Every finding on record at Rocky Knoll Health Care

Based on interview and record review, the facility did not report injuries of unknown origin to the State Agency (SA) for 1 resident (R) (R1) of 3 sampled residents.On 5/22/26, staff observed yellow and purple discoloration on R1's right ankle. An X-ray revealed multiple fractures. The injury of unknown origin was not reported to the SA.Findings include: The Facility's Abuse, Neglect and Exploitation Policy indicates: All residents residing at Rocky [NAME] Health Care Center have the right to be free from mistreatment, neglect, abuse, injury, misappropriation of property, and exploitation Injuries of Unknown Source - An injury should be classified as an injury of unknown source when all of the following criteria are met: The source of the injury was not observed by any person; The source of the injury could not be explained by the resident; The injury is suspicious because of the extent of the injury, location of the injury, the number of injuries observed at one particular point in time, orthe incidence of injuries over time .Reporting: All staff, employees .residents, and resident representatives are knowledgeable about the nursing home's reporting procedures and requirements. Per the Centers for Medicare & Medicaid Services' (CMS) direction, all nursing homes must immediately report all alleged violations involving mistreatment, neglect, abuse .including injuries of unknown source .to the Administrator (or designee) and to the Division of Quality Assurance (DQA) and Adult Protective Services. R1 was admitted to facility on 11/14/25 and had diagnoses including osteoporosis and history of falls. A Minimum Data Set (MDS) assessment, dated 6/2/26, indicated R1 was dependent on staff for transfers. On 7/28/26, Surveyor reviewed R1's medical record. R1 had a fall on 5/16/26 in which a Certified Nursing Assistant (CNA) lowered R1 to the floor. The facility assessed R1 for 72 hours following the fall and notified Legal Guardian (LG)-D and the physician. R1 remained at baseline with transfers and did not show signs of injury or pain. On 5/22/26, staff observed yellow/purple discoloration on R1's right ankle. An X-ray revealed multiple fractures in the right ankle. The facility initiated an investigation, interviewed staff, and educated staff on falls, assessments, notification, and documentation. The facility determined the injury was most likely caused by the fall on 5/16/26. The facility completed the investigation appropriately but did not report the injury of unknown origin to the SA when it was discovered or following the investigation. On 7/28/26 at 1:04 PM, Surveyor interviewed Nursing Home Administrator (NHA)-A who confirmed the facility did not report the injury of unknown origin to the SA. NHA-A stated the fall was witnessed and an origin for the jury was identified. Surveyor explained that because the fractures were discovered approximately one week after the fall, it could not immediately be determined that they resulted from the fall, therefore, a self-report and investigation were required to determine if another incident or fall occurred.

Based on observation, staff interview, and record review, the facility did not ensure food was stored and prepared in a safe and sanitary manner. This practice had the potential to affect all 138 residents residing in the facility. The facility did not consistently follow safe food cooling protocol. The facility did not ensure wash and rinse cycles for the dishwasher met the minimum required temperatures. The facility did not ensure cooked, pureed, and reheated food or food held for service reached a temperature of 165 degrees Fahrenheit (F). Findings include:On 6/8/26, Dietary Manager (DM)-F verified the facility follows the Food and Drug Administration (FDA) Food Code. Cooling Procedure: The 2022 FDA Food Code documents at 3-501.14 Cooling: (A) Cooked Time/Temperature Control for Safety Food shall be cooled: (1) Within 2 hours from 57 Celcius (C) (135 Fahrenheit (F)) to 21 C (70 F); and (2) Within a total of 6 hours from 57 C (135 F) to 5 C (41 F) or less. (B) Time/Temperature Control for Safety Food shall be cooled within 4 hours to 5 C (41 F) or less. If food is not cooled to 70 F within 2 hours, it must be either reheated to 165 F for 15 seconds and then re-cooled, or it must be discarded. This is because food that spends too long in the danger zone (between 41 F and 135 F) is at risk of rapid bacterial growth, which can lead to foodborne illness. Proper cooling is essential to prevent the risk of foodborne illness, and failing to meet the cooling time requirements can result in food safety violations. During an initial kitchen tour that began at 8:45 AM on 6/8/26, Surveyor and DM-F observed the following items in the reach-in cooler: ~ A container labeled Veg dated 6/7/26~ A container labeled Mashed potato dated 6/7/26~ A container labeled Lasagna dated 6/7/26~ A container labeled Beef dated 6/7/26~ A container labeled Ham dated 6/6/26~ A container labeled Grilled chicken dated 6/4/26~ A container labeled Egg bake dated 6/4/26~ A container labeled Peppers and sausage dated 6/7/26DM-F indicated the cooling log is on the cooler for staff to obtain and document the temperatures of all food put in the cooler for future resident consumption. DM-F indicated temperatures are obtained every two hours until the food reaches 41 degrees F or below. DM-F verified the container labeled Peppers and sausage was not on the cooling log. DM-F indicated they would provide previous cooling logs to ensure all food observed in the reach-in cooler was documented as cooled to an appropriate temperature. During a continuous kitchen observation that began at 2:16 PM on 6/8/26, Surveyor and DM-F reviewed the cooling logs and noted the above items that were cooked, cooled, and saved for resident consumption were not documented as reaching a safe cooled temperature within six hours:Dishwashing Temperatures: The 2022 FDA Food Code documents at 4-501.112 Mechanical Ware Washing Equipment, Hot Water Sanitization Temperatures: The temperature of hot water delivered from a ware washer sanitizing rinse manifold must be maintained according to the equipment manufacturer's specifications and temperature limits specified in this section to ensure surfaces of multi-use utensils such as kitchenware and tableware accumulate enough heat to destroy pathogens that may remain on such surfaces after cleaning. The surface temperature must reach at least 71 C (160 F) as measured by an irreversible registering temperature measuring device to affect sanitization .The lower temperature limits of 74 C (165 F) for a stationary rack, single temperature machine, and 82 C (180 F) for other machines are based on the sanitizing rinse contact time required to achieve the 71 C (160 F) utensil surface temperature. During an initial kitchen tour that began at 8:45 AM on 6/8/26, Surveyor and DM-F observed staff wash breakfast dishes. The dishwasher's data plate indicated the required minimum temperatures are 160 degrees F for the wash cycle and 180 degrees F for the rinse cycle. Surveyor observed the following temperatures for the wash and rinse cycles: ~ Wash cycle: 166 degrees F; Rinse cycle: 177 degrees F~ Wash cycle: 159 degrees F; Rinse cycle: 181 degrees F~ Wash cycle: 158 degrees F; Rinse cycle: 186 degrees FSurveyor observed the June 2026 dishwashing temperature log and noted the dishwasher did not reach the required minimum wash cycle temperature of 160 degrees F on 7 occasions or the required minimum rinse cycle temperature of 180 degrees F on 3 occasions. The lowest wash cycle temperature was 154 degrees F. The lowest rinse cycle temperature was 160 degrees F. Surveyor also noted the internal temperature of the dishwasher did not reach the required temperature of 160 degrees F on 4 occasions. Surveyor interviewed DM-F who verified the temperature should reach 160 degrees F for the wash cycle and 180 degrees F for the rinse cycle. DM-F was not aware the dishwasher was not consistently reaching the required minimum temperatures and stated DM-F would provide the May 2026 dishwashing temperature log for review. During a continuous kitchen observation that began at 2:16 PM on 6/8/26, Surveyor reviewed the May 2026 dishwashing temperature log and noted the dishwasher did not reach the required minimum wash temperature of 160 degrees F on 21 occasions. The dishwasher did not reach the required minimum rinse cycle temperature of 180 degrees F on 4 occasions. The lowest wash cycle temperature was 151 degrees F. The lowest rinse cycle temperature was 161 degrees F. Surveyor also noted the internal temperature of the dishwasher did not reach the required temperature of 160 degrees F on 5 occasions. The lowest documented internal temperature was 151 degrees F. Surveyor interviewed DM-F who confirmed the dishwasher did not reach the required minimum wash, rinse, or internal temperatures on multiple occasions. Reheating for Hot Holding:The 2022 FDA Food Code documents at 3-403.11 Reheating for Hot Holding: (A) Except as specified under (B) and (C) and (E) of this section, Time/Temperature Control for Safety Food that is cooked, cooled, and reheated for hot holding shall be reheated so that all parts of the food reach a temperature of at least 165 degrees F for 15 seconds. (B) Except as specified under (C) of this section, Time/Temperature Control for Safety Food reheated in a microwave oven for hot holding shall be reheated so that all parts of the food reach a temperature of at least 165 degrees F and the food is rotated or stirred, covered, and allowed to stand covered for 2 minutes after reheating.During a continuous kitchen observation that began at 2:16 PM on 6/8/26, Surveyor reviewed the facility's cooked food, hot holding, and reheated temperature logs for lunch from 6/1/26 through 6/8/26 and noted 33 pureed meals were not reheated to ensure they reached 165 degrees F. Surveyor observed temperatures between 115 degrees F and 155 degrees F with the lowest documented temperature of 115 degrees F on 3 occasions. Surveyor interviewed DM-F who verified food is cooked, pureed, and then reheated and staff obtain temperatures of the items prior to service. DM-F was not aware the documented temperatures did not reach the minimum requirements.

Based on staff interview and record review, the facility did not ensure care plans were revised for 2 residents (R) (R9 and R11) of 28 sampled residents. R9 started Hospice care on 11/5/25. R9's care plan did not indicate R9 was on Hospice. R11 returned to the facility on 3/5/26 from a hospitalization where a catheter was inserted. R11's care plan did not indicate R11 had a catheter. Findings include: The facility's Comprehensive Care Plan policy, revised December 2025, indicates: Care Plan Review and Revision: 1. The comprehensive care plan is a dynamic document and shall be reviewed and revised whenever necessary to accurately reflect the resident's current condition, goals, and needs. 2. The care plan shall be reviewed and revised when: .A significant change in condition occurs . 1. R9 was admitted to the facility on [DATE] and had diagnoses including Alzheimer's disease, dementia, and urine retention. R9's Minimum Data Set (MDS) assessment, dated 5/6/26, stated R9 had a Brief Interview for Mental Status (BIMS) score of 11 out of 15, indicating moderately impaired cognition. R9 had an activated Power of Attorney for Healthcare (POAHC). On 6/8/26, Surveyor reviewed R9's medical record which contained an order for Hospice care dated 11/5/25. R9's care plan did not contain a focus, goals, or interventions related to Hospice care. On 6/10/26 at 10:54 AM, Surveyor interviewed Director of Nursing (DON)-B who indicated staff should include Hospice interventions on a resident's care plan. 2. R11 was admitted to the facility on [DATE] and had diagnoses including Parkinson's disease, dementia. and urinary retention. R11's MDS assessment, dated 3/26/26, contained a staff assessment that indicated R11 was cognitively impaired. Between 6/8/26 and 6/10/26, Surveyor reviewed R11's medical record and noted R11 had a catheter. R11's medical record did not contain a care plan related to catheter use. (Of note: R11 returned to the facility on 3/5/26 from the hospital where a catheter was inserted.) On 6/10/26 at 11:49 AM, Surveyor interviewed DON-B who confirmed R11 did not have a care plan that addressed catheter use.

Based on staff interview and record review, the facility did not ensure the resident environment was as free of accident hazards as possible for 1 resident (R) (R37) of 4 sampled residents.R37 was admitted to the facility on [DATE] and had a history of falls. R37 fell at the facility on 5/27/26 and 5/30/26. admission and post-fall risk assessments did not accurately reflect R37's status.Findings include:The facility's Fall Prevention, Assessment, and Management Policy, revised 2/2026, indicates: The purpose is to ensure each resident is assessed for fall risk and receives individualized, person-centered interventions to reduce the likelihood of falls, injuries, and related harm .Fall risk assessments will include, but are not limited to: cognitive status (orientation, confusion, impaired judgment), history of falls and contributing circumstances, mobility, gait, balance and assistive device use, orthostatic hypotension or vital sign changes, diagnoses impacting mobility or cognition, medications that may increase fall risk, vision and hearing status, elimination patterns and toileting needs, environmental and behavioral risk factors .R37 was admitted to the facility on [DATE] following a syncopal episode that resulted in a fall with injury. R37 had diagnoses including mulitple rib fractures, history of falling, atrial fibrillation, hypertension, and orthostatic hypotension. A care plan, dated 5/20/26, indicated R37 was continent of bowel but incontinent of bladder and required the assistance of one staff for toileting. The care plan was revised on 5/27/26 to indicate R37 required the assistance of two staff with a gait belt and walker for transfers. An admission fall risk assessment, dated 5/20/26, contained a score of 22 which indicated R37 was at high risk for falls. The assessment indicated R37 did not have a fall resulting in fracture within six months prior to admission and had no noted drop between lying and standing for blood pressure. (Of note: R37 was admitted to the facility due to a fall at home resulting in rib fractures and had a diagnosis of orthostatic hypotension.) R37's medical record indicated R37 fell on 5/27/26 during a syncopal episode (fainting) while toileting which did not result in injury. A post-fall risk assessment, dated 5/28/26, contained a score of 8 which indicated R37 was at low risk for falls. The assessment indicated Not assessed/no information related to R37 having a fall(s) since admission/entry or reentry to the facility. (Of note: R37 fell prior to admission, a prior fall assessment indicated R37 was at high risk for falls, and the assessment completed on 5/28/26 was post-fall.) R37 fell again on 5/29/26 during a syncopal episode in physical therapy and was assisted back to the wheelchair by staff which did not result in injury. R37 fell again on 5/30/26 and was found on the floor of their bathroom with the wheelchair tipped back. R37 stated they were attempting to use the bathroom. An assessment indicated R37 had a compound fracture of the right femur, was tachycardic (fast heart rate exceeding 100 beats per minute at rest), and reported pain. R37 was transferred to the hospital and did not return to the facility. A post-fall risk assessment, dated 5/30/26, contained a score of 16 which indicated R37 was at moderate risk for falls. The assessment indicated R37 did not have any falls since admission/entry or reentry to the facility or the prior assessment despite the fact R37 was admitted following a fall at home and had falls on 5/27/26 and 5/29/26.On 6/10/26 at 10:44 AM, Surveyor interviewed Unit Manager Registered Nurse (RN)-E who indicated R37 had orthostatic blood pressures which caused syncopal episodes. RN-E stated medication/medication parameters to treat the condition were continuously being adjusted. RN-E verified R37's admission fall assessment and post-fall assessments were not accurately completed. RN-E indicated assessments should be accurately completed to reflect a resident's needs so appropriate interventions and assistance can be provided.

Based on observation, staff interview, and record review, the facility did not maintain an infection prevention and control program designed to prevent the development and transmission of communicable disease and infection for 1 resident (R) (R9) of 5 sampled residents. R9 was on enhanced barrier precautions (EBP) related to an indwelling catheter. R9's catheter bag was observed on the floor on multiple occasions. In addition, staff did not wear gowns or gloves during catheter care. Findings include: The facility's Enhanced Barrier Precautions policy, revised 6/2026, indicates: .Enhanced Barrier Precautions (EBP) help prevent the transmission of multidrug-resistant organisms (MDROs) during high-contact care activities .EBP apply to any resident who has a wound or indwelling medical device even if they aren't colonized with an MDRO. EBP requires that anyone providing or assisting a resident with high-contact care wear a gown and gloves . R9 was admitted to the facility on [DATE] and had diagnoses including Alzheimer's disease, dementia, and urine retention. R9's Minimum Data Set (MDS) assessment, dated 5/6/26, stated R9 had a Brief Interview for Mental Status (BIMS) score of 11 out of 15, indicating moderately impaired cognition. On 6/8/26 at 12:34 PM, Surveyor observed R9 in a wheelchair. R9's catheter bag was hooked to the frame of the wheelchair and was resting on the floor. On 6/9/26 at 9:03 AM, Surveyor observed R9 in a wheelchair in the dining room. R9's catheter bag was touching the floor. On 6/9/26 at 9:05 AM, Surveyor interviewed Licensed Practical Nurse (LPN)-C who verified R9's catheter bag was touching the floor. Without donning a gown or gloves, LPN-C adjusted the bag to prevent it from touching the floor. LPN-C indicated a gown and gloves should have been worn. On 6/9/26 at 10:25 AM, Surveyor observed R9 in bed in a low position. R9's catheter bag was resting on the floor. Surveyor interviewed LPN-C who verified the bag was on the floor and asked Certified Nursing Assistant (CNA)-D to adjust the bag. Without donning a gown or gloves, CNA-D adjusted the bag and placed a pad underneath it. On 6/10/26 at 10:45 AM, Surveyor interviewed Director of Nursing (DON)-B who indicated staff should wear a gown and gloves during all catheter care. DON-B also verified catheter bags should not be on the floor without a barrier.

