and to ensure safe administration of oxygen as evidenced by no oxygen in use signage. Findings include: Review of the facility's policy titled, Oxygen Administration dated 8/2/2023 revealed, under the Policy Statement: It is the policy of the facility to provide oxygen safely and accurately to appropriate patients/residents. Review of R73's Electronic Medical Record (EMR) revealed she was admitted with diagnoses including, but not limited to chronic systolic heart failure, pulmonary hypertension, atrial fibrillation, and ventilator associated pneumonia. Review of R73's Admission [NAME] Data Set (MDS) dated [DATE], revealed Section C-Cognitive Patterns: Basic Interview Mental Status score of 13, which indicated she was cognitively intact; Section O- Special Treatments and Programs indicated use of oxygen therapy while a resident at the facility. Review of R73's physician orders revealed orders for oxygen at two (2) liters per hour via nasal canula. Review of R73's care plan revealed that she was at risk for decreased cardiac output related to diagnoses of hypertension and hyperlipidemia with an intervention that included administer oxygen as ordered. Observation and interview conducted on 1/9/2024 at 3:09 pm revealed R73 receiving oxygen at one and half liters via nasal cannula. R73 stated that she should be receiving oxygen at two (2) liters. During this time, there was no oxygen in use signage observed that would alert staff and visitors that the oxygen was in use in the room. Observation on 1/10/2024 at 9:00 am revealed R73 receiving oxygen at one and a half liters via nasal canula. There was no oxygen in use signage on the door frame noted. An interview conducted on 1/11/2024 at 3:42 pm with the Director of Health Services (DHS), she stated for any resident with physician's orders to receive oxygen, she expects the concentrator be set at the correct amount. She stated that any resident that was receiving oxygen should have an oxygen in use sign outside the door. An interview conducted on 1/11/2024 at 3:55pm with the DHS and the Senior Nurse Consultant verified that that R73 was not receiving oxygen at two (2) liters per hour and that there was no oxygen in use signage on the door. The Senior Nurse Consultant stated that she had gone around the building that morning to check to make sure all oxygen concentrators were set at the correct amount and that all rooms had oxygen in use signage on the door. She stated that she missed this resident previously because she did not see the concentrator from the hallway. She stated that nurses must get to eye level when they check for correct oxygen amounts.

Based on observation, staff interviews, record review and review of the facility's policy titled, Handwashing, the facility failed to reduce the spread of germs and decrease the spread of infection for one of 44 sampled Residents (R) (R25). Specifically, the facility failed to perform hand hygiene during treatment of a sacral wound. Findings include: Review of the facility's policy titled, Handwashing dated 9/19/2017, Policy Statement revealed, It is the policy of the facility that partners will clean their hands by either using soap and water or antiseptic hand sanitizer. Cleaning your hands reduces the spread of germs and decreases the spread of infections. Under the section titled, Procedure revealed When to perform hand hygiene: Before eating, Before and after any direct patient skin contact, After contact with blood, body fluids, excretions, mucus membranes, non-intact skin, or wound dressings, After any contact with objects/medical equipment on the vicinity of the patient, If your hands move from a contaminated body site to a clean body site, After removing gloves and After using the rest room. Review of R25's Electronic Medical Record (EMR) revealed, she had diagnoses that included but not limited to Parkinsonism, schizophrenia, type 2 diabetes, and pressure ulcer of sacral region, stage four (4). Review of R25's Quarterly Minimum Data Set (MDS) dated [DATE], revealed for Section C: Cognitive Patterns-a Basic Interview Mental Status score of 00, which indicated severely impaired cognition; Section GG: Functional Abilities and Goals- indicated she was totally dependent on others for care; Section H: Bladder and Bowel-indicated she was always incontinent of bladder and bowel. Review of R25's physician orders revealed orders for wound to sacrum to be cleaned with wound cleanser, pat dry, and apply skin prep around the wound; then apply calcium alginate and cover the wound with a dry dressing, three times a