Based on record review, interviews, and facility policy review, the facility failed to ensure an allegation of abuse was reported timely to the State Agency (SA) for 1 resident (R) (R1) of 4 sampled residents. This had the potential to affect resident safety in the facility.R2 hit R1 in the dining room on 5/30/25. The allegation of abuse was not reported to the SA in a timely manner.Findings include:Review of the facility's Reporting Patient Abuse, Neglect, Exploitation, Mistreatment, and Misappropriation of Property policy, revised 03/25, indicates: Initial Report, a. For alleged violations of abuse or if there is resulting serious bodily injury, the facility will report the allegation immediately, but no later than 2 hours after the allegation is made .Review of the admission Record found under the Profile tab in the electronic medical record (EMR) revealed R2 was admitted on [DATE] with diagnoses of neurocognitive disorder with Lewy bodies, dementia without behavior disturbance, psychotic disturbance, mood and anxiety disturbance, and anxiety disorder. Review of the Quarterly Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 3/13/25, indicated R2 had a Brief Interview for Mental Status (BIMS) score of 10 out of 15 which indicated R2 had moderately impaired cognition.Review of the admission Record found under the Profile tab of the EMR revealed R1 was admitted on [DATE] with diagnoses of Alzheimer's late onset, dementia without behavior disturbance, psychotic disturbance, mood and anxiety disturbance, and hearing loss.Review of the Quarterly MDS assessment, with an ARD of 5/29/25, indicated R1 had a BIMS score of 00 out of 15 which indicated R1 had severely impaired cognition.Review of the facility's report to the SA indicated on 6/1/25, a Registered Nurse (RN) read an email that was sent on 5/30/25 from an agency Licensed Practical Nurse (LPN) that indicated R2 became agitated during dining and grabbed R1. There was no injury noted and behavior charting was started for R2.A progress note for R2 indicated R2 became agitated in the dining room and began hitting and kicking at staff when staff tried to assist R2 back to R2's table to finish eating. R2 stood from the chair and grabbed onto R1's right arm. Staff assisted R2 back to the chair. R2 was finished eating and staff brought R2 to R2's room for night cares. R1 and R2 were separated and assessed for pain and injury at the time of the incident. None were noted. R2 was placed on 1:1 supervision. Dining room seating was reorganized to separate R1 and R2 and keep other residents out of R2's reach. The police were notified.During an interview on 7/11/25 at 11:48 AM, Certified Nursing Assistant (CNA)3 revealed that R2 became agitated in the dining room on 5/30/25 at approximately 5:45 PM. R2 was yelling and stood up from the table and grabbed R1's arm. CNA3 indicated someone ran to get a nurse. R1 and R2 were separated and LPN1 took R2 out of the dining room. CNA3 indicated there was a lot going on that evening and it was chaos.During an interview on 7/11/25 at 11:59 AM, CNA4 revealed that R2 became upset in the dining room on 5/30/25 at approximately 5:45 PM and stood up from the table yelling. R1 told R2 to shut the hell up. R2 then grabbed R1's arm and hit R1. CNA4 indicated CNA3 ran to get a nurse and R1 and R2 were separated. CNA4 stated LPN1 entered the dining room and tried to calm R2 down. LPN1 was at eye level with R2 in R2's wheelchair when R2 kicked LPN1 in the chest. LPN1 then took R2 out of the dining room. CNA4 stated R1 was assessed, had no injuries, and didn't say anything. CNA4 stated they were all shocked because R1 never says anything.During an interview on 7/11/25 at 12:36 PM, LPN1 revealed LPN1 heard LPN1's name called and went to the dining room. LPN1 tried to calm R2 and was at eye level with R2 in R2's wheelchair when R2 kicked LPN1 in the chest. LPN1 took R2 to the nurses' station and continued to try to calm R2 down. When that didn't work, LPN1 pushed R2 around the building. After R2 calmed down, LPN1 took R2 back to the dining room to eat dessert. LPN1 informed LPN2 (R2's primary nurse) the next time LPN1 saw LPN2 which was between 6:45 PM and 7:00 PM.During an interview on 7/11/25 at 2:12 PM, CNA5 revealed R2 was yelling and R1 told R2 to shut the hell up on 5/30/25 at approximately 5:45 PM. R2 then grabbed R1's arm and hit R1. CNA5 indicated someone ran to get a nurse and R1 and R2 were separated. R2 was taken out of the dining room by LPN1. CNA5 stated there was a lot going on that evening. CNA5 revealed that LPN1 was told what happened.LPN2 was unavailable for interview.According to the facility's investigation, LPN2 overheard two CNAs discussing the event in the dining room on 5/30/25 at 9:00 PM. LPN2 asked the CNAs to write statements and notified the charge Registered Nurse (RN), who was not available for interview after three attempted calls. LPN2 also sent an email to the Director of Nursing (DON) which was read on 6/1/25. The incident was then reported to the SA.During an interview on 7/11/25 at 4:45 PM, Surveyor and the Nursing Home Administrator (NHA) discussed the facility's Abuse policy which indicates for alleged violations of abuse or if there is resulting serious bodily injury, the facility will report the allegation immediately, but no later than 2 hours after the allegation is made. The NHA admitted the NHA overlooked the or in the statement. According to the Misconduct Report provided by the facility, the incident was not reported to the SA until 6/1/25.

Based on observation, staff interview, and record review, the facility did not ensure food was stored, prepared, and served in a sanitary manner. This practice had the potential to affect all 134 residents residing in the facility. Staff did not store or date food in a manner to ensure food safety. Staff did not follow safe food cooling protocols. Staff did not adhere to temperature requirements when testing parts per million (PPM) of the sanitizing solution. Staff did appropriately process clean dishes and did not maintain dishwasher temperature testing strips. Staff did not follow microwave safe heating procedures. Staff did not consistently wear hair restraints in the kitchen and while serving food. Staff did not perform proper hand hygiene prior to applying and removing gloves and while preparing and serving food. Findings include: Food Labeling/Storage: The facility's Food Storage Policy, revised September 2024, indicates: All products are correctly stored in appropriate areas .2. The Director of Dining Services or Designee will ensure food is clearly marked, dated, labeled, and discarded in accordance with the Food and Drug Administration (FDA) Food Code . The 2022 FDA Food Code documents at 3-501.17 Ready-to-Eat, Time/Temperature Control for Safety Food (TCS), Date Marking: (A) Except when packaging food using a reduced oxygen packaging method as specified under S 3-502.12, and except as specified in (E) and (F) of this section, refrigerated, ready-to-eat, time/temperature control for safety food prepared and held in a food establishment for more than 24 hours shall be clearly marked to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded when held at a temperature of 5 Celsius (C) (41 Fahrenheit (F)) or less for a maximum of 7 days. The day of preparation shall be counted as Day 1. The 2022 FDA Food Code documents at 3-501.18 Ready-to-Eat, Time/Temperature Control for Safety Food, Disposition: (A) A food specified in 3-501.17(A) or (B) shall be discarded if it: (1) Exceeds the temperature and time combination specified in 3-501.17(A), except time that the product is frozen; (2) Is in a container or package that does not bear a date or day; or (3) Is inappropriately marked with a date or day that exceeds a temperature and time combination as specified in 3-501.17(A). During an initial tour of the kitchen that began at 9:26 AM on 3/3/25, Surveyor and Director of Dining Services (DDS)-H observed the following items: Cooler: ~ A container of cottage cheese with an open date of 2/23 (per DDS-H) and no use-by date ~ A container of cheese spread with an open date of 2/19 (per DDS-H) and no use-by date ~ A container of sour cream with an open date of 2/28 (per DDS-H) and no use-by date ~ A package of ham with an open date of 2/28 (per DDS-H) and no use-by date ~ A package of cheddar cheese with an open date of 1/28 (per DDS-H) and no use-by date ~ A package of sliced American cheese with an open date of 2/26 (per DDS-H) and no use-by date ~ A container of cooked noodles with a made date of 2/28 (per DDS-H) of 2/28 and no use-by date ~ A container of cooked burgers with a made date of 2/28 (per DDS-H) of 2/28 and no use-by date ~ A container of egg salad with a made date of 3/1 (per DDS-H) and no use-by date ~ A container of cooked chicken breast with a made date of 3/1 (per DDS-H) and no use-by date ~ A container of cooked corn chip chicken with a made date of 3/1 (per DDS-H) and no use-by date ~ A container of cooked cube steak with a made date of 3/1 (per DDS-H) and no use-by date ~ A container of cooked macaroni and cheese with a made date of 3/1 (per DDS-H) and no use-by date ~ Two containers of fruit with made dates of 3/3 (per DDS-H) and no use-by dates ~ Two containers of cooked hard boiled eggs with made dates of 2/26 (per DDS-H) and no use-by dates ~ A container of cooked fish with a made date of 2/28 (per DDS-H) and no use-by date. ~ A container of Italian pasta with a made date of 2/28 (per DDS-H) and no use-by date ~ A container of cooked egg bites with a made date of 3/3 (per DDS-H) and no use-by date ~ A container of cooked green beans with a made date of 3/2 (per DDS-H) and no use-by date ~ A container of ham with a made date of 3/2 (per DDS-H) and no use-by date ~ A container labeled eggs with a made date of 3/2 (per DDS-H) and no use-by date ~ An unlabeled container of washed and separated grapes (per DDS-H) with no prepared or use-by dates ~ A unlabeled container of sliced summer sausage with an open date of 2/28 (per DDS-H) and no use-by date ~ Two unlabeled peanut butter and jelly sandwiches with made dates of 2/28 (per DDS-H) and no use-by dates ~ An unlabeled container of cut strawberries with a prepared date of 2/28 (per DDS-H) and no use-by date Freezer: ~ Three open and unlabeled packages of waffles (per DDS-H). One package had an open date of 2/9 (per DDS-H) and no use-by date. The other two packages had no open or use-by dates. ~ Four containers labeled soft bite meat with no made or use-by dates ~ An unsealed box of gluten-free snickerdoodle cookie dough that was open to air with no open or use-by dates ~ Eight unlabeled pieces of gluten-free cornbread with made dates of 1/23 (per DDS-H) and no use-by dates ~ Two containers of gluten-free banana french toast with no made or use-by dates ~ Eight unlabeled gluten-free muffins (per DDS-H) with no made or use-by dates ~ An unlabeled package of pepperoni with an open date of 2/13 (per DDS-H) and no use-by date ~ An unlabeled package of sausage patties with an open date of 2/4 (per DDS-H) and no use-by date Dry Storage: ~ A package of strawberry Jell-O with an open date of 2/13 (per DDS-H) and no use-by date ~ A package Cherry Jell-O with an open date of 2/7 (per DDS-H) and no use-by date ~ A package of cheesecake filling with an open date of 2/16 (per DDS-H) and no use-by date ~ A package of baking powder with an open date of 2/17/25 (per DDS-H) and no use-by date ~ A package of powdered sugar with an open date of 2/28 (per DDS-H) and no use-by date ~ A package of fettuccine noodles with an open date of 2/12 (per DDS-H) and no use-by date ~ A package of elbow noodles with an open date of 3/1 (per DDS-H) and no use-by date ~ A package of cheese sauce mix with an open date of 1/18 (per DDS-H) and no use-by date ~ A package of chicken gravy with an open date of 3/1 (per DDS-H) and no use-by date ~ A container of fried onions with an open date of 3/1 (per DDS-H) and no use-by date ~ A package of Cheerios with an open date of 2/17 (per DDS-H) of 2/17 and no use-by date ~ A package of [NAME] Puffs with an open date of 2/26 (per DDS-H) and no use-by date ~ A package of Corn Flakes with an open date of 3/3 (per DDS-H) and no use-by date ~ A package of [NAME] Krispies with an open date of 2/28 (per DDS-H) and no use-by date ~ A container of brown sugar with an open date of 2/19 (per DDS-H) and no use-by date ~ A container of dry thickener with an open date of 2/26/25 and no use-by date ~ A container of taco seasoning with an open date of 1/22/25 (per DDS-H) and no use-by date ~ A package of herb seasoning with an open date of 10/4/24 (per DDS-H) and no use-by date ~ An unlabeled package of Fruit Loops with an open date of 2/28 (per DDS-H) and no use-by date On 3/4/25 at 7:48 AM, Surveyor noted the following additional items: Cooler: ~ A container of beef dated 3/3 with no use-by date ~ A container of sliced beets dated 3/3 with no use-by date ~ A container of cooked bacon dated 3/3 with no use-by date Dry Storage: ~ A container of brown sugar dated 3/4 with no use-by date ~ A bulk container of flour dated 8/7/24 with no use-by date ~ A bulk container of sugar dated 2/13/25 with no-use by date ~ A bulk container of panko dated 6/28/24 with no use-by date ~ An unlabeled container of an unknown item dated 8/6/24 with no use-by date During an initial kitchen tour that began at 9:26 AM on 3/3/25, Surveyor interviewed DDS-H who indicated DDS-H did not know the use-by dates for the open items in the dry storage area. DDS-H observed the items in the walk-in cooler and indicated DDS-H did not know the expiration dates for many of the undated items but believed they were one month or the expiration date on the package. DDS-H indicated staff should use stickers for the items with use-by dates. DDS-H indicated staff should label all items in the freezer so they can be identified and ensure they have use-by dates. DDS-H stated, I think the use-by date is our biggest issue. On 3/4/25 at 9:32 AM, Surveyor interviewed [NAME] (CK)-P who stated the unidentified item in the bulk container should be labeled with the item's name. CK-P then labeled the bulk container panko. CK-P indicated CK-P did not put the item in the container but knew it was panko. CK-P indicated CK-P did not know the use-by dates of the containers of panko that were dated 6/28/24 and 8/6/24. Cooling Temperatures: The 2022 FDA Food Code documents at 3-501.14 Cooling: (A) Cooked time/temperature control for safety food shall be cooled: (1) Within 2 hours from 57 C (135 F) to 21 C (70 F); and (2) Within a total of 6 hours from 57 C (135 F) to 5 C (41 F) or less. (B) Time/temperature control for safety food shall be cooled within 4 hours to 5 C (41 F) or less. The 2022 FDA Food Code documents at section 3-501.15 Cooling Methods: (A) Cooling shall be accomplished in accordance with the time and temperature criteria specified under S 3-501.14 by using one or more of the following methods based on the type of food being cooled: (1) Placing the food in shallow pans; (2) Separating the food into smaller or thinner portions; (3) Using rapid cooling equipment; (4) Stirring the food in a container placed in an ice water bath; (5) Using containers that facilitate heat transfer; (6) Adding ice as an ingredient; or (7) Other effective methods. The facility's General HACCP Guidelines for Food Safety policy, dated 2021, indicates: .5. Essentials of Cooling: A. Cool from 135 F to 70 F in 2 hours and from 70 F to 41 in 4 hours (not to exceed 6 hours). During an initial kitchen tour that began at 9:26 AM on 3/3/25, Surveyor observed the facility's food cooling logs with DDS-H. Surveyor noted a water damaged food cooling log near the three-compartment sink did not contain any documentation. DDS-H showed Surveyor a second cooling log posted on the cook's cooler which also did not contain any documentation. During an initial kitchen tour that began at 9:26 AM on 3/3/25, Surveyor interviewed DDS-H who stated the water damaged cooling log near the three-compartment sink most likely hadn't been used in a while. After viewing the second blank cooling log, DDS-H indicated cooks should use the cooling logs for all cooked food put in the coolers and freezers. DDS-H looked though folders in DDS-H's office but was unable to find the cooling logs. DDS-H indicated there should be cooling logs. Surveyor noted the following items in the cooler that were not on a cooling log: ~ A container of cooked chicken breast dated 3/1 ~ A container of cooked corn chip chicken dated 3/1 ~ A container of cooked cube steak dated 3/1 ~ A container of cooked macaroni and cheese dated 3/1 ~ Two containers of cooked hard boiled eggs dated 2/26 ~ A container of cooked fish dated 2/28 ~ A container of Italian pasta dated 2/28 ~ A container of cooked egg bites dated 3/3 ~ A container of cooked green beans dated 3/2 ~ A container of cooked ham dated 3/2 ~ A container of cooked eggs dated 3/2 On 3/4/25 at 7:48 AM, Surveyor noted the cooling log by the three-compartment sink was still blank and the cooling log on the cook's cooler door had an entry for beef made on 3/3. Surveyor noted the following new items in the cook's cooler that were not on the cooling log: ~ A container of sliced beets dated 3/3 ~ A container of cooked bacon dated 3/3 On 3/4/25 at 10:17 AM, Surveyor interviewed DDS-H who indicated DDS-H had not found the January and February 2025 cooling logs. On 3/4/25 at 3:26 PM, Surveyor received the January and February 2025 cooling logs from DDS-H who indicated a coworker had the logs. Surveyor reviewed the cooling logs and noted the only item on the cooling log from the list above was fish sticks from 2/28. Surveyor noted the eight pieces of gluten-free cornbread dated 1/23 from the initial kitchen tour were not on the January 2025 cooling log. Sanitizing Solution: The 2022 FDA Food Code documents at 4-501.114 Manual and Mechanical Warewashing Equipment, Chemical Sanitization-Temperature, pH, Concentration, and Hardness: A chemical sanitizer used in a sanitizing solution for a manual or mechanical operation at contact times specified under 4-703.11(C) shall meet the criteria specified under 7-204.11 Sanitizers, Criteria, shall be used in accordance with the Environmental Protection Agency (EPA)-registered label use instructions. The 2022 FDA Food Code documents at 4-501.116 Warewashing Equipment, Determining Chemical Sanitizer Concentration: Concentration of the sanitizing solution shall be accurately determined by using a test kit or other device During an initial kitchen tour that began at 9:26 AM on 3/3/25, Surveyor observed red sanitizing buckets in the kitchen and a quat sanitizer testing log posted near the three-compartment sink. Surveyor noted the testing log contained two entries (one dated 2/7 and another dated 3/3) and there was no column for testing the temperature of the sanitizing solution. Surveyor observed a quat sanitizer poster on the wall that indicated the testing solution should be between 65 and 75 degrees Fahrenheit. After testing the temperature of the water, the Hydrion test strip should be dipped in the sanitizing solution for 10 seconds to determine the PPM. During an initial kitchen tour that began at 9:26 AM on 3/3/25, Surveyor interviewed DDS-H who indicated the sanitizing buckets were tested on ce per shift with Hydrion test strips. DDS-H stated DDS-H does not test the temperature of the sanitizing solution and just uses the test strips to record the PPM. DDS-H indicated staff should follow the quat sanitizer testing poster which indicated appropriate sanitization was 150-400 PPM for the sanitizing buckets and for manually washed cookware, dishes, and utensils. Surveyor noted the Hydrion quaternary test strip package indicated the sanitizing solution should be between 65 and 75 degrees F at the time of testing. DDS-H indicated staff should test the sanitizing solution more often than what is on the log. DDS-H indicated DDS-H would look for more testing logs. On 3/4/25 at 7:34 AM, Surveyor interviewed CK-T who indicated CK-T uses sanitizing buckets every day and changes them as often as every hour if particles were in the water. CK-T indicated CK-T does not always test the sanitizing solution and sometimes only documents the first test. CK-T could not explain why there were no entries on the log that indicated CK-T had tested the sanitizing solution. On 3/4/25 at 10:17 AM, Surveyor interviewed DDS-H who indicated DDS-H could not locate the February 2025 sanitizing log. On 3/4/25 at 3:26 PM, Surveyor received the February 2025 sanitizing log. DDS-H indicated a coworker had the log which was recently recovered. Surveyor reviewed the log and noted the majority of days contained only one entry and indicated the temperature of the sanitizing solution was not tested . In addition, seven of the twenty eight days in the month did not contain an entry Dishwashing: The 2022 FDA Food Code documents at 4-302.13 Temperature Measuring Devices, Manual Warewashing: Water temperature is critical to sanitization in warewashing operations. This is particularly true if the sanitizer being used is hot water. The effectiveness of cleaners and chemical sanitizers is also determined by the temperature of the water used. A temperature measuring device is essential to monitor manual warewashing and ensure sanitization. Effective mechanical hot water sanitization occurs when the surface temperatures of utensils passing through the warewashing machine meet or exceed the required 71 C (160 F). Parameters such as water temperature, rinse pressure, and time determine whether the appropriate surface temperature is achieved. Although the Food Code requires integral temperature measuring devices and a pressure gauge for hot water mechanical warewashers, the measurements displayed by these devices may not always be sufficient to determine that the surface temperatures of utensils are reaching 71 C (160 F). The regular use of irreversible registering temperature indicators provides a simple method to verify that the hot water mechanical sanitizing operation is effective in achieving a utensil surface temperature of 71 C (160 F). The facility's Dish Machine Use policy, dated 10/2005, indicates: Food service staff required to operate the dish machine will be trained in all steps of dish machine use to ensure the dishwashing operation is done in a clean, safe, and sanitary manner .4. The operator will check temperatures using the machine gauge with each dish machine cycle, and will record the results in a facility-approved log. The operator will monitor the gauge frequently during the dish machine cycle. Inadequate temperatures will be reported to the supervisor and corrected immediately. During an initial kitchen tour that began at 9:26 AM on 3/3/25, Surveyor observed a posting on the wall near the dishwashing station titled Dishwashing Record High Temperature and dated March 2025. The posting contained missing entries from 3/1/25 through 3/3/25. Surveyor requested the February 2025 dishwashing log from DDS-H. On 3/4/25 at 9:21 AM, Surveyor observed Dietary Aide (DA)-N put away clean dishes directly after processing dirty dishes. DA-N did not complete hand hygiene prior to touching the clean dishes. On 3/4/25 at 9:21 AM, Surveyor interviewed DA-N who denied that DA-N did not complete hand hygiene. When Surveyor asked DA-N how to record dishwashing temperatures, DA-N indicated DA-N reads the temperature off the dish machine and records the temperature on the wall posting. When Surveyor asked DA-N to run a temperature test strip through the dishwasher, DA-N pasted a [NAME] Temp Rite dishwasher adhesive label on the outside of an empty dish rack and ran it through the dishwasher. DA-N indicated the results are recorded on the Dishwashing Record High Temperature sheet. When Surveyor asked how DA-N was able to record a number on the sheet when the Temp Rite adhesive label does not produce an actual temperature reading, DA-N indicated DA-N did not know how to use Temp Rite dishwasher adhesive labels. On 3/4/25 at 9:27 AM, Surveyor interviewed DA-O who indicated DA-O did not know how to use Temp Rite dishwasher adhesive labels because they did not work. DA-O stated DA-O records temperatures from the dishwashing machine. On 3/4/25 at 10:17 AM, Surveyor interviewed DDS-H who indicated DDS-H expects staff to know how to use the adhesive labels, however, DDS-H knows that staff do not always use them and instead use dishwashing machine panel temperatures. DDS-H indicated staff do not like to use the adhesive labels because they get stuck in the dishwasher. DDS-H indicated DDS-H does not record or save the results from the adhesive labels. Microwaving Procedures: The 2022 FDA Food Code documents at 3-403.11 Reheating For Hot Holding (B): .Time/temperature control for safety food reheated in a microwave oven for hot holding shall be reheated so that all parts of the food reach a temperature of at least 165 degrees F and the food is rotated or stirred, covered, and allowed to stand covered for 2 minutes after reheating. The 2022 FDA Food Code documents at 3-401.12 Microwave Cooking: The rapid increase in food temperature resulting from microwave heating does not provide the same cumulative time and temperature relationship necessary for the destruction of microorganisms as do conventional cooking methods. In order to achieve comparable lethality, the food must attain a temperature of 74 degrees C (165 degrees F) in all parts of the food. Since cold spots may exist in food cooking in a microwave oven, it is critical to measure the food temperature at multiple sites when the food is removed from the oven and then allow the food to stand covered for two minutes post microwave heating to allow thermal equalization and exposure. Although some microwave ovens are designed and engineered to deliver energy more evenly to the food than others, the important factor is to measure and ensure that the final temperature reaches 74 degrees C (165 degrees F) throughout the food. On 3/3/25 at 12:27 PM, Surveyor observed DA-I microwave a bowl of soup for 2 minutes. When the microwave cycle was complete, DA-I served the steaming soup to a resident. DA-I did not stir the soup, let the soup stand for two minutes after heating, or temp the soup before serving it. On 3/4/25 at 8:24 AM, Surveyor observed DA-I microwave a bowl of soup for 2 minutes. DA-I stopped the cycle 14 seconds early and served the steaming soup to a resident. DA-I did not stir the soup, let the soup stand for two minutes after heating, or temp the soup before serving it. On 3/4/25 at 9:13 AM, Surveyor interviewed DA-I who indicated DA-I did not temp the soup on 3/3/25 or 3/4/25 because DA-I did not have a thermometer. Hair Restraints: The 2022 FDA Food Code documents at 2-402.11 Hair Restraint Effectiveness: (A) Except as provided in (B) of this section, food employees shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed food, clean equipment, utensils and linens, and unwrapped single service and single-use articles. The facility's Personal Adherence to Sanitary Procedures policy, dated 10/2005, indicates: .2. Hair is to be completely restrained .i. Wear hair bonnet covering all hair. ii. Keep hair off collar and neck . On 3/3/25 at 12:10 PM, Surveyor observed Dietary Assistant (DAS)-J prepare food in the main kitchen. DAS-J then transported the food and began serving the food in the second floor dining room and unit kitchen. DAS-J wore a hair restraint but did not wear a beard restraint. Surveyor noted DAS-J's beard stuck out approximately two inches from the sides and bottom of a surgical mask. On 3/4/25 at 7:57 AM, Surveyor observed DA-I prepare a food cart in the main kitchen for the second floor dining room. Surveyor noted DA-I's hair restraint did not cover approximately three to four inches of hair on the back and sides of DA-I's head. DA-I also served food in the dining room and second floor kitchen without DA-I's hair fully restrained. On 3/4/25 at 8:52 AM, Surveyor noted DAS-J's hair restraint did not fully cover DAS-J's hair. Surveyor also noted DAS-J was not wearing a beard restraint and DAS-J's beard stuck out of the sides and bottom of a surgical mask. DAS-J served food in the dining room and second floor kitchen without DAS-J's hair and beard fully restrained. On 3/4/25 at 9:13 AM, Surveyor interviewed DAS-J and DA-I regarding hair and beard restraints. DAS-J indicated DAS-J did not know DAS-J needed to wear a beard restraint and did not know where to find one. DA-I indicated DA-I knew DA-I's hair should be fully covered, however, DA-I was in a rush that morning. On 3/4/25 at 9:20 AM, Surveyor observed DAS-J and DA-I in the main kitchen. Surveyor noted DAS-J was not wearing a beard restraint and DA-I's hair restraint did not fully cover the back of DA-I's hair. On 3/4/25 at 9:43 AM, Surveyor interviewed DDS-H who indicated staffs' hair should be fully covered while preparing and serving food. DDS-H indicated staff with facial hair should wear a beard restraint. Hand Hygiene: The 2022 FDA Food Code documents at 2-301.14: Food Employees shall clean their hands and exposed portions of their arms as specified under S 2-301.12 immediately before engaging in food preparation including working with exposed food, clean equipment and utensils, and unwrapped single-service and single-use articles. The 2022 FDA Food Code documents at 3-301.11 Preventing Contamination From Hands: (A) Food employees shall wash their hands as specified under S 2-301.12. (B) Except when washing fruits and vegetables as specified under S3-302.15 or as specified in (D) and (E) of this section, food employees may not contact exposed, ready-to-eat food with their bare hands and shall use suitable utensils such as deli tissue, spatulas, tongs, single-use gloves, or dispensing equipment. The facility's Personal Adherence to Sanitary Procedures policy, dated 10/2005, indicates: All dietary employees will practice optimal personal hygiene at all times to minimize contamination of food and/or residents in accordance with food service department procedures as follows: .A. Clean hands: i. Before handling or serving food; ii. After using the toilet; iii. After handling soiled dishes, rags, mops, or garbage; iv. After sneezing or blowing nose; v. After taking a break, eating a meal, or smoking; vi. After touching face and hair; vii. After returning to kitchen area from any other area . On 3/4/25 at 8:24 AM, Surveyor observed DA-I serve breakfast from a steam table in the second floor kitchen/dining room with gloved hands. DA-I served food to twenty three residents, opened a can of soup, multiple drawers and various condiment packets, and picked up dishes, food covers, and toast from the toaster with the same gloved hands. Surveyor noted also observed DA-I remove bread from the toaster, spread butter and condiments on the bread, and serve it directly to residents. On 3/4/25 at 9:00 AM, Surveyor observed DA-I answer a phone in the second floor dining room with gloved hands. DA-I then hung up the phone and removed gloves. DA-I did not complete hand hygiene before donning a clean pair of gloves and continued with breakfast service. On 3/4/25 at 9:20 AM, Surveyor observed DA-I and DAS-J enter the main kitchen from the second floor dining room. Neither DA-I or DAS-J completed hand hygiene before they began kitchen tasks. On 3/4/25 at 10:17 AM, Surveyor interviewed DDS-H who indicated DDS-H expects staff to know and follow the facility's hand hygiene and glove use policies. DDS-H indicated staff should change gloves prior to and after switching tasks and before applying new gloves. On 3/5/25 at 1:29 PM, Surveyor interviewed Nursing Home Administrator (NHA)-A who indicated NHA-A expects dietary staff to be aware of and follow the FDA Food Code and the facility's policies regarding food prep, food storage, food serving, hand hygiene, and food temperatures.

Based on observation and resident and staff interview, the facility did not maintain dignity for 7 residents (R) (R29, R5, R45, R50, R18, R34, and R10) of 7 residents who required dining assistance. R29, R5, R45, R50, R18, R34, and R10 required assistance with dining. During the lunch meal on 3/3/25 and the breakfast meal on 3/4/25, staff did not sit down while feeding R29, R5, R45, R50, R18, R34, and R10. Findings include: From 3/3/25 to 3/5/25, Surveyor reviewed R29's medical record. R29 was admitted to the facility on [DATE] and had diagnoses including dementia, anxiety, and functional quadriplegia. R29's Minimum Data Set (MDS) assessment, dated 1/16/25, indicated R29 was rarely or never understood From 3/3/25 to 3/5/25, Surveyor reviewed R5's medical record. R5 was admitted to the facility on [DATE] and had diagnoses including severe dementia with anxiety, epilepsy, and functional quadriplegia. R5's MDS assessment, dated 2/13/25, indicated R5 was rarely or never understood. From 3/3/25 to 3/5/25, Surveyor reviewed R45's medical record. R45 was admitted to the facility on [DATE] and had diagnoses including Parkinson's disease, dementia, dysphagia, and weakness. R45's MDS assessment, dated 12/5/24, had a Brief Interview for Mental Status (BIMS) score of 11 out of 15 which indicated R45 had moderately impaired cognition. From 3/3/25 to 3/5/25, Surveyor reviewed R50's medical record. R50 was admitted to the facility on [DATE] and had diagnoses including vascular dementia, epilepsy, and memory deficit following a stroke. R50's MDS assessment, dated 12/19/24, had a BIMS score of 2 out of 15 which indicated R50 had severely impaired cognition. From 3/3/25 to 3/5/25, Surveyor reviewed R18's medical record. R18 was admitted to the facility on [DATE] and had diagnoses including anxiety, disorientation, mild cognitive impairment, and left side paralysis following a stroke. R18's MDS assessment, dated 12/16/24, had a BIMS score of 15 out of 15 which indicated R15 was not cognitively impaired. From 3/3/25 to 3/5/25, Surveyor reviewed R34's medical record. R34 was admitted to the facility on [DATE] and had diagnoses including Alzheimer's disease, dementia, anxiety, and diverticulosis. R34's MDS assessment, dated 12/12/24, had a BIMS score of 9 out of 15 which indicated R34 had moderately impaired cognition. From 3/3/25 to 3/5/25, Surveyor reviewed R10's medical record. R10 was admitted to the facility on [DATE] and had diagnoses including Huntington's chorea, Parkinson's disease, dementia, epilepsy, dysphagia (difficulty swallowing), and functional quadriplegia. R10's MDS assessment, dated 1/2/25, indicated R10 was rarely or never understood. On 3/3/25 at 12:10 PM, Surveyor observed 21 residents in the second floor main dining room during the lunch meal and noted the following: ~ At 12:32 PM, Surveyor observed Certified Nursing Assistant (CNA)-R feed R29. CNA-R sat next to R29 for approximately two minutes then fed R29 while standing. Surveyor noted a staff who was assisting R5 had to step away. CNA-R continued to stand and feed R29 and R5. ~ At 12:44 PM, Surveyor observed CNA-S stand while feeding R45 and R50. CNA-S fed R45 a bite of food and then fed R50 a bite of food. Surveyor noted two other staff feeding residents at the same table were seated while feeding the residents. On 3/3/25 at 12:40 PM, Surveyor interviewed CNA-R who indicated CNA-R was an agency staff who worked at the facility for two months. CNA-R indicated it is a regular practice to stand while feeding residents. On 3/3/25 at 12:44 PM, Surveyor interviewed CNA-S while CNA-S was feeding R45 and R50. CNA-S indicated CNA-S had worked at the facility for [AGE] years and it was typical to stand and feed residents. CNA-S indicated CNA-S usually feeds two residents at a time. On 3/4/25 at 8:04 AM, Surveyor observed 23 residents in the second floor main dining room during the breakfast meal and noted the following: ~ At 8:46 AM, Surveyor observed Registered Nurse Manager (RNM)-K stand and feed R29. Surveyor offered a chair to RNM-K, however, RNM-K continued to stand and feed R29. RNM-K then left R29 to assist others with obtaining items, including clothing protectors. At 8:53 AM, Surveyor observed RNM-K sit down and feed R29. At 9:02 AM, RNM-K stood up to feed R29. At 9:04 AM, RNM-K left and CNA-L finished feeding R29 while standing. ~ At 9:05 AM, Surveyor observed a staff standing while feeding R18 and R5. The staff alternated between feeding R18 and R5 bites of food. On 3/4/25 at 9:06 AM, Surveyor interviewed CNA-L who was feeding R29. Surveyor noted five staff standing and feeding residents in the dining room. CNA-L indicated staff stand while feeding residents because it is easier than getting up and down. On 3/4/25 at 9:08 AM, Surveyor interviewed CNA-M who was standing and feeding R34. CNA-M confirmed CNA-M usually stands while feeding residents. On 3/4/25 at 9:09 AM, Surveyor interviewed CNA-R who was standing and feeding R10 and R45 at the same time. CNA-R confirmed CNA-R usually stands while feeding residents. CNA-R indicated CNA-R often feeds two residents at a time because the residents eat slowly and there is time to do so. On 3/5/25 at 11:50 AM, Surveyor interviewed Director of Nursing (DON)-B who indicated staff should not stand while feeding residents. DON-B stated staff should sit and be at eye level with the resident they are feeding. DON-B indicated staff should be aware of and follow the facility's expectations for serving food and assisting residents.

Based on staff interview and record review, the facility did not ensure the Ombudsman was notified of emergency room (ER) or hospital transfers for 6 residents (R) (R23, R36, R56, R91, R93 and R99) of 7 residents reviewed for hospitalization . The Long-Term Care Ombudsman was not notified of ER or hospital transfers for R23, R36, R56, R91, R93, and R99. In addition, the facility did not have a process in place to notify the Ombudsman of ER or hospital transfers. Findings include: The facility's Notice of Transfer, Bed Hold Notice and Return to Facility policy, dated 10/2024, did not include a statement regarding Ombudsman notification. 1. From 3/3/25 to 3/5/25, Surveyor reviewed R23's medical record. R23 was admitted to the facility on [DATE]. R23's medical record indicated R23 was transferred to the ER or hospital on the following dates: ~ On 9/21/24, R23 had a change in condition and was transferred to the hospital. ~ On 9/25/24, R23 was transferred to the ER. ~ On 9/26/24, R23 was transferred to the ER. ~ On 10/24/24, R23 had a change in condition and was transferred to the hospital. ~ On 12/16/24, R23 was transferred to the ER. Surveyor reviewed the facility's September, October, and December 2024 Ombudsman Notification for transfers/discharges which did not include R23's hospital or ER transfers. 2. From 3/3/25 to 3/5/25, Surveyor reviewed R36's medical record. R36 was admitted to the facility on [DATE]. R36's medical record indicated R36 had a changed in condition on 9/6/24 and was transferred to the ER. Surveyor reviewed the facility's September 2024 Ombudsman Notification for transfers/discharges which did not include R36's ER transfer. 3. From 3/3/25 to 3/5/25, Surveyor reviewed R56's medical record. R56 was admitted to the facility on [DATE]. R56's medical record indicated R56 had a change in condition on 9/10/24 and was transferred to the hospital. Surveyor reviewed the facility's September 2024 Ombudsman Notification for transfers/discharges which did not include R56's hospital transfer. 4. From 3/3/25 to 3/5/25, Surveyor reviewed R91's medical record. R91 was admitted to the facility on [DATE]. R91's medical record indicated R91 had a change in condition on 1/7/25 and was transferred to the hospital. Surveyor reviewed the facility's January 2025 Ombudsman Notification for transfers/discharges which did not include R91's hospital transfer. 5. From 3/3/25 to 3/5/25, Surveyor reviewed R93's medical record. R93 was admitted to the facility on [DATE]. R93's medical record indicated R91 had a change in condition on 10/10/24 and was transferred to the hospital. Surveyor reviewed the facility's October 2024 Ombudsman Notification for transfers/discharges which did not include R93's hospital transfer. 6. From 3/3/25 to 3/5/25, Surveyor reviewed R99's medical record. R99 was admitted to the facility on [DATE]. R99's medical record indicated R99 had a change in condition on 1/2/25 and was transferred to the hospital. Surveyor reviewed the facility's January 2025 Ombudsman Notification for transfers/discharges which did not include R99's hospital transfer. On 3/5/25 at 11:38 AM, Surveyor interviewed Director of Nursing (DON)-B who stated nursing staff issue the Notice of Transfer at the time of transfer and Health Information (HI) follows up to ensure the facility has the documentation. DON-B was uncertain about Ombudsman notification. On 3/5/25 at 12:09 PM, Surveyor interviewed Heath Information Director (HID)-D who stated HID-D sends a monthly report generated from the electronic medical record to the Ombudsman. HID-D confirmed ER and hospital transfers are not included in the list HID-D sends to the Ombudsman.