week. Review of R25's care plan revealed that she was at risk for further impaired skin integrity issues related to impaired bed mobility, incontinence of bowel and a resolved sacral wound that reopened on 4/5/2023. Interventions included, but not limited to treatments as ordered to sacral wound and monitor for signs and symptoms of infection. Observation conducted on 1/11/2024 at 11:15 am with Licensed Practical Nurse (LPN) AA providing wound care for R25 revealed upon entering R25's room, LPN AA prepared the supplies. She knocked on the door and announced herself. She explained to the resident what she was going to do and then assessed the resident for pain or discomfort. She washed her hands at the sink and then applied gloves as the Certified Nursing Assistant (CNA) repositioned the resident on her right side. LPN AA removed the old dressing and then removed her gloves. LPN AA did not perform hand hygiene prior to donning clean gloves and began to clean the wound with wound cleanser and 4 x 4 gauzes. LPN AA removed the dirty gloves and did not perform hand hygiene prior to donning clean gloves. LPN AA applied skin prep and then applied the dressing to the wound bed and then applied the border dressing over the wound. LPN AA removed her gloves and then washed her hands. LPN AA applied clean gloves and then dated the dressing. LPN AA then removed gloves, then removed the trash, and did not perform hand hygiene. LPN AA reassessed the resident for comfort and then the CNA repositioned her in the bed. Interview conducted on 1/11/2024 at 11:34 am with LPN AA revealed when asked by the surveyor when should hand hygiene be performed she stated, hand hygiene should be completed before and after the wound treatment however she often wondered if she should do it more often but was not sure. Interview conducted on 1/11/2024 at 12:01 pm with the Director of Health Services (DHS) confirmed that hand hygiene should be performed before and after treatment, after encountering body fluids and old wound dressing, when going from dirty to clean and after removing gloves.

Based on observations, interviews, and review of the policy titled COVID-19 Isolation and Cohorting Process and job descriptions titled LPN (Licensed Practical Nurse) Skin Integrity Coordinator, and Registered Nurse Skin Integrity Coordinator, the facility failed to ensure that infection control measures were followed for standard precautions during the provision of wound care for one resident (R) R#87; in addition, the facility failed to ensure staff followed appropriate protocol for personal protective equipment (PPE) use. The sample size was 39. Findings include: 1.Review of the policy titled COVID-19 Isolation and Cohorting Process revised 7/27/22, revealed [name] will provide designated Levels of units within the center for isolating and cohorting residents when making decisions to accept hospital and community admissions, transfers and with management of COVID-19 positive and presumptive in-house residents during the COVID-19 pandemic .When entering the Level I or II area/room, you must make sure you have the proper PPE on. The proper PPE are N95 Mask and Eye Protection. N95 masks will be used throughout the levels I and II .gown and gloves are donned (put on) outside the doorway of the resident room where care will be provided. Gown will be changed between rooms, doffing (removing) them in the resident's room and disposing of them in the regular waste receptacle inside by the door .gloves should never be worn in the hallway and always removed before exiting the resident's room .Level III Care Area/Room: PPE to be used by all partners on the unit to include: gloves as indicated .N95 mask if High to Substantial Community Transmission level or Outbreak testing, eye protection as indicated if High to Substantial Community Transmission level or Outbreak Testing .facilities located in area with high to substantial community transmission (are orange or red) should wear eye protection in addition to their N95 to ensure the eyes are all protected from exposure to respiratory secretions during patient care encounters . During an observation and interview on 8/10/22 at 5:25 a.m. revealed Certified Nursing Assistant (CNA) NN coming out of the room [ROOM NUMBER] and then entering room [ROOM NUMBER]. CNA NN was wearing a surgical mask, gloves carrying a bag of soiled briefs, and wearing an isolation gown at the time of the observation. CNA NN confirmed she had just provided peri care to residents in room [ROOM NUMBER], and was providing care for residents in room [ROOM