Based on observation, staff interview, and record review, the facility did not ensure medications were labeled and stored appropriately for 2 residents (R) (R43 and R228) of 6 sampled residents. This practice had the potential to affect more than 4 of the 134 residents residing in the facility. On 3/3/25, two bags of unidentified and unsecured medications were observed in R43's room. During observations of medication administration, staff left a tray of medication unattended on top of the medication cart. Findings include: The facility's Self Administration of Medication Policy, dated 12/2024, indicates: .2. A resident may only self-administer medications and/or have medications left at the bedside after the Interdisciplinary Team (IDT) has determined which medications may be self-administered. 3. When determining if self-administration is clinically appropriate for a resident, the IDT should at a minimum consider the following: a. If the medications are appropriate and safe for self-administration and/or to leave at the bedside .g. The resident's ability to ensure the medication is stored safely and securely. 4. Appropriate notation of these determinations is documented in the resident's medical record and care plan. 5. An order for self-administration of medication and or to leave medications at the bedside must be obtained from the attending physician. The facility's Medication Storage in the Facility Policy, revised January 2018, indicates: Medications and biologicals are stored safely, securely, and properly following manufacturer's recommendations or those of the supplier. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medication .Medication rooms, carts, and medication supplies are locked when not attended by persons with authorized access. The facility's Bedside Medication Storage Policy, revised January 2018, indicates: Bedside medication storage is permitted for residents who wish to self-administer medication, upon the written order of the prescriber, and once self-administration skills have been assessed and deemed appropriate in the judgement of the facility's interdisciplinary resident assessment team. 1. From 3/3/25 to 3/5/25, Surveyor reviewed R43's medical record. R43 was admitted to the facility on [DATE] and had diagnoses including type 2 diabetes, pulmonary fibrosis, eosinophilic asthma, Parkinsonism, congestive heart failure, and presence of cardiac pacemaker. R43's Minimum Data Set (MDS) assessment, dated 1/23/25, had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R43 was not cognitively impaired. On 3/3/25 at 1:56 PM, Surveyor knocked on R43's door and peered in R43's room in an attempt to interview R43. R43 did not appear to be in the room. Surveyor observed two gallon size or larger clear plastic bags (one was open) on a table in R43's room that was visible from the doorway. Surveyor noted the bags contained unidentified medications with what appeared to be pharmacy labels. R43's medical record contained a self-administration of medication assessment dated [DATE]. The assessment indicated R43 was able to demonstrate secure storage of medication kept in R43's room (keep key, lock and unlock medication box/drawer). Surveyor attempted to locate R43 on at least two occasions on 3/3/25 and at least three occasions on 3/4/25. On 3/4/25, Surveyor requested self-administration of medication and bedside medication storage orders for R43. Surveyor received a self-administration order, dated 2/5/25, for fluticasone propionate nasal suspension (a nasal spray) and fluticasone-salmeterol inhalation aerosol powder. In addition, an order dated 2/6/25 indicated R43 could self-administer insulin with staff supervision. On 3/4/25, Surveyor reviewed R43's medication administration record (MAR) which contained the following orders: ~ Fluticasone propionate nasal suspension 50 mcg/act (micrograms per actuation) two sprays in each nostril once daily for nasal congestion. Unsupervised self-administration. (Start date: 4/23/24). ~ Fluticasone-salmeterol inhalation aerosol powder breath activated 113-14 mcg/act inhale 1 puff two times daily for shortness of breath and wheezing. Unsupervised self-administration. (Start date: 4/22/24). ~ Sodium chloride nasal solution 0.65 % (saline). One spray in each nostril four times daily for nasal dryness/congestion. Unsupervised self-administration. (Start date: 4/22/24). ~ Sodium chloride nasal solution 0.65 % (saline). One spray in each nostril every 2 hours as needed for dry nasal cavity. Unsupervised self-administration. (Start date: 4/22/24). On 3/4/25 at 1:33 PM, Surveyor interviewed Director of Nursing (DON)-B who indicated a resident should have a self-administration of medication order and assessment completed prior to being able to self-administer medication. DON-B also indicated medications should be stored in a locked area. When asked the protocol if a resident does not secure their medication, DON-B indicated staff should reevaluate the resident to ensure the resident meets the criteria to self-administer medication. DON-B indicated the resident should be reeducated and the medication should be secured. On 3/4/25 at 1:53 PM, Surveyor interviewed Medication Assistant (MA)-Y who indicated MA-Y was not able to administer R43's medication because R43 was not in the facility. Surveyor and MA-Y then entered R43's room and observed two bags of medication on a table. The following medications were observed in the bags: ~ Nystop powder ~ Diclofenac sodium gel 1% ~ Three containers of clobetasol propionate topical solution .05% ~ Lidocaine topical ointment ~ Two containers of fluocinonide 0.05% ~ Bacitracin ointment 500 ~ Two containers (one almost empty) of triamcinolone acetonide cream .1% ~ Two containers of ketoconazole shampoo 2% ~ Dermaklenz wound cleanser (house stock) ~ Sciatiflex (no pharmacy label) ~ Hempvana pain relief cream (no pharmacy label) ~ Iodosorb (no pharmacy label) After the medications were identified, Surveyor asked if R43 cleansed R43's wounds with wound cleanser. MA-Y replied, Your guess is as good as mine. When Surveyor asked if the medications should be secured or locked, MA-Y indicated MA-Y believed the medications should be locked because a resident could have access to the medications if they wandered into R43's room. On 3/4/25 at 2:41 PM, Surveyor interviewed DON-B who indicated R43 is able to administer R43's insulin in front of staff. DON-B indicated the medications in R43's room should be secured or locked even if they are self-administered. DON-B verified unsecured medications pose a safety issue because they're accessible to other residents. DON-B indicated R43 is not adhering to protocol by not securing the medications and will need to be evaluated again. DON-B looked at R43's medication and self-administration orders with Surveyor and indicated there should be an order for each medication R43 is assessed as able to self-administer. DON-B indicated the facility's self-administration of medication policy needed to tweaked regarding securing/locking medications. 45943 2. On 3/4/25 from 8:03 AM to 8:44 AM, Surveyor observed LPN-C intermittently leave a tray of medication unattended on top of the medication cart in the hallway while LPN-C passed medication. The tray contained a bottle of Florajen 15 billion live cultures/capsule (stock supply) and R228's insulins (a bottle of insulin glargine 100 units/milliliter (ml), a Humulin R U-500 insulin Kwik pen (500 units/ml), and a pre-filled syringe of Basaglar insulin (100 units/ml)). During that time, Surveyor observed residents in the hallway near the medication cart. On 3/4/25 at 8:44 AM, Surveyor interviewed LPN-C who indicated LPN-C did not usually leave medication on top of the medication cart. On 3/4/25 at 11:18 AM Surveyor interviewed DON-B who indicated medications should not be left on top of the medication cart for resident safety.

Based on observation, staff interview, and record review, the facility did not establish and maintain an infection prevention and control program designed to prevent the development and transmission of communicable disease and infection for 4 residents (R) (R17, R55, R89, and R116) of 4 sampled residents. On 3/4/25, Licensed Practical Nurse (LPN)-C dropped a pill on the floor in the dining room and then administered the medication to R17. During multiple care observations on 3/3/25, staff did not follow enhanced barrier precautions (EBP) for R55. During an observation of care on 3/3/25, Certified Nursing Assistant (CNA)-F removed soiled gloves and did not wash or sanitize hands before touching R89 and objects in R89's environment. During a wound care observation on 3/5/25, staff did not follow EBP precautions for R116. Findings include: The facility's Hand Washing/Hand Hygiene Policy revised 11/2024, indicates: Hand washing/Hand hygiene is regarded by this facility as the single most important means of preventing the spread of infection .Hand hygiene: A general term for cleaning your hands by handwashing with soap and water or the use of an antiseptic hand rub, also known as alcohol-based hand rub .All personnel shall follow our established hand washing/hand hygiene procedures to prevent the spread of infection and disease to residents, staff, and visitors .The use of gloves does not replace hand washing/hand hygiene. If your task requires gloves, perform hand hygiene prior to donning gloves and immediately after removing gloves. The facility's Enhanced Barrier Precautions policy, revised 4/2024, indicates: Enhanced Barrier Precautions (EBP) refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms (MDROs) that employs targeted gown and glove use during high-contact resident care activities .c. Each resident requiring enhanced barrier precautions will have a picture of a laminated gown hanging on the outside of their door and will have enhanced barrier precaution signage and gowns inside the room .2. b. Enhanced barrier precautions will be initiated for residents with any of the following: .i. Wounds (e.g., chronic wounds such as pressure ulcers, diabetic foot ulcers, unhealed surgical wounds, and chronic venous stasis ulcers) and/or indwelling medical devices (e.g., central lines, urinary catheters, feeding tubes, tracheostomy/ventilator tubes) even if the resident is not known to be infected or colonized with an MDRO. ii. Infection or colonization with a Centers for Disease Control and Prevention (CDC)-targeted MDRO when contact precautions do not otherwise apply .4. High-contact resident care activities include: a. bathing, dressing, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, device care use (central lines, urinary catheters, feeding tubes, tracheostomy/ventilator tubes), wound care (any chronic skin opening requiring a dressing) . 1. From 3/3/25 to 3/5/25, Surveyor reviewed R17's medical record. R17 was admitted to the facility on [DATE] and had diagnoses including pulmonary hypertension due to heart disease, atrial fibrillation, idiopathic pulmonary fibrosis, history of heart attacks, and presence of a cardiac pacemaker. R17's Minimum Data Set (MDS) assessment, dated 2/11/25, had a Brief Interview for Mental Status (BIMS) score of 5 out of 15 which indicated R17 had severely impaired cognition. On 3/4/25 at 8:39 AM, Surveyor observed LPN-C administer medication to residents in the second floor dining room. Surveyor observed LPN-C drop a pill on the floor under a dining table during medication administration for R17. LPN-C then picked up the pill off the floor and administered the pill to R17. On 3/4/25 at 8:41 AM, Surveyor interviewed LPN-C who verified LPN-C dropped one of R17's medications on the floor. LPN-C stated the medication was losartan and confirmed LPN-C picked up the pill off the floor and administered it to R17. LPN-C indicated R17 did not have a problem with taking the medication after it was on the floor. LPN-C verified LPN-C should not administer a medication that fell on the floor and should have disposed of the pill and administered another one. On 3/4/25 at 11:19 AM and 11:50 AM, Surveyor interviewed Director of Nursing (DON)-B who indicated staff should not administer medication in the dining room and should not administer medication that fell on the floor. DON-B stated if a medication falls on the floor, staff should destroy the medication and administer another one. DON-B indicated staff should follow the facility's medication pass and infection control procedures. 2. From 3/3/25 to 3/5/25, Surveyor reviewed R55's medical record. R55 was admitted to the facility on [DATE] and had diagnoses including calculus in bladder, calculus of kidney, artificial openings of urinary tract, benign prostatic hyperplasia with lower urinary tract symptoms, and history of urinary tract infections. R55's MDS assessment, dated 12/19/24, had a BIMS score of 9 out of 15 which indicated R55 had moderately impaired cognition. On 3/3/25 at 1:11 PM, Surveyor observed Occupational Therapist (OT)-X enter R55's room. When R55 stated R55 needed to have a bowel movement, OT-X brought R55 to the bathroom and continued cares behind the door. OT-X did not wear a gown and gloves when OT-X entered the bathroom with R55. Surveyor noted there was a picture of a gown outside the door to R55's room but no EBP sign inside R55's room. On 3/3/25 at 1:18 PM, Surveyor observed OT-X exit R55's room with a clear plastic garbage bag. Surveyor noted the bag contained soiled wipes but no gown. Surveyor observed OT-X sanitize hands, exit the room, and carry the bag down the hall without gloves. On 3/3/25 at 1:18 PM, Surveyor interviewed OT-X who indicated OT-X wore gloves when OT-X assisted R55 in the bathroom but not a gown. OT-X indicated OT-X did not have to wear a gown because OT-X assisted R55 with a bowel movement and not catheter care. OT-X indicated OT-X was going to assist R55 with a transfer. On 3/3/25 at 1:20 PM, Surveyor observed OT-X reenter R55's room. OT-X placed a gait belt on R55 and assisted R55 to a standing position. OT-X encouraged R55 to ambulate several steps to a recliner and assisted R55 with sitting in the recliner. OT-X did not wear a gown or gloves while providing assistance. OT-X then sanitized hands and exited R55's room. On 3/3/25 at 1:47 PM, Surveyor noted R55's door was closed and heard talking in the room. A short time later, Surveyor observed CNA-S exit the room and noted CNA-S was not wearing PPE and did not have anything in CNA-S' hands. On 3/3/25 at 1:47 PM, Surveyor interviewed CNA-S who indicated CNA-S emptied R55's catheter bag and wore gloves but no gown. CNA-S indicated the gowns in the room were for changing R55's bandages and were not needed to empty a catheter bag. On 3/3/25, Surveyor reviewed R55's plan of care and noted R55 did not have a care plan for EBP. Surveyor observed a Kardex on the back of R55's door that indicated Ensure Enhanced Barrier Precautions (EBP) (gloves and gown) are adhered to for all high-contact cares. On 3/5/25 at 11:50 AM, Surveyor interviewed DON-B who indicated a resident on EBP should have an EBP care plan. DON-B indicated a resident's plan of care should be updated with EBP information within 24 hours of initiating EBP. DON-B indicated staff should be aware of and follow infection control measures for residents with catheters. On 3/5/25 at 1:29 PM, Surveyor interviewed Nursing Home Administrator (NHA)-A who indicated EBP should be on a resident's care plan within 24 hours of initiation. NHA-A also indicated staff should be aware of and follow infection control policies. 45943 3. On 3/3/25 at 10:56 AM, Surveyor observed CNA-F and CNA-G transfer R89 to the toilet via EZ Stand lift. CNA-F and CNA-G donned gloves prior to the transfer. CNA-F removed R89's soiled brief which contained a moderate amount of urine. CNA-F and CNA-G removed gloves, completed hand hygiene, and donned clean gloves. CNA-F put a clean brief between R89's legs and wiped R89's peri-rectal area. CNA-F removed soiled gloves but did not wash or sanitize hands before touching the clean brief and R89's clothing. CNA-F then completed hand hygiene. On 3/3/25 at 11:07 AM, Surveyor interviewed CNA-F who verified CNA-F should have completed hand hygiene after removing soiled gloves. On 3/4/25 at 11:22 AM, Surveyor interviewed DON-B who verified staff should complete hand hygiene when gloves are removed and prior to touching other items. 45942 4. From 3/3/25 to 3/5/25, Surveyor reviewed R116's medical record. R116 was admitted to the facility on [DATE] and had diagnoses including pressure ulcer of left heel (stage 3), anemia, and vitamin D deficiency. R116's MDS assessment, dated 12/19/24, had a BIMS score of 9 out of 15 which indicated R116 had moderately impaired cognition. R116 had an activated Power of Attorney (POA). On 3/3/25 at approximately 10:15 AM, Surveyor noted there was no EBP sign inside R116's room or picture of a gown outside R116's room to indicate EBP was required. On 3/5/25 at 10:32 AM, Surveyor interviewed Infection Preventionist (IP)-V who indicated R116 was not on EBP. On 3/5/25 at 10:42 AM, Surveyor observed IP-V and Registered Nurse (RN)-BB complete wound care for R116's bilateral heel pressure injuries without adhering to EBP precautions. On 3/5/25 at 11:02 AM, Surveyor interviewed IP-V who indicated the facility determined R116's pressure injuries would heal within a time frame that would not be considered a chronic wound. IP-V indicated only chronic wounds required EBP precautions. IP-V indicated if the facility anticipates a wound is not going to heal, EBP is implemented. IP-V was unsure the time frame in which R116's pressure injuries would heal. IP-V verified IP-V and RN-BB did not implement EBP or don personal protective equipment (PPE) in accordance with EBP when wound care was completed for R116. On 3/5/25 at 1:34 PM, Surveyor interviewed NHA-A who indicated residents with chronic pressure injuries should be placed on EBP. On 3/5/25 at 1:45 PM, Surveyor interviewed DON-B who indicated pressure injuries are considered chronic wounds and residents with chronic wounds should be placed on EBP.

Based on staff interview and record review, the facility did not ensure a physician was notified of a change in condition for 1 resident (R) (R93) of 7 sampled residents. On 1/1/25, R93 had a low blood pressure reading of 84/43 mmHg (millimeters of mercury). R93's physician was not notified. Findings include: The facility's Notification of Change policy, revised 2/2025, indicates: Communication within the Interdisciplinary Team (IDT), resident .and Medical Doctor is maintained. A facility should immediately inform the resident, consult with the resident's physician, and notify, consistent with his or her authority, the resident representative(s) when there is .a significant change in the resident's physical, mental or psychosocial status (that is a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications); a need to alter treatment .Physician notification should occur when a resident experiences symptoms such as chest pain, loss of consciousness, or other signs or symptoms of heart attack or stroke that may signify a significant change . From 3/3/25 to 3/5/25, Surveyor reviewed R93's medical record. R93 was admitted to the facility on [DATE] and had diagnoses including acute and chronic respiratory failure with hypoxia (low levels of body oxygen), chronic obstructive pulmonary disease and hypertensive heart disease with heart failure. R93's Minimum Data Set (MDS) assessment, dated 1/21/25, had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R93 was not cognitively impaired. R93 had a court-appointed Guardian who was responsible for R93's healthcare decisions. R93's medical record indicated R93 was transferred to the hospital on 10/10/24 due to low blood pressure and returned to the facility on [DATE]. R93 had an order (dated 10/15/24) to call R93's primary care provider for systolic blood pressure (top number) (SBP) less than 85 or greater than 175. R93's medical record indicated R93's blood pressure was 84/43 mmHg on 1/1/25 at 8:25 AM. R93's medical record did indicate staff updated R93's physician in accordance with the physician's order. On 3/4/25 at 1:20 PM, Surveyor requested documentation that R93's physician was updated on 1/1/25. Director of Nursing (DON)-B was unable to provide documentation and indicated the physician should have been updated per R93's order.

Based on observation, staff interview, and record review, the facility did not provide privacy during medication administration for 2 residents (R) (R17 and R228) of 5 sampled residents. On 3/4/25, Licensed Practical Nurse (LPN)-C lifted the back of R17's shirt and lowered the back of R17's pants to administer a lidocaine patch in the dining room. On 3/4/25, LPN-C administered insulin to R228 in the hallway. Findings include: The National Institutes of Health (NIH) National Library of Medicine article Maintaining Patients' Dignity During Clinical Care: A Qualitative Interview Study (November 2, 2010) indicates: In Western countries, measures to maintain dignity in patients' care include maintaining privacy of the body, providing spatial privacy. 1. From 3/3/25 to 3/5/25, Surveyor reviewed R17's medical record. R17 was admitted to the facility on [DATE] and had diagnoses including heart failure, atrial fibrillation, idiopathic pulmonary fibrosis, and presence of a cardiac pacemaker. R17's Minimum Data Set (MDS) assessment, dated 2/11/25, had a Brief Interview for Mental Status (BIMS) score of 5 out of 15 which indicated R17 had severely impaired cognition. On 3/4/25 at 8:39 AM, Surveyor observed LPN-C administer medication to residents in the second floor dining area. Surveyor observed LPN-C pull up the back of R17's shirt and partially pull down R17's pants. LPN-C then applied a patch to R17's backside. Surveyor noted there were 22 others residents and various staff in the dining room at the time. On 3/4/25 at 8:41 AM, Surveyor interviewed LPN-C who indicated LPN-C applied a Lidocaine patch on R17's lower back. LPN-C indicated LPN-C probably should not have administered the patch in the dining room in front of others due to privacy. On 3/4/25 at 11:19 AM, Surveyor interviewed Director of Nursing (DON)-B who indicated it was not appropriate to lift or lower R17's clothing in the dining room to administer a patch. DON-B indicated the patch should have been applied in the privacy of R17's room. 45943 2. On 3/4/25 at 8:05 AM, Surveyor observed LPN-C administer Basaglar and Humulin insulin to R228 in the hallway. LPN-C lifted up R228's shirt and administered the insulin in R228's abdomen. Surveyor noted there were residents and staff in the hallway at the time. On 3/4/25 at 11:18 AM, Surveyor interviewed DON-B who indicated it was not appropriate to lift R228's clothing in the hallway to administer insulin. DON-B indicated staff should have administered the insulin injections in the privacy of R228's room.

Based on staff interview and record review, the facility did not ensure 3 residents (R) (R13, R36, and R38) of 7 sampled residents met the PASRR (Pre-Admission Screening and Resident Review) requirements. R13 was prescribed Abilify (an antipsychotic medication) on 1/5/23. A new PASRR Level II Screen was not completed. R36 had a positive PASRR Level 1 Screen upon admission and remained at the facility beyond the 30 day exemption period. A Level II Screen was not completed until 3/4/25. R38 had a negative PASRR Level I Screen upon admission. A Level II Screen was not completed when R38 received a qualifying diagnosis and was prescribed medication. Findings include: The facility's Preadmission Screen and Resident Review (PASRR) policy, revised February 2025, indicates: .All persons seeking admission to a nursing facility must receive a Level I Screen prior to admission. If a person is suspected of having a serious mental illness or a developmental disability, they will require a Level II Screen. The Level II Screen will determine if the resident is appropriate for nursing facility placement and if the resident needs specialized services or specialized psychiatric rehabilitative services to address his/her disability needs .If the resident remains in the facility longer than 30 days, the facility will screen the individual using the state's Level I Screening process and refer any resident who has or may have MD, ID or a related condition to the appropriate state-designated authority for Level II PASRR evaluation and determination. If an individual who enters the facility as an exemption is later found to require more than 30 days of skilled nursing care, the state mental health or intellectual disability authority will conduct a Level II review within 40 calendar days of admission .The facility must notify the state mental health authority of significant changes in residents .Referral to the state mental health authority should be made as soon as the criteria indicative of a significant change are evident. Examples of such changes include, but are not limited to: A resident who demonstrates increased behavioral, psychiatric, or mood-related symptoms, a resident with behavioral, psychiatric, or mood-related symptoms that have not responded to ongoing treatment, a resident who experiences an improved medical condition such that the residents' plan of care or placement recommendations may require medications, a resident whose significant change is physical, but has behavior, psychiatric, or mood-related symptoms, or cognitive abilities that may influence adjustment to an altered pattern of daily, a resident whose condition or treatment is or will be significantly different than described in the resident's most recent PASRR Level II evaluation and determination .The Social Worker will monitor for significant changes, include new medications and diagnoses . 1. From 3/3/25 to 3/5/25, Surveyor reviewed R13's medical record. R13 was admitted to the facility on [DATE] and had diagnoses including bipolar disorder, chronic generalized disorder, major depressive disorder, and post-traumatic stress disorder. R13's Minimum Data Set (MDS) assessment, dated 2/13/25, had a Brief Interview for Mental Status (BIMS) score of 10 out of 15 which indicated R13 had moderately impaired cognition. Surveyor noted a PASRR Level I Screen for R13 was last completed on 10/11/16. R13's medical record indicated R13 was prescribed Abilify 5 milligrams for bipolar disorder on 1/5/23 as indicated on R13's signed medication consent form. R13's medical record did not indicate the facility completed an updated PASRR Level II Screen. On 3/5/25 at 10:09 AM, Surveyor interviewed Social Worker (SW)-E who verified R13's Abilify consent was signed on 1/5/23 and R13's last Level II Screen was completed in 2016. SW-E indicated a PASRR Level II Screen should have been sent in when Abilify was prescribed and started on 1/5/23. 2. From 3/3/25 to 3/5/25, Surveyor reviewed R36's medical record. R36 was admitted to the facility on [DATE] and had diagnoses including major depressive disorder, generalized anxiety disorder, and post-traumatic stress disorder. R36's MDS assessment, dated 1/23/25, had a BIMS score of 15 out of 15 which indicated R36 was not cognitively impaired. A PASRR Level II Screen was scanned on 3/3/25. No previous Level II Screen was noted. On 3/4/25 at 3:22 PM, Surveyor interviewed Assistant Administrator (AA)-AA who indicated a PASRR Level II Screen was not sent in when R36 was admitted because R36 was supposed to have a short-term stay. After it was determined that R36 would remain beyond 30 days, the facility did not send for a Level II Screen. AA-AA confirmed a Level II Screen was submitted on 3/4/25 at 10:44 AM. On 3/5/25 at 9:50 AM, Surveyor interviewed SW-E who indicated a PASRR Level I Screen is completed prior to admission and will indicate a 30 day exemption. If a resident remains in the facility beyond 30 days, the facility will send for a Level II Screen. SW-E indicated the Level II Screen is sent right away when the facility becomes aware the resident will stay in the facility for long-term care. SW-E indicated the facility knew R36 would stay long-term in April or May of 2024. SW-E confirmed R36's Level II Screen was not sent in until 3/4/25. 45943 3. From 3/3/25 to 3/5/25, Surveyor reviewed R38's medical record. R38 was admitted to the facility on [DATE]. On 1/4/19, R38 was not suspected of having a mental illness and was not prescribed psychotropic medication. R38's medical record contained a PASRR Level I Screen, dated 9/10/21, that indicated R38 had a serious mental illness and was prescribed Zoloft (the Level I Screen did not include a diagnosis for Zoloft). A PASRR Level II Screen, dated 9/14/21, indicated R38 did not need specialized services. On 5/2/24, R38 was diagnosed with anxiety. On 7/18/24, R38 had a diagnosis of dementia with severe anxiety. R38 was prescribed buspirone HCL 15 milligrams (mg) 1 tablet by mouth two times a day for anxiety on 11/8/24. R38 was also prescribed Lorazepam 0.5 mg 1 tablet by mouth one time a day for anxiety/restlessness on 2/13/25. A PASRR Level II Screen was not completed following the additional diagnoses and medications. On 3/5/25 at 10:02 AM, Surveyor interviewed SW-E who verified a PASRR Level II Screen was not completed when R38 was diagnosed with anxiety and when buspirone was prescribed.

Based on staff and resident interview and record review, the facility did not ensure the necessary care and services were provided to prevent pressure injuries from developing and/or promote healing for 1 resident (R) (R376) of 2 sampled residents. R376 had an unstageable pressure injury on the middle spine. The facility did not assess the wound and implement wound orders according to the facility's policy. In addition, staff did not ensure R376's wound treatment was completed as ordered and R376's care plan did not contain goals or interventions for treatment. Findings include: The facility's Wound and Treatment policy, revised 12/2024, indicates: Rocky [NAME] strives to ensure that a resident entering the facility without pressure injuries does not develop pressure injuries unless the individual's clinical condition demonstrates unavoidable skin breakdown. Residents with pressure injuries receive necessary treatment and services, consistent with professional stands of practice, to promote healing, prevent infection, and prevent new ulcers from developing .Skin integrity assessments are completed by a licensed nurse as soon as possible upon admission and within 8 hours, as soon as possible upon readmission but within 8 hours, and then weekly thereafter and as needed .1) The resident's skin is to be assessed from head to toe for any skin integrity impairments .5) Skin integrity impairments are to be monitored and care planned. 6) Interventions are to be implemented and care planned. 7) All interventions are to be communicated to staff members .2) Effective prevention and treatment is based upon consistently providing routine and individualized interventions. 3) Based upon the assessment and the resident's clinical condition, choices and identified needs, basic or routine care could include .a. Redistribute pressure (such as repositioning, protecting and/or offloading heels, etc.); .c. Provide appropriate, pressure-redistributing, support surfaces; .e. Maintain or improve nutrition and hydration status, where feasible .1) Repositioning or relieving constant pressure is a common, effective intervention for an individual with a pressure injury or who is at risk of developing one. 2) Assessment of a resident's skin integrity after pressure has been reduced or redistributed should guide the development and implementation of repositioning plans. a) Such plans are addressed in the comprehensive care plan consistent with the resident's need and goals. b) Repositioning is critical for a resident who is immobile or dependent upon staff for repositioning as the resident is unable to make small movements on their own that would help to relieve prolonged pressure to one area .Infections: .Since bacteria reside in non-viable tissue, debridement of the tissue and wound cleansing are important to reduce bacteria and avoid adverse outcomes such as sepsis. The facility's Baseline Care Plan policy, revised 12/2024, indicates: A baseline care plan will be developed and implemented for each resident within 48 hours of admission .The baseline care plan is intended to promote continuity of care .and safeguard against adverse events that are most likely to occur right after admission .1. The baseline care plan .provides instructions for the provision of effective and person-centered care to each resident .and must include as a minimum the following information: A. Physician orders .F. Initial goals based on admission orders and the resident's stated goals. G. Instructions needed to provide effective and person-centered care. H. Address the resident's health and safety concerns to prevent decline or injury. On 3/5/25, Surveyor reviewed R376's medical record. R376 was admitted to the facility on [DATE] post hospitalization for chronic compression fractures. R376 was transferred to the hospital on 2/24/25 and readmitted to the facility on [DATE]. R376 had diagnoses including diabetes mellitus with other diabetic kidney complication and atrial fibrillation. R376's Minimum Data Set (MDS) assessment, dated 2/24/25, indicated R376 had an unhealed unstageable pressure injury. The MDS assessments for R376's admissions on 2/21/25 and 2/28/25 did not contain information regarding R376's cognitive status, mobility, or skin. R376 did not have a care plan that indicated R376 had a pressure injury. A skin assessment, dated 2/21/25 at 2:04 PM, indicated R376 had an unstageable pressure injury on the mid-back that measured 2.3 centimeters (cm) (length) x 2 cm (width) x 0.1 cm (depth) with 100% slough in the wound bed. R376's medical record indicated R376 was admitted to the hospital on 2/24/25 for acute metabolic encephalopathy likely secondary to sepsis with bacteremia. R376 returned to the facility on [DATE]. R376's hospital discharge instructions contained the following: Low Back Wound Care Instructions: Every day remove the old bandage and wash the wound well with a mild soap and water, rinse and pat dry. Low Back: Apply a nickel-thick amount of Santyl to the wound bed followed by a dry cover dressing. You may apply a foam pad or callus pad around the wound to help off load pressure. A hospital inpatient wound care consult note indicated R376 was seen by a wound care Nurse Practitioner (NP) on 2/25/25 for lower back ulceration. A skin assessment, dated 3/1/25 at 1:39 PM, indicated R376 had a pressure injury on the mid-spine that was 2.5 cm (length) x 2 cm (width) x 0.1 cm (depth) with slough in the wound bed. (R376's medical record did not contain a wound assessment or a wound care order from 2/28/25 when R376 was readmitted from the hospital.) R376's March 2025 treatment administration record (TAR) contained the following order (dated 3/1/25): Mid back: Cleanse wound with wound cleanser. Apply skin prep to surrounding area and apply petroleum dressing covered with border foam daily. One time a day. The TAR indicated R376's dressing change was completed on 3/2/25 and 3/4/25 but did not indicate R376's dressing was changed on 3/1/25 or 3/3/25. On 3/5/25 at 10:18 AM, Surveyor interviewed R376 who stated R376 was given a new cushion earlier that day to put behind R376's back. R376 indicated R376's wound dressing was not changed daily. On 3/5/25 at 10:35 AM, Surveyor interviewed Registered Nurse (RN)-W who indicated R376 had a pressure injury on the mid-back. RN-W indicated RN-W completed R376's wound treatment earlier that day with a physician. RN-W stated R376's wound care order was changed due to continued slough in the wound bed. On 3/5/25 at 12:03 PM, Surveyor interviewed Director of Nursing (DON)-B who indicated orders from the hospital are transcribed upon admission and should start immediately. DON-B indicated when a resident is admitted to the facility a skin assessment and wound care are completed on the day of admission. Unless an order states not to remove a dressing, DON-B indicated the resident's wound is assessed, a new treatment is applied, and there is follow up by the wound nurse. DON-B indicated wounds and interventions are care planned within 48 hours of admission and care plans should include interventions to alleviate pressure. In addition, DON-B indicated staff should complete and document daily wound treatments.

Based on observation, staff and resident interview, and record review, the facility did not ensure 1 resident (R) (R43) of 1 sampled resident received the necessary care and services for oxygen therapy. R43's oxygen order did not specify the flow rate. On 3/4/25, R43 was observed without oxygen. In addition, R43's plan of care did not indicate R43 used continuous oxygen. Findings include: The facility's Respiratory Care Policy, revised 9/20/24, indicates: A resident who needs respiratory care .is provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences .Oxygen Therapy: .iii. For a resident receiving oxygen therapy, the resident's record must reflect ongoing assessment of the resident's respiratory status, response to oxygen therapy and include at a minimum, the attending practitioner's orders and indication for use .iv. The resident's care plan should identify the interventions for oxygen therapy based upon the resident's assessment and orders, such as but not limited to: .2. When to administer, such as continuous or intermittent and/or when to discontinue; 3. Equipment settings for the prescribed flow rates . The facility's Comprehensive Care Plan Policy dated 12/2024, indicates: To ensure a comprehensive person-centered care plan is developed and implemented for each resident based on their individual needs .that includes measurable objectives and time frames to meet his or her preferences and goals and address the resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment .The comprehensive care plan must describe the following: a. Services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being . A Nursing Assistant Care Plan (Certified Nursing Assistant (CNA) Kardex) will be maintained for each resident. The care plan will be updated by licensed staff with the input of nursing assistants .3. Changes will be highlighted on the care plan .4. The licensed nurse will update the care plan in the electronic medical record .5. Care plans will be updated quarterly and as needed . From 3/3/25 to 3/5/25, Surveyor reviewed R43's medical record. R43 was admitted to the facility on [DATE] and had diagnoses including pulmonary fibrosis, interstitial pulmonary disease, eosinophilic asthma, dependence on supplemental oxygen, congestive heart failure, and presence of cardiac pacemaker. R43's Minimum Data Set (MDS) assessment, dated 1/23/25, had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R43 was not cognitively impaired. On 3/4/25 at 8:01 AM, Surveyor observed R43 in the hallway near the nurses' station outside the second floor dining room. Surveyor heard R43 ask if someone could hook up R43's oxygen. Surveyor observed R43 ask a second time when Licensed Practical Nurse (LPN)-C walked by. R43 had on a nasal cannula and was holding the end of the oxygen tubing in R43's hand. LPN-C walked around the back of R43's wheelchair and connected the tubing to a portable oxygen concentrator on the back of the wheelchair. On 3/4/25 at 8:02 AM, Surveyor interviewed R43 who indicated R43 had to go to the nurses' station to have R43's oxygen hooked up because staff who got R43 ready for breakfast did not connect the oxygen. R43 could not identify the staff who did not attach the oxygen tubing. R43 indicated R43 was without oxygen for approximately five minutes and it was not the first time it occurred. R43 indicated R43 was not short of breath. On 3/4/25 at 1:10 PM, Surveyor interviewed LPN-C who indicated R43 needs oxygen on at all times. LPN-C confirmed LPN-C attached the tubing when R43 asked for assistance. LPN-C did not know which staff got R43 ready that morning. On 3/5/25 at 10:42 AM, Surveyor interviewed LPN-C who indicated oxygen specifications for R43 should be on R43's medication administration record (MAR), care plan, and Kardex (an abbreviated care plan used by nursing staff) on the back of R43's door. On 3/5/25 at 10:46 AM, Surveyor interviewed Registered Nurse (RN)-Z who indicted R43's MAR or treatment administration record (TAR) should contain R43's oxygen flow needs and track oxygen saturation levels. R43's medical record contained an order, dated 4/24/24, for oxygen via nasal cannula to keep oxygen saturation above 90%. The order did not specify the oxygen level or flow (via liters per minute) rate. Staff documented R43's oxygen saturation level each shift on the MAR. A second oxygen order, dated 4/25/24, indicated it was okay to provide oxygen at 2 liters via nasal cannula for emergent situations and update the Medical Doctor (MD) if initiated (use only if has no other orders for oxygen). Since R43 had an oxygen order from 4/24/24 the as needed order from 4/25/24 would not have been used. A care plan, initiated 7/14/23, indicated R43 had the potential for altered respiratory status and difficulty breathing and contained interventions to watch for signs and symptoms of respiratory distress. The care plan did not mention R43's oxygen therapy. R43's plan of care mentioned oxygen at 2 liters while ambulating in the hallway under a restorative program (initiated 3/30/22). R43 did not have a care plan for continuous oxygen use. On 3/5/25, Surveyor noted R43's Kardex did not include oxygen use. The Kardex contained an intervention for oxygen at 2 liters while ambulating in the hallway under a restorative program. The Kardex did not indicate R43 used continuous oxygen. On 3/5/25 at 11:50 AM, Surveyor interviewed Director of Nursing (DON)-B who indicated R43 was on oxygen therapy. DON-B indicated a resident's care plan should be up-to-date with the resident's needs so staff know how to care for the resident. DON-B confirmed a resident who uses oxygen should have a care plan for oxygen therapy including how many liters per minute the resident requires. DON-B indicated the resident's Kardex should also indicate the resident's oxygen needs. DON-B indicated an assessment should be completed with any changes and the care plan and the Kardex should be updated accordingly. On 3/5/25 at 1:29 PM, Surveyor interviewed Nursing Home Administrator (NHA)-A who indicated a resident's care plan and Kardex should be updated with new diagnoses, cares, and treatment orders. NHA-A indicated a resident's care plan and Kardex should be updated within 24 hours and a care plan should be initiated right away.