NUMBER]. She also stated that she had not been educated specifically on removing PPE when going from one room to the next. 2. Review of the job description titled, LPN (Licensed Practical Nurse) Skin Integrity Coordinator, revised 12/16 indicated .universal precautions and maintain infection control standards when performing treatments and disposing of soiled dressings . Review of the policy titled, Registered Nurse Skin Integrity Coordinator, revised 12/16 indicated .universal precautions and maintain infection control standards when performing treatments and disposing of soiled dressings . Review of R#87's undated Face Sheet in the electronic medical record (EMR) revealed an admitted on 1/26/21 with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] Review of R#87's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Cover with abdominal pad and wrap with [MEDICATION(S)] on Monday, Wednesday, and Friday. Observation on 8/11/22 at 11:07 a.m., Registered Nurse (RN) DD during the provision of wound care to R#87's right heel. LPN II assisted by holding the resident's leg elevated for easier access during wound care. RN DD sanitized her hands, donned clean gloves, wore N95 mask and protective eyewear. RN DD removed soiled dressing, doffed gloves, used hand sanitizer, donned clean gloves, cleaned wound with normal saline (NS), and patted dry with gauze. She then applied skin prep to peri wound, applied Medi-honey, [MEDICATION(S)], Opti-foam silver and covered with ABD pad and wrapped with [MEDICATION(S)]. She then secured with tape and dated appropriately with the same gloves she had on after patting the wound dry with gauze. RN DD did not sanitize or change gloves between cleaning the wound and applying clean wound medication and clean dressing. During a joint interview on 8/11/22 at 11:30 a.m. RN DD and LPN II, stated they didn't realize that during R#87's wound care procedure that RN DD did not change gloves after cleaning wound and prior to medicating/applying dressing. RN DD and LPN II confirmed that hand sanitizing and glove change should be performed when going from a dirty area to a clean area during wound care.

Based on record review, observations, interview, and review of the policy titled, Oxygen Administration, the facility failed to maintain the cleanliness of the oxygen concentrator filter, change nasal canula tubing, and bag nasal canula tubing and Continuous Positive Airway Pressure ([CONDITION(S)]) mask when not in use, for four residents (R) (R#5, R#31, R#52, and R#55) of four residents reviewed who required respiratory care. Findings include: Review of the policy titled, Oxygen Administration, revised 11/01/19, revealed it is the policy of.to provide oxygen in safely and accurately to appropriate patients. Scope: This policy applies to Nurses .Procedure .Equipment: Oxygen Concentrator .Infection Control Policy of O2 Humidifier Bottles .7. The large external, black filter should be washed with soap and water once each week and as needed (PRN). Dry with towel and reinsert. Do not discard unless damaged . Regulate liter flow rate to ordered .flow rate.change oxygen tubing . 1. Review of R#5's undated Face Sheet in the electronic medical record (EMR) revealed an admitted [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the EMR under the Orders tab revealed an order dated 2/29/19, [CONDITION(S)] at NOC [night] 14/7 cm [centimeters of water pressure] medium face mask to be worn during sleep. During an interview and observation on 8/8/22 at 11:37 a.m., R#5's [CONDITION(S)] mask was laying on the night stand open to the environment. R#5 stated that the staff take the mask off in the mornings. In a concurrent follow-up observation and interview on 8/9/22 at 3:32 p.m., the Director of Nursing (DON) was shown the mask laying on the night stand open to the environment. The DON confirmed that the mask should be in a bag when not in use. The DON stated that it could have been set there by the resident. The DON further stated that the expectation is that the staff to place it in a bag when it is not in use. During an observation and interview on 8/10/22 at 9:39a.m., R#5's mask was laying on the nightstand. Licensed Practical Nurse (LPN) GG was shown the mask and confirmed it was not in a bag and should be. 2. Review of R#31's undated Face Sheet in the EMR revealed an admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R#31's physician orders (PO) in the EMR revealed an order on 5/12/22, Oxygen: Oxygen(O2) at 2 LPM [Liters per minute] via nasal cannula keep O2 Sats [Saturation level] > [greater than] 94% every shift. During an observation on 8/8/22 at 11:35 a.m., R#31's filter on the oxygen concentrator was covered in a thick layer of dust. During an observation and interview on 8/9/22 at 3:32 p.m., The DON was shown the concentrator filters. She confirmed the filters had a thick layer of dust and stated that were dirty. The DON further stated the dust could interfere with the resident not getting enough oxygen. She then revealed that she needed to verify if it is maintenance or nursing that cleans the concentrator filters. During an interview and observation on 8/10/22 at 9:39 a.m., LPN GG was shown the filters on R#31's concentrator, LPN GG confirmed that the thick layer of dust was not acceptable. 3. Review of R#52's undated Face Sheet located in the EMR revealed an admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R5#2's PO in the EMR revealed an order on 8/31/21, O2 at 2 L [Liters] via NC [nasal cannula] to maintain O2 Sats above 95%. During an observation on 8/8/22 at 12:21 p.m., R#52's filter for the oxygen concentrator was covered in a thick layer of dust. During an interview and observation on 8/9/22 at 3:33 p.m., the DON confirmed the dust on the filter and stated that the filter should not be covered in dust. During an interview on 8/11/22 at 9:55 p.m., the Administrator was asked about the mask and the concentrator filters. The Administrator stated she was not aware of the issues and expected the Infection Preventionist to make rounds and catch those type of issues. At the time of exit, on 8/12/22 at 12:25 a.m., no policies were provided to the team for storing masks and cannulas in bags when not in use. 4. Review of R#55's undated Face Sheet tab located in the EMR revealed R#55 was most recently admitted to the facility on [DATE]. Review of R#55's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R#55's quarterly Minimum Data Set (MDS) with an ARD of 5/31/22 revealed R#55's Brief Interview Mental Status was scored a three out of 15, indicating R#55 was severely cognitively impaired. Oxygen was marked by the facility as special treatments for R#55 while a resident. Review of R#55's care plan in the EMR revealed .CHANGE RESPIRATORY CIRCUIT/SUPPLIES AS ORDERED AND PRN [as needed]. Nursing Approach Start Date: 11/23/21 and no intervention for changing or cleaning oxygen concentrator filter. Review of R#55's PO revealed an order to .Change respiratory circuit/supplies as needed .Change respiratory circuit supplies weekly . dated 4/16/19. There was no physician's order to clean oxygen concentrator filter. During an observation on 8/8/22 at 1:19 p.m. R#55 was observed with oxygen being administered via nasal cannula while lying in her bed. R#55 nasal cannula oxygen tubing had no label with a date of the last time the tubing was changed. R#55's oxygen concentrator had a plastic vent cover on the back of the machine (over the filter). It was not clean and was covered with dust particles. During an observation on 8/9/22 at 2:10 p.m. of R#55 revealed R#55's nasal cannula oxygen tubing had no label with a date of the last time the tubing was changed. R#55's oxygen concentrator had a plastic vent cover on the back of the machine (over the filter) It remained covered with dust particles. During an interview and observation on 8/9/22 at 3:02 p.m. with LPN DDD confirmed nursing staff were responsible for ensuring oxygen tubing was changed and labeled with the date of change. She also confirmed changing oxygen tubing and maintaining oxygen equipment was important to avoid exposure to resident of respiratory bacteria. LPN DDD confirmed and verified R#55's nasal cannula oxygen tubing did not have a label with date of the last time it had been changed. LPN DDD confirmed she was unsure when R#55's oxygen tubing was last changed. She further confirmed R#55's oxygen concentrator had a vent cover on the back and was covered in dust particles. During an interview on 8/10/22 at 12:04 p.m. the Maintenance Director (MD) confirmed he did not have a maintenance policy regarding oxygen concentrator filters. The MD stated cleaning oxygen concentrator filter was not under his scope of practice. During an interview on 8/10/22 at 2:39 p.m. the Assistant Director of Nursing (ADON) confirmed nursing staff were responsible for changing residents' oxygen tubing to include nasal cannulas, mask, and nebulizer tubing. The ADON confirmed all the facility's oxygen tubing should be changed weekly and labeled with date of change. ADON confirmed all oxygen tubing should be stored in a bag when not in use to avoid exposure to germs.