Based on staff interview and record review, the facility did not implement their antibiotic stewardship program and monitor antibiotic use for 1 resident (R) (R115) of 3 sampled residents. R115 was prescribed a prophylactic antibiotic. R115's medical record did not indicate the prophylactic antibiotic was routinely assessed. In addition, the facility's infection surveillance log for antibiotic use contained inaccurate documentation for continued appropriate use of an antibiotic for R115. Findings include: The facility's Antibiotic Stewardship Policy, revised 2/2025, indicates: .Residents placed on antibiotics will be reviewed by the Infection Control Preventionist, Director of Nursing (DON), or Designee. The facility's Antibiotic Stewardship Program, revised 10/2022, indicates: .Tracking: Monitor antibiotic use and outcome(s) from antibiotic use Provide regular feedback on antibiotic use and resistance to prescribers, nursing staff, other relevant staff, and quarterly to the Quality Assurance and Performance Improvement (QAPI) committee .Infection Preventionist (IP): The IP will be responsible for surveillance, infection definition based on standards of practice, education, tracking, data management, analysis of data, communication with .Medical Director and Consult Pharmacist and ongoing system review. On 3/5/25, Surveyor reviewed R115's medical record. R115 was initially admitted to the facility on [DATE] following hospitalization for a left hip fracture and Clostridium difficile. R115 was prescribed vancomycin (an antibiotic) 1 tablet 4 times daily for 10 days for suspected Clostridium difficile due to loose stools on 9/5/24. R115's stool tested positive for Clostridium difficile toxin on 9/6/24. R115 was discharged from the facility on 10/1/24. R115 was readmitted to the facility on [DATE] post hospitalization for a right lower leg fracture and enterocolitis due to Clostridium difficile. Additional diagnoses for R115 included sepsis, diarrhea, bacteriuria, and history of urinary tract infections (UTIs). R115's Minimum Data Set (MDS) assessment, dated 2/17/25, had a Brief Interview for Mental Status (BIMS) score of 13 out of 15 which indicated R115 was not cognitively impaired. Upon admission on 12/31/24, R115 had an order for prophylactic vancomycin. R115 was last seen by an infectious disease physician on 1/15/25 who indicated to continue use of prophylactic vancomycin. The facility's last documented communication with the physician regarding the risks versus benefits of continued prophylactic antibiotic treatment was on 1/15/25. On 2/25/25, R115 was diagnosed with a UTI. Bactrim (an antibiotic) was started on 2/28/25. Documentation on the facility's monthly infection surveillance log, dated 2/24/25, indicated R115 did not meet the criteria for a UTI and was asymptomatic. R115's urinary analysis (UA) contained greater than 100,000 colony-forming units (CFUs) of E. coli. According to McGeer's criteria (a set of clinical guidelines used by the facility for infection surveillance that focuses on identifying potential infections and guiding antibiotic stewardship to assess antibiotic use), an infection is indicated when a UA contains 100,000 CFUs per millimeter or greater of E coli bacteria. Bactrim was continued for seven days. On 3/4/25 at 11:14 AM, Surveyor interviewed Infection Preventionist (IP)-V and Registered Nurse (RN)-U regarding the facility's infection prevention and control program. IP-V indicated IP-V was responsible for the infection prevention and control program since May of 2024. Surveyor reviewed the facility's policies and procedures, including infection surveillance logs that listed residents and infectious processes and the use of antibiotics. IP-V indicated IP-V used McGeer's criteria as a standard of practice for antibiotic stewardship. RN-U indicated R115 was seen by an infectious disease physician for prophylactic antibiotic use. RN-U stated IP-V updates the physician if a resident does not meet McGeer's criteria. RN-U stated R115 had an order for prophylactic vancomycin so IP-V did not follow R115's antibiotic use. RN-U indicated IP-V is responsible for following up with the physician regarding antibiotic use each month and documenting the follow-up. On 3/5/25 at 1:00 PM, Surveyor shared with Director of Nursing (DON)-B the concern that R115 was prescribed a prophylactic antibiotic without documentation of continued surveillance. DON-B indicated it is IP-V's responsibility to track long-term antibiotic use and indicated IP-V is provided a monthly pharmacy report of all residents on antibiotics. DON-B stated the list should remind IP-V to review residents on antibiotics. DON-B indicated DON B was unsure how IP-V tracked the use of long-term antibiotics. On 3/5/25 at 4:55 PM, Surveyor interviewed IP-V regarding IP-V's responsibilities related to prophylactic antibiotic use. IP-V stated it is IP-V's responsibility to contact the physician monthly and ask if an antibiotic is still appropriate. IP-V indicated contact with the physician should be documented in the resident's medical record. Surveyor noted the last documentation of prophylactic antibiotic use for R115 was in January of 2025.

Based on staff interview and record review, the facility did not ensure an allegation of sexual abuse was reported to the State Agency (SA) for 2 residents (R) (R2 and R5) of 3 sampled residents. On 4/21/24, R5 approached R2 in the lobby. R5 kissed R2 on the mouth and R2 touched R5's breast. The allegation of sexual abuse was not reported to the SA. Findings include: The facility's Freedom From Abuse, Neglect, and Exploitation policy, with a review date of 10/23, indicates: The facility will provide a safe resident environment and protect residents from abuse .Sexual abuse includes, but is not limited to: Unwanted intimate touching of any kind especially of breasts or perineal area. Generally, sexual contact is non-consensual if the resident either: Appears to want the contact to occur, but lacks the cognitive ability to consent; or does not want the contact to occur. Capacity means a resident has the ability to understand potential consequences and choose a course of action for a given situation. A resident's apparent consent to engage in sexual activity is not valid if it is obtained from a resident lacking the capacity to consent .Initial Report: For alleged violations .that do not result in serious bodily injury, the facility will report the allegation no later than 24 hours .7. If an incident potentially meets the federal definition, it is not necessary to review the state definitions. 8. Federal definitions do not specify that the alleged incident has to involve a caregiver, so mistreatment by anyone, including resident-to-resident incidents, if appropriate, must be submitted to the Division of Quality Assurance (DQA) immediately. On 7/3/24, Surveyor reviewed R2's medical record. R2 was admitted to the facility on [DATE] with diagnoses including vascular dementia with moderate behavioral disturbance, major depressive disorder, and anxiety disorder. R2's Minimum Data Set (MDS) assessment, dated 3/1/24, had a Brief Interview for Mental Status (BIMS) score of 8 out of 15 which indicated R2 had moderately impaired cognition. R2 had an activated Power of Attorney for Healthcare (POAHC) and passed away at the facility on 6/25/24. On 7/3/24, Surveyor reviewed R5's medical record. R5 was admitted to the facility on [DATE] with diagnoses including Alzheimer's disease with late onset, dementia in other diseases with mood disturbance, generalized anxiety disorder, and major depressive disorder. R5's MDS assessment, dated 4/24/24, had a BIMS score of 4 out of 15 which indicated R5 had severely impaired cognition. R5 had an activated POAHC. R2's medical record contained an incident note, dated 4/21/24 at 1:05 PM, that indicated: R2 was wheeling R2's self back from the dining room when R5 sought out R2, pulled back R2's wheelchair, and kissed R2 on the mouth. R2 responded by caressing R5's right breast. R5 removed R2's hand from R5's breast and stated, No, no. We can't do that. R2 and R5 were separated and supervised when R2 and R5 were out of their rooms. Administrative staff and R2 and R5's POAHC were updated. All were in agreement with the separation/supervision plan. R5's medical record contained an incident note, dated 4/21/24 at 11:16 AM, that indicated: Late Entry: R5 sought out R2 who was using the railing for assistance to wheel R2's self out of the dining room. R5 pulled R2 around in R2's wheelchair and kissed R2 on the mouth. R2 responded by caressing R5's breast. R5 removed R2's hand from R5's breast and stated, No, no. We can't do that. Staff assessed R5's right breast and noted no injury, bruising or pain. R5 and R2 were separated and supervised when R5 and R2 were out of their rooms. Administrative staff and R5 and R2's POAHC were updated. All were in agreement with the separation/supervision plan. On 7/3/24, the facility provided a risk management incident report which included the Wisconsin Department of Health Services (DHS) form P-00361, dated 6/2018, and titled Resident to Resident Interaction Decision Tree. Highlighted on the decision tree was the following: Did the Resident Act Willfully? The facility answered Yes. The decision tree then led to the question: Did the other resident suffer pain, physical injury, psychological or emotional harm as a result of the altercation? If the victim cannot give a response, consider whether a reasonable person would have experienced psychological distress. The facility highlighted No which led to the decision to not report the incident to the SA. The facility also provided DHS form P-00976 Misconduct Definitions, dated 11/2017, that contains 2 columns. The first column lists the Code of Federal Regulations CFR 483.5. On the form, sexual abuse is defined as nonconsensual sexual contact of any type with a resident. Sexual abuse includes, but is not limited to sexual harassment, sexual coercion, or sexual assault. The form states: Note that the federal definition of abuse indicates that the act needs to be willful and that it needs to have resulted in physical or psychosocial harm to the resident or, if the resident cannot provide a response, would be expected to have caused harm to a reasonable person. The form also states: For a definition of willful refer to the interpretive guidance at F689 where, under resident-to-resident altercations it notes: A resident-to-resident altercation should be reviewed as a potential situation of abuse which should be investigated under the guidance of 42 CFR 483.12. Willful means the individual intended the action itself, regardless of whether or not the individual intended to inflict injury or harm. Even though a resident may have cognitive impairment, he/she can still commit a willful act. The 2nd column on the form lists Wisconsin Administrative Code Chapter DHS 13 Caregiver Misconduct Definitions. The column provides a definition of abuse as an act or repeated acts by a caregiver or non-client resident. The facility highlighted in the DHS Caregiver Misconduct definitions column the following: Abuse does not include an act or acts of mere .incapacity. On 7/3/24 at 3:57 PM, Surveyor interviewed Nursing Home Administrator (NHA)-A and Assistant Administrator (AA)-C regarding reporting to the SA. NHA-A and AA-C indicated the facility did not report the allegation of sexual abuse to the SA because they determined the incident was not an abuse situation and no harm occurred as indicated by R5's skin assessment. When Surveyor asked if R2 or R5 suffered emotional or psychological harm in the days following the event, AA-C stated the facility completed a Social Services Assessment for R5 and provided Surveyor with a copy of the assessment. Surveyor noted the assessment was completed on 4/24/24 (which was more than 24 hours after the initial report was due to the SA). In addition, Surveyor requested any assessments related to capacity to consent for R2 and R5. The facility provided a Social Services Assessment, dated 4/24/24 (which was more than 24 hours after the incident occurred), which indicated R5's decision making was severely impaired. The assessment indicated R5 was able to make simple decisions as to whether R5 preferred coffee or milk, but complex medical decisions were made by R5's family. Section 12 of the assessment, titled Intimacy, assessed the following: Are you currently in a relationship? The assessment indicated R5 was not in a current relationship. Do you have any interest in pursuing a relationship while at the facility? The assessment indicated R5 did not have an interest in pursuing a relationship while at the facility. Surveyor noted the check boxes for an intimacy care plan were not checked. AA-C and NHA-A confirmed official capacity to consent assessments were not completed for R2 or R5.

Based on staff interview and record review, the facility did not thoroughly investigate an allegation of sexual abuse for 2 residents (R2 and R5) of 3 sampled residents. On 4/21/24, R5 approached R2 in the lobby. R5 kissed R2 on the mouth and R2 touched R5's breast. The facility did not thoroughly investigate the allegation of sexual abuse. The facility's investigation did not include interviews with R5 and R2, interviews with other resident interviews, and interviews with staff who were working at the time of the incident. Findings include: The facility's Freedom from Abuse, Neglect, and Exploitation policy, with a revised date of 10/23, indicates: Protection and Investigation: 6. Begin a thorough investigation. 7. Information will be collected that corroborates or disproves the incident and findings documented for each incident. 9. An analysis will be conducted as to why the situation occurred, risk factors that contributed to the abuse, and whether there is a need for systemic action. A thorough investigation may include the following: .3. Interviewing the alleged victim(s) witnesses(es): b. in cases of potential sexual abuse, evaluating and determining if the resident(s) has the capacity to consent and whether the resident actually consented to the sexual activity. Refer to Capacity to Consent policy and procedure. 4. Interviewing accused individuals. 5. Interviewing other residents to determine if they have been abused or mistreated. 6. Interviewing staff who worked the same shift .to determine if they witnessed any mistreatment by the accused; 7. Interviewing staff who worked other shifts to determine if they were aware of an injury or incident. 9. Involving regulatory authorities who may assist . On 7/3/24, Surveyor reviewed R2's medical record. R2 was admitted to the facility on [DATE] with diagnoses including vascular dementia with moderate behavioral disturbance, major depressive disorder, and anxiety disorder. R2's Minimum Data Set (MDS) assessment, dated 3/1/24, had a Brief Interview for Mental Status (BIMS) score of 8 out of 15 which indicated R2 had moderately impaired cognition. R2 had an activated Power of Attorney for Healthcare (POAHC) and passed away at the facility on 6/25/24. On 7/3/24, Surveyor reviewed R5's medical record. R5 was admitted to the facility on [DATE] with diagnoses including Alzheimer's disease with late onset, dementia in other diseases with mood disturbance, generalized anxiety disorder, and major depressive disorder. R5's MDS assessment, dated 4/24/24, had a BIMS score of 4 out of 15 which indicated R5 had severely impaired cognition. R5 had an activated POAHC. R2's medical record contained an incident note, dated 4/21/24 at 1:05 PM, that indicated: R2 was wheeling R2's self back from the dining room when R5 sought out R2, pulled back R2's wheelchair, and kissed R2 on the mouth. R2 responded by caressing R5's right breast. R5 removed R2's hand from R5's breast and stated, No, no. We can't do that. R2 and R5 were separated and supervised when R2 and R5 were out of their rooms. Administrative staff and R2 and R5's POAHC were updated. All were in agreement with the separation/supervision plan. R5's medical record contained an incident note, dated 4/21/24 at 11:16 AM, that indicated: Late Entry: R5 sought out R2 who used the railing to assist R2 when wheeling out of the dining room. R5 pulled R2 around in R2's wheelchair and kissed R2 on the mouth. R2 responded by caressing R5's breast. R5 removed R2's hand from R5's breast and stated, No, no. We can't do that. Staff assessed R5's right breast and noted no injury, bruising, or pain. R5 and R2 were separated and supervised when R5 and R2 were out of their rooms. Administrative staff and R5 and R2's POAHC were updated. All were in agreement with the separation/supervision plan. When Surveyor requested to review the facility's investigation, the facility provided a risk management report, dated 4/21/24, that indicated R5 and R2 were immediately separated and supervised. The report also indicated R5 and R2's POAHC were updated and in agreement with the interventions put in place. R2's care plan was updated to include a stop sign banner across R2's door so R5 did not enter R2's room. R5's care plan was updated with the following intervention: (R5) seeks affection from male residents and needs to be kept separate from male residents. Closely monitor (R5) when out of room and redirect (R5) away from male peers when attempting to touch or kiss others. The facility also provided staff education regarding updates to R2 and R5's care plans. On 7/3/24 at 3:57 PM, Surveyor interviewed Nursing Home Administrator (NHA)-A and Assistant Administrator (AA)-C regarding interviewing other residents as part of the investigation. AA-C stated R2 and R5 were the only 2 residents involved in the situation and AA-C was unsure what other residents should have been interviewed. On 7/8/24 at 2:52 PM, the facility provided Surveyor with staff statements regarding the incident via email. The facility did not provide other resident interviews or assessments. On 7/9/24 at 3:50 PM, NHA-A indicated via email that the facility did not complete other resident interviews because the incident was a witnessed, singular event and abuse was ruled out. NHA-A stated residents on the unit had dementia and memory deficits and many were not interviewable. NHA-A also stated because the facility followed the flow sheet and ruled out abuse, the facility did not feel safety was a concern and indicated there were no other incidents beyond the witnessed incident.

Based on observation, staff interview, and record review, the facility did not ensure care plan interventions were followed which resulted in a resident-to-resident interaction between 2 residents (R) (R2 and R5) of 11 sampled residents. On 4/21/24, R5 approached R2 and kissed R2 on the mouth. R2 then touched R5's breast. The incident occurred while R2 self-propelled R2's wheelchair back from the dining room. R2's care plan contained an intervention to escort R2 to and from R2's room and keep R2 separate from female residents. The intervention was not consistently followed. Findings include: On 7/3/24, Surveyor reviewed R2's medical record. R2 was admitted to the facility on [DATE] with diagnoses including vascular dementia with moderate behavioral disturbance, major depressive disorder, and anxiety disorder. R2's Minimum Data Set (MDS) assessment, dated 3/1/24, had a Brief Interview for Mental Status (BIMS) score of 8 out of 15 which indicated R2 had moderately impaired cognition. R2 had an activated Power of Attorney for Healthcare (POAHC) and passed away at the facility on 6/25/24. R2 had a care plan intervention, initiated on 3/18/24, that indicated: Escort (R2) to/from room. To be direct supervision at all times when out of room. To be seated near an exit and sit with all males when in dining room. To be kept separate from female residents. On 7/3/24, Surveyor reviewed R5's medical record. R5 was admitted to the facility on [DATE] with diagnoses including Alzheimer's disease with late onset, dementia in other diseases with mood disturbance, generalized anxiety disorder, and major depressive disorder. R5's MDS assessment, dated 4/24/24, had a BIMS score of 4 out of 15 which indicated R5 had severely impaired cognition. R5 had an activated POAHC. R2's medical record contained an incident note, dated 4/21/24 at 1:05 PM, that indicated: R2 was wheeling R2's self back from the dining room when R5 sought out R2, pulled back R2's wheelchair, and kissed R2 on the mouth. R2 responded by caressing R5's right breast. R5 removed R2's hand from R5's breast and stated, No, no. We can't do that. R2 and R5 were separated and supervised when R2 and R5 were out of their rooms. Administrative staff and R2 and R5's POAHC were updated. All were in agreement with the separation/supervision plan. R5's medical record contained an incident note, dated 4/21/24 at 11:16 AM, that indicated: Late Entry: R5 sought out R2 who was using the railing to assist R2 when wheeling out of the dining room. R5 pulled R2 around in R2's wheelchair and kissed R2 on the mouth. R2 responded by caressing R5's breast. R5 removed R2's hand from R5's breast and stated, No, no. We can't do that. Staff assessed R5's right breast and noted no injury, bruising or pain. R5 and R2 were separated and supervised when R5 and R2 were out of their rooms. Administrative staff and R5 and R2's POAHC were updated. All were in agreement with the separation/supervision plan. On 7/3/24 at 12:52 PM, Surveyor interviewed Certified Nursing Assistant (CNA)-G who stated CNA-G was working when the incident between R2 and R5 occurred but did not witness the incident. CNA-G was aware that R2 should be escorted to and from the dining room and stated R2 was seated at a table with all males near the door. CNA-G saw R2 leave the dining room and stated staff would have been a minute behind R2 because staff intervened quickly. On 7/3/24 at 1:06 PM, Surveyor interviewed CNA-F who was a regular staff on the unit. CNA-F was aware that R2 needed to be escorted to and from R2's room. CNA-F stated staff were busy in the dining room assisting residents with eating during meal time. CNA-F confirmed R2 was seated at an all male table near the exit and stated R2 did not always want to wait for staff to escort R2 back to R2's room. When asked if R2 exited the dining room independently on 4/21/24, CNA-F stated R2 probably did because R2 was often impatient. On 7/3/24 at 2:15 PM, Surveyor interviewed Registered Nurse (RN)-E who was working when the incident occurred and wrote the progress notes in R and R5's medical records. RN-E stated RN-E witnessed part of the incident. RN-E observed R2 pull on the railing and head from the dining room toward R2's room. RN-E was near the med cart and there were staff in the vicinity, but R2 was not being escorted. RN-E stated R2 was quick. RN-E heard commotion, looked up, saw R2 and R5's lips come apart, and saw R2's hand touch R5's breast. RN-E stated R5 stopped R2's hand right away. RN-E stated the interaction was unexpected and R5 approached R2 first. RN-E stated R2's care plan interventions regarding female residents were well known to staff. RN-E stated RN-E would have called the on-call manager but could not recall the name of the manager. RN-E completed a skin assessment of R5 to ensure there was no injury to R5's breast and put interventions in place to ensure R5 and R2's safety. On 7/3/24 at 2:45 PM, Surveyor interviewed CNA-D who was working at the time of the incident and intervened after the incident occurred. CNA-D said R2 was often impatient and staff did not bring R2 to the dining room until R2's meal was ready because R2 would not stay in the dining room. CNA-D stated R2 sat at a table with 2 other male residents on 4/21/24 and CNA-D assisted the other male residents while R2 ate. CNA-D stated R2 ate quickly and wanted to leave the dining room as soon as R2 was finished. CNA-D saw R2 leave the dining room and told R2 that CNA-D would be right there, however, CNA-D continued to assist the other 2 residents and forgot to assist R2 back to R2's room. When CNA-D heard a staff state that R5 was near R2, CNA-D got up right away and saw R5 lean over and kiss R2 and saw R2 touch R5's breast. CNA-D stated R2 stopped touching R5 when R5 pushed R2's hand away and said R2 and R5 couldn't do that. CNA-D intervened and took R2 to R2's room. CNA-D was aware that R2 should have been escorted from the dining room to R2's room and confirmed R2 was not being escorted at the time the incident occurred. On 7/3/24 at 3:57 PM, Surveyor interviewed Nursing Home Administrator (NHA)-A and Assistant Administrator (AA)-C who stated NHA-A and AA-C expect staff to escort R2 to and from the dining room as indicated in R2's plan of care.

Based on observations, staff interviews and record review, and based on the comprehensive assessment of a resident, the facility had not ensured that a resident without pressure ulcers had not developed pressure ulcers unless the individual's clinical condition demonstrated that they were unavoidable; and a resident having pressure ulcers received necessary treatment and services to promote healing and prevent new ulcers from developing in 3 (resident #4, #5 and #8) of 10 resident's reviewed with pressure ulcers. The facility assessed resident #4 to be at low risk for the development of pressure ulcers upon admission to the facility, but had not completed a comprehensive pressure ulcer risk assessment of the resident to include multiple comorbities that put her at risk for pressure ulcers. The facility utilizes exclusively the Braden Scale for Prediction of Pressure Ulcers to identify residents at risk. Ultimately, the resident developed an unstageable pressure ulcer to the right heel. Heel protection for the resident had not been implemented until after the development of that pressure ulcer. The resident also developed a stage III pressure ulcer to the coccyx/sacral and ischial areas. The facility had not revised the resident's plan of care to include a repositioning schedule to reduce pressure to the area and had not revised the resident's plan of care to include decreased seating time in the presence of skin integrity issues. The pressure ulcers did resolve but within days, the resident again presented with a stage II pressure ulcer to the coccyx area. Again, the facility had not revised the resident's plan of care to include a repositioning schedule to reduce pressure to the area and had not revised the resident's plan of care to include decreased seating time. The resident developed additional stage II and stage I pressure ulcers to the ischial and coccyx area. At the time of development of additional pressure ulcers, the facility had not revised the resident's plan of care to include a repositioning schedule to reduce pressure to the area and had not revised the resident's plan of care to include decreased seating time. The resident had a care plan intervention in place for use of an Allevyn dressing to the pressure area on her ishium to protect the area and facilitate healing. That care plan intervention had not been consistently implemented. Additionally, the resident had a care plan intervention for the use of a Heel Boot to the right heel at all times. The facility had not consistently implemented that care plan intervention. As a result of the facility's actions, the resident developed an avoidable pressure ulcer to the heel; two stage II and one stage I pressure ulcers to the ischial and coccyx areas. Resident #5 developed a reddened area on her coccyx on 10/18/12. The facility had not documented comprehensive skin assessments of the area on a routine basis until 2/6/13 at which time the assessment of the pressure area also had not been comprehensive to include the site of the ulcer, the wound bed characteristics, and the stage of the wound. The only documented assessments of the pressure ulcer from 10/19/12 to 2/5/13 were completed by the facility's Nurse Practitioner during monthly compliance visits. Additionally, licensed staff had not received training on the assessment of pressure related ulcers. Resident #8 was at risk for the development of pressure ulcers related to severe cognitive impairment, contractures and immobility. Multiple observations were made whereby resident #8 sat in her wheelchair with her heels in direct contact with a sheepskin covered wooden footboard, which was matted and worn. Additionally, resident #8 was found positioned in bed without heels floating or heel protectors in place. Findings include: The NPUAP (National Pressure Ulcer Advisory Panel) serves as the authoritative voice for improved patient serves as the authoritative voice for improved patient outcomes in pressure ulcer prevention and treatment through public policy, education and research. The 2009 NPUAP Position Paper on "Staging Pressure Ulcers" indicated, "Differentiating pressure ulcers from other wound etiologies is within the domain of registered nurses. As per the Scope and Standards of Nursing Practice detailed in the statement from ANA president, Rebecca M. Patton,, MSN, RN, CNOR, RN's are expected to assess the patient's skin, stage the wound and implement an individualized plan of care based on the patient needs. Due to licensed practical/vocational nurse state practice act restrictions, wounds that have the appearance of a pressure ulcer should be inspected and described by these nurses. Nurses in particular examine the skin and are most likely to be the first professional to examine any [MEDICAL CONDITION]. In the absence of licensed independent practitioners/wound care specialist, the registered nurse needs to identify and stage the pressure ulcer so that early and appropriate care can be rendered. This care involves independently initiated nursing care, such as turning and repositioning. In order to facilitate accurate [DIAGNOSES REDACTED]." The Quick Reference Guide entitled, "Pressure Ulcer Prevention", published by the NPUAP in 2009 indicated high pressures over bony prominence's, for a short period of time, and low pressures over bony prominence's, for a long period of time, are equally damaging. In order to lessen the individual's risk of pressure ulcer development, it is important to reduce the time and the amount of pressure he/she is exposed to. Ensure that the heels are free of the surface of the bed. Heel protection devices should elevate the heel, completely off loading them. Use a structured approach to risk assessment to identify individuals at risk of developing pressure ulcers. A structured approach may be achieved through the use of a risk assessment scale in combination with a comprehensive skin assessment and clinical judgement. Evidence suggests that the introduction of those elements, in conjunction with the establishment of skin care team, education programs, and care protocols, can reduce the incidence of pressure ulcers. Consider the impact of the following factors on an individual's risk of pressure ulcer development: Nutritional indicators; Factors affecting perfusion and oxygenation; Skin moisture; Advanced age; and general health status. The Quick Reference Guide, published by the NPUAP in 2009 entitled "Pressure Ulcer Treatment" indicated pressure ulcers develop over bony prominence's, but may also result from tissue pressure across the buttocks and other areas of high adipose tissue concentration. Assess the pressure ulcer initially and re-asses it at least weekly, document findings. A 2 week period is recommended for evaluating progress toward healing. However, weekly assessment provide an opportunity for the health care professional to detect early complications and the need for changes in the treatment plan. With each dressing change, observe the pressure ulcer for developments that may indicate the need for a change in treat,/ Assess and accurately document physical characteristics such as location, category/stage, size, tissue type(s), wound bed and periwound condition, wound edges, sinus tracts, undermining, tunneling, exudate, necrotic tissue, odor, presence/absence of granulation tissue, and [MEDICATION NAME]. Do not position an individual directly on a pressure ulcer. Minimize seating time and consult a seating specialist if pressure ulcer worsen on the seating surface selected. If sitting in a chair is necessary for individuals with pressure ulcers on the sacrum or coccyx or ischial, limit sitting to three times a day in periods of 60 minutes of less. Avoid seating an individual with an ischial ulcer in a fully erect posture in bed or chair. Consider periods of bedrest to promote ischial and sacral ulcer healing. Establish pressure-relief schedules that prescribe the frequency and duration of weight shifts. The facility's Pressure Ulcer Preventive Measure Protocol, dated 3/05 indicated it is recommended that turning and repositioning for bed and chair bound individuals be turned at least every 2 hours on a pressure reducing mattress or at least every 2 hours on a non pressure reducing mattress. Hourly position change is required for dependent resident who are in bed or a reclining chair with the head of the bed or back of the chair raised 30 degrees or more. Shirt weight for chair bound individuals every 15 minutes. If patient cannot perform shifts, caregivers should reposition every hour. R.N. (Registered Nurse) will provide written, visual, or verbal instruction to staff for the resident regarding reposition and rest periods in bed. Licensed staff will document in nurse's notes/Licensed Weekly Summary a summary of intervention and compliance, improvement or decline, and body finding. The protocol the facility utilized had not included the current standards of practice for prevention and assessment of pressure ulcers. 1. Resident #4 was admitted to the facility on [DATE] after sustaining a sacral fracture. The resident's admitting [DIAGNOSES REDACTED]. The resident's admission screen dated 9/24/12 indicated the resident had, a small scab at site 18 on the left elbow; bruising at site 45, right ankle interior; bruising at site 46, left ankle inner; and bruising at site 14, abdomen. The comment section of the assessment noted, "rash with peeling skin to bilateral upper extremities, bilateral lower extremities and torso (allergic reaction) and peeling skin to bilateral hands. A corresponding admission nursing entry in the resident's medical record indicated only bruising was noted on the resident's body to include the right and left ankle, abdomen, and left elbow. The entry also indicated the resident's pedal pulses were equal and weak/thready. The facility completed a Braden Scale for the prediction of pressure ulcer risk on admission for resident #4. The facility assessed the resident to be at low risk for the development of pressure related ulcers. The resident's care plan related to impairment to skin integrity dated 9/25/12 indicated the resident had tape burn to coccyx are and open area to buttock related to allergic reaction to antibiotics during hospitalization . Interventions also dated 9/25/12 included pressure reduction devises to assist in protecting the skin, encourage good nutrition and hydration in order to promote healthier skin, follow facility protocols for treatment of [REDACTED]. to the physician. Keep skin clean and dry, and encourage resident not to pick at peeling skin areas. A weekly skin assessment, conducted on resident #4 on 9/27/12 indicated, "open blister like area right buttock, stage II. 2.5 cm by 5 cm area; skin peeling away from site. No drainage is present. Wound bed is pink. Resident currently positioned on left side. Allevyn thin applied after cleansing. MD to be updated for further orders". On 9/28/12, a nurse manager assessed the resident and indicated, "entry on 9/27/12 incorrect. Upon further assessment, skin appears to be peeling at multiple sites: arms, hands, back, buttocks. Area to buttocks is not pressure related. Peeling possibly related to antibiotic. Will continue with turning/repositioning program, treatment as ordered, and pressure reduction devices. Care plan updated". A 5 day admission MDS (minimum data set) dated 10/1/12 was conducted on the resident which indicated the resident had scored an 11 of 15 (the higher the score, the more cognizant) on the cognition screen; required extensive assistance from staff to perform bed mobility and transfers; was non ambulatory; required extensive assistance from staff to perform all activities of daily living; had constant pain rated at a scale of 8 by the resident (the scoring is assessed by utilizing a 1-10 scale for pain. The higher the score, the more pain); was occasionally incontinent of bowel and bladder, and was at risk for pressure ulcers. An accompanying pressure ulcer CAA (care area assessment) triggered with the MDS assessment that indicated the resident required regular schedule of turning and that the resident was participating in therapy to regain strength, balance, endurance, and independence to allow for return to independent living. Pressure reduction devices are in place as appropriate. No current pressure ulcers. Resident does have peeling skin to majority of body related to allergic reaction to an antibiotic she was given in the hospital prior to admission to the facility. Treatment ordered. Routine skin assessments. Nursing entries resident#4's medical record indicated the following documentation; * On 9/24/12, resident refused to get out of bed for supper. * On 9/25/12, resident couldn't tolerate sitting in wheel chair for too long and wanted back into bed. Stated much more comfortable in bed. * On 9/26/12, resident is not participating with therapy. Refused to get up today. * On 9/27/12, resident had been out of bed for 1.5 hours. Tolerated only fair. Therapy states that she didn't do so well. Has pain with movement or weight bearing i.e.: sitting. * On 9/27/12, resident currently positioned on left side. * On 9/28/12, resident not wanting to get out of bed due to pain. Had been up for a short time again today with much encouragement. Pain inhibiting therapy. Cushion in wheel chair. MD updated. * On 9/30/12, resident refusing to do any care or movement of her body independently. * Beginning on 10/3/12, the resident presented with a change in behaviors to include disruptive yelling out, refusing to feed self, and anxiety. * On 10/5/12, an indwelling Foley catheter was placed for a period of 1 week. * On 10/19/12, the resident's right heel was noted to be open with a black, firm center, measuring 2 cm by 1.4 cm. Left heel was noted to have a faint small dark spot. Is already on air mattress and heel boot are requested. An Allevyn dressing was applied to right heel. A fax was sent to the doctor to update on bilateral heels. On 10/19/12, the resident's plan of care was revised to include bilateral blue boots on feet. The facility had not introduced care plan interventions into the resident's plan of care, per the standard of practice, and the resident presented with an avoidable pressure ulcer to the right heel. Review of the resident's plan of care dated 10/19/12 indicated the focus of "resident has an actual pressure ulcer to her heel related to impaired mobility". An intervention dated 10/19/12 included to assist with routine repositioning and turning program; follow facility policies/protocols for the prevention and treatment of [REDACTED]. On 2/13/12 at approximately 1:00 p.m., DON-A verified to surveyor # that resident #4's plan of care had not included an intervention to protect heels until after an unstageable pressure ulcer had developed on the resident's right heel. DON-A stated, "we use the Braden Scale exclusively to determine pressure ulcer risk and that's why she (resident #4) was assessed to be at low risk for the development of pressure ulcers. We don't take into consideration the other health factors the resident may have". On 10/12/12, a nursing entry indicated the resident's physician was contacted due to a change in the resident wound on her coccyx. The physician indicated to continue with current treatment ([MEDICATION NAME] followed by [MEDICATION NAME] covered with [MEDICATION NAME] daily) and the physician indicated he did not wish to refer the resident to a wound specialist at this time. On 10/29/12, due to little improvement to the buttocks wound, the resident's physician ordered a consult with a wound physician, and a foot cradle at the end of the resident's bed was initiated. On 11/2/12, the resident was assessed by a wound care physician. The note indicated "dark eschar, pressure ulcer, unstageable at right heel. Measures 12 mm (millimeters). Right buttock pressure ulcer at least stage III. Some advancement of edges but devitalized tissue at center limits progress. Recommend discontinuing adaptive and instead use Santyl with dry dressing daily. For right heel ulcer, treat with Santyl and dry dressing along with pressure relief. Review of the resident's plan of care had not indicated that when the area of skin integrity issues presented on her coccyx/buttocks had not improved, that interventions to include a specific turning schedule, limited seating time had not been initiated. The resident's Kardex, a plan of care utilized by the direct care staff had also not been updated to include the above interventions. The resident continued to be evaluated by a wound physician with appointments on 11/6/12; 11/9/12; 11/30/12 ( at which time the ulcers on the sacrum and right heel were assessed to be pressure ulcers at a stage II level);12/7/12; 1/4/13; 1/11/13; 1/25/13( at which time the physician noted that pressure ulcer on right heel near totally resolved and the sacral pressure ulcer had decreased in size to 2 mm). On 12/17/12, the facility conducted another Braden Scale for the resident and assessed the resident at that time to be at high risk for the development of pressure ulcers. On 12/21/12, the resident's plan of care was revised to include discontinuing bilateral heel boots and to include the use of a Heel Bo to the right heel at all times. An MDS was again conducted for the resident which mimicked the 5 day admission MDS in it's assessment of the resident with the exception that the resident was now frequently incontinent of bowel, had an indwelling Foley catheter in place. The pain assessment section of the MDS indicated the resident was unable to answer the pain assessment questions, and the facility determined the resident had indicators of frequent, moderate pain. The assessment also indicated that the resident current had 1 stage II pressure ulcer and 1 stage II pressure ulcer that had healed. On 1/29/13, the resident's indwelling catheter was removed. A nursing entry dated 2/1/13 indicated the open area to the resident's buttocks/coccyx were now healed. On 2/6/13, a skin integrity weekly summary conducted on resident #4 indicated, "part of area on coccyx that was healed has reopened. Area is 1 cm by 1 cm. Skin prep was applied around area and an Allevyn was applied. Wound physician will be her this week to assess. The resident's plan of care again was not revised to include a specific turning and repositioning schedule to include off loading pressure to fragile and now open area on the resident's coccyx, and a care plan intervention had not been implemented to include limiting seating time. On 2/11/13 during an initial tour of the facility, surveyor # observed resident #4 seated in a wheel chair with a pressure reducing cushion on the seat. The resident had shoes on both feet. A Heel Bo was not on her right foot. The surveyor made periodic observations for the resident until 1:15 p.m., at which time the resident was placed into bed. When the resident was placed into bed, and her incontinence brief was removed, and it was noted by the surveyor that the resident had been incontinent of bladder and bowel. The resident's coccyx to ishium on the right side contained a wide strip of fragile, healed skin, dark pink/red in color with 3 open areas contained within the healed area. The resident did not have a dressing present on any of the areas. This was verified by CNA (Certified Nursing Assistant)-C. The resident's shoes were removed, and the resident had grippy socks on and a flat pillow was placed under the residents calves which did not promote free floating of her heels. The resident was complaining of right foot pain. The surveyor summoned LPN (Licensed Practical Nurse)-G into the resident's room. LPN-G stated "an Allevyn dressing is to be placed on the open area on her coccyx and changed every 3 days or as needed. The aides usually check and should tell us if the dressing isn't on. No one told me it was not on today. The areas on her right buttock/coccyx had healed on 2/1/14 but when I was working on 2/6/13, I saw that she had reopened but at that time, there was only one open area, and now there are three. The original area that opened on the ishium area is a stage II pressure ulcer and is 1 cm by .05 cm; the open area near the coccyx is a stage II pressure ulcer and measures 1 cm by .5 cm, and the third area over the coccyx is a stage I pressure ulcer and measures 1 cm by 1 cm. The Allevyn dressing that we were using is no longer large enough to cover all of the open areas. We do weekly skin assessments but there is no notation of what the wound bed looked like when it reopened on 2/6/13 or what the area has looked like since". The resident's wounds were dressed and the resident remained on her back in bed until 3:15 p.m. with both heels in full contact with the mattress and was not in a side lying position. On 2/12/13 at 9:45 a.m., surveyor # interviewed CNA-C. CNA-C verified to the surveyor that there was no care plan intervention in place for the need for resident #4 to be positioned off her bottom or for limited seating time. CNA-C was aware the resident had presented with new open areas to her buttocks/coccyx. On 2/12/13 at 9:50 a.m., surveyor # interviewed CNA-V. CNA-V stated, "I got her (#4) up at 6:55 a.m. this morning. I laid her down at 8:45 a.m. because she asked me to. She would normally have gone to an activity, but they were baking so she didn't want to go. There isn't a directive that she should be in bed, or that she is to have limited time up in the chair". On 2/11/13 at 1:55 p.m., CNA-T verified to surveyor # that she had assisted resident #4 with cares that morning at 7:00 a.m. and noted there was no dressing to the open area on the resident's ischial/coccyx area. CNA-T also verified to the surveyor that she had not alerted nursing staff to her findings. On 2/11/13 at 2:00 p.m., RN (Registered Nurse)-B stated to surveyor # , "we are going to call the wound doctor. All of the open areas on her (#4) bottom are all stage II's and are over bony prominence's". On 2/11/13 at 3:20 p.m., surveyor # summoned LPN-H into resident #4's room. LPN-H verified to the surveyor that resident #4's heels were both in full contact with the mattress and also verified that per the resident's current plan of care, the resident is to have a Heel Bo on her right foot at all times. LPN-H stated, "she doesn't have it (Heel Bo) on. She shouldn't have a shoe on her right foot at all. Her lower legs have a pillow under them, but her heels are in full contact with the mattress". LPN-H observed the resident's right heel and stated, "there is a .7 cm by 1 cm scabbed over area on her right heel". On 2/11/13 at 3:25 a.m., surveyor # interviewed CNA-U. CNA-U verified to the surveyor that resident #4's current plan of care was to wear a Heel Bo on her right foot at all times. CNA-U also verified to the surveyor that the resident's Kardex had not indicated a specific scheduled turning program and had not indicated that the resident was to be seated for a limited time. On 2/11/13, a fax was sent to resident #4's physician that indicated, "resident has 3 reopened areas to left buttock; far left side measures 1 cm by .5 cm, middle area measuring 1 cm by .5 cm, right side measuring 1 cm by 1 cm; Allevyn applied, changed every 3 days. Also, right heel area measuring .07 cm by 1 cm; heel boot on at all times. Please address as soon as possible". A corresponding nursing entry in the resident's medical record indicated the same above information. The open areas were not located on the resident's left buttocks/coccyx, they were located on the right buttocks, coccyx areas. The wound bed, drainage type, exact location, surrounding wound tissues had not been documented. On 2/13/13 at 8:00 a.m., surveyor # reviewed resident #4's Kardex dated 2/11/13, 2/12/13 and 2/13/13. The Kardex indicated "resident requires assist to turn in bed. Resident requires assist to effectively turn and reposition. Explain the procedure prior to initiating. Encourage resident to position from side to side". The plan of care had not indicated a specific scheduled repositioning program or limited seating time for the resident. The resident's chart plan of care dated 2/13/13 indicated an up dated intervention to include, "should be up for meals only. May go to preferred activities, upon return to floor she should be placed in bed". The chart plan of care did not match the resident's Kardex, utilized by direct care staff to determine the resident's care needs regarding the above mentioned intervention. Additionally, the chart plan of care and Kardex had not included a scheduled repositioning program. Review of the resident's Kardex dated 2/14/13 indicated that an intervention to include, "resident requires assist to turn and position from side to side with pillows as allows every 2 hours when in bed. If patient refuses, staff to alert the unit nurse. Nurse to document refusal". The Kardex dated 2/14/13 had not included that the resident was to have limited seating time. On 2/14/13 at 9:05 a.m. surveyor # interviewed RN-B. RN-B verified to surveyor # that resident #4's Kardex dated 2/14/13 had not included that the resident was to have limited seating time per the resident's medical record plan of care. 2. Resident #5's admission face sheet dated 8/17/11 indicated the resident had [DIAGNOSES REDACTED]. The resident had been placed on Hospice services on 12/1/11. The resident's MDS dated [DATE] indicated the resident was assessed to be very cognitively impaired; required extensive assistance from staff to perform all activities of daily living including transfer, bed mobility, ambulation, dressing eating and hygiene; was frequently incontinent of bladder and always incontinent of bowel. The resident was assessed to be at risk for pressure ulcer development, but at the time of the assessment, did not have previously healed or current pressure ulcers. The pressure ulcer CAA dated 8/8/12 indicated skin is monitored weekly with bath and as needed. Changes reported to nurse. Braden score is 15. Pressure relief mattress in bed and wheel chair. Resident does ambulate. The resident's admission potential for pressure ulcer development plan of care included interventions to follow facility policies/protocols for the prevention of skin breakdown and to monitor/document/report changes in skin status, appearance, color, wound healing, sound size, stage, signs of infection. A nursing entry in resident #4's medical record dated 10/18/12 indicated, "during HS cares, staff noted reddened are on coccyx. Nurse assessed and measured 3 cm by 2 cm. House stock A and D and protective ointment applied. A nursing entry dated 10/22/12 indicated, "new orders from NP noted Zinc Oxide". A NP (Nurse Practitioner) note dated 10/22/12, indicated that resident #5 had presented with an open area to coccyx, stage II 1 cm by .2 cm. an order for [REDACTED]. Turn and reposition side to side every 2 hours. Keep off back. Apply pillow between legs. Has overlay air mattress. May be up in chair only when family here. ROHO cushion in recliner. On 10/26/12, the resident's physician changed the treatment to the coccyx wound with addition of an Allevyn protective dressing to be changed every 5 days and as needed. A nursing entry in the resident's medical record dated 10/26/12 indicated, "new orders. Discontinue Zinc Oxide to coccyx. Continue to wash with normal saline, apply skin prep to surrounding tissue. Apply Allevyn". The facility's NP assessed the resident's coccyx wound on 11/19/12 and indicated the resident coccyx was healing slowly. The facility assessed the resident's coccyx wound on 11/24/12 . The assessment indicated, "resident has a reddened/abraised area on coccyx. Area was cleansed with normal saline, skin prep applied and Allevyn was put on area to cover it". There was no staging of the wound or size of the wound noted on the assessment. The facility's NP assessed the resident's coccyx monthly on the following dates with the following documented notations: * On 11/25/12, has abraised/pink coccyx with Allevyn applied for protection. * On 12/27/12, coccyx abrasion still open superficially. Allevyn over same for skin protection due to thinness. * On 1/24/13, coccyx abrasion still open superficially. Allevyn over same for skin protection due to thinness. Upon surveyor # 's review of the resident's medical record on 2/13/13, no documented skin assessments had been completed on a weekly basis by licensed staff from 11/24/12 to 2/6/13 related to the pressure ulcer on the resident's coccyx. On 2/6/13, a weekly assessment was conducted for resident #5 which indicated, "resident has one small open area 1 cm by .5 cm and also superficial area that is reddened. Skin prep was applied and Allevyn changed". The assessment was not completed in a comprehensive manner to include the site of the open area, the staging of the open area, the characteristics of the wound bed or if any drainage was noted. On 2/112/13, a weekly assessment was conducted for resident #5 which indicated, "pressure ulcer, unstageable on coccyx. 1 cm by .2 cm. Area washed. Skin prep to surrounding tissue cover with Allevyn every 5 days. Wound is not open and surrounding skin is blanchable. On 2/13/13 at 9:45 a.m., surveyor # interviewed RN-B. RN-B stated, "wound assessments are to be done weekly. Staff have not been taught how to assess pressure ulcers or what is expected to be documented during wound assessments. The wound assessment for her (#5) dated 2/6/13 isn't inclusive. We know we have issues with pressure ulcer prevention and assessments. We used to have 5 certified wound nurses here, and now we only have one" On 2/14/13 at 10:00 a.m., DON (Director of Nursing)-A verified to surveyor # that assessments of resident #5's pressure ulcer on the coccyx had not been documented as completed from 11/24/12 to 2/6/13 and that had been completed on 11/24/12 and 2/6/13 had not been comprehensively documented. The facility "Preventive Measures Protocol" last revised 3/05, indicated the following measures for the maintenance of skin integrity..."Hourly position change is required for dependent residents who are in bed or a reclining chair with the head of the bed or back raised 30 degrees or more...shift weight for chair-bound individuals every 15 minutes, if patient can't perform shifts, caregivers should reposition every hour...Use pillow/pad/form wedges, etc. to reposition bony prominences when in bed /chair...relieve pressure under heels by using pillows or other devices..." 3. On 2/11/13 surveyor # reviewed the medical record for resident #8. The undated facesheet contained within the medical record indicated resident #8 was admitted to the facility with profound mental [MEDICAL CONDITIONS] and spastic [MEDICAL CONDITION]. The 12/13/12 quarterly MDS (Minimum Data Set) assessment indicated resident #8 was dependent upon staff for total assistance with bed mobility and positioning, transfers, hygiene and bathing. Resident #8 was 56 inches tall and weighed 98 lbs and was always incontinent of bowel and bladder. Additionally, the MDS indicated resident #8 was at risk for the development of pressure ulcers. The written plan of care for resident #8, with a focus "Potential for pressure ulcer development related to immobility," last revised 10/21/10, indicated, "follow facility policies and procedures for the prevention/treatment of X

Based on observation, staff interviews and record review, the facility did not ensure that a resident who entered the facility without pressure ulcers did not develop pressure ulcers unless the individual's clinical condition demonstrated they were unavoidable for 1 (resident #11) of 20 residents reviewed for the risk of pressure ulcer development in a total sample of 24 residents. Resident #11 had a history of [REDACTED]. Staff indicated the blisters were caused from the elastic strap used to secure her [MEDICATION NAME] bag. Although the blisters were healed, the facility did not develop interventions to prevent the pressure areas from redeveloping. On 12/24/12, resident #11 re-developed two blisters to her right thigh again caused by the [MEDICATION NAME] bag strap. Examples include: The National Pressure Ulcer Advisory Panel defines a Stage 2 pressure ulcer as, "Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled blister." The European Pressure Ulcer Advisory Panel and National Pressure Ulcer Advisory Panel "Pressure Ulcer Prevention Quick Reference Guide" indicates health care providers need to inspect residents' skin regularly for signs of redness in in individuals identified at risk for pressure ulcer development. The guide also indicates health care providers need to monitor for the skin for pressure damage caused by medical devices. On 2/26/12 surveyor # reviewed the medical record for resident #11. The 2/26/12 face sheet indicated resident #11 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The current MDS (Minimum Data Set) assessment dated [DATE] indicates that resident #11 is alert and oriented with a BIMS (Brief Interview for Mental Status) score of 10 out of 15. The assessment indicates resident #11 understands others and is able to make self understood. Resident #11 requires extensive assistance of staff for dressing, toilet use, and personal hygiene. The MDS assessment also indicates that resident #11 is at risk for pressure ulcer development, has no unhealed pressure ulcers, has open [MEDICAL CONDITION] other than ulcers, rashes, or cuts and requires application of nonsurgical dressings. The assessment also indicates resident #11 has pressure reducing devices in chair and bed. Review of the MDS assessments completed on 7/7/11 and 9/28/11 indicated that resident #11 was at risk for pressure ulcer development, and had pressure reducing devices in the chair and bed. The 8/31/11 to 9/14/11 treatment sheets for resident #11 indicated staff were to monitor two blisters on the outer aspect of resident #11's right thigh and to alternate placement of the [MEDICATION NAME] strap (per resident #11's physician) until resolved to prevent further irritation. The treatment sheets indicated the blisters were resolved on 9/14/11. Review of the care plan finds that resident #11's care plan was not updated to include interventions to prevent the development of pressure ulcers in the future. The 2/24/12 treatment sheet for resident #11 indicated: blister area upper thigh from leg strap. Upper blister 1.5 cm (centimeter) by 0.2 cm and a 0.2 cm by 0.1 cm blister below that area. Keep strap above or below. On 2/26/12 at 10:15 a.m. surveyor # observed LPN-J (Licensed Practical Nurse) provide wound care for resident #11. LPN-J removed resident #11's blankets and observed the elastic [MEDICATION NAME] leg strap centered around the resident's right thigh. Surveyor # observed that the blisters were resolved, however, the skin remained reddened in the area. When completed, LPN-J indicated that she insured the leg strap was on the lower area of resident #11's thigh. On 2/26/12 at 11:00 a.m. surveyor # interviewed RN-I (Registered Nurse) about interventions to prevent the leg strap from causing blisters. RN-I indicated staff were now adjusting the elastic leg strap daily and were loosening it so it was not too tight. RN-I indicated from 9/4/11 (date previous blisters had resolved) to 2/26/12 (date current two blisters developed) the plan of care for resident #11 did not include interventions intended to prevent to skin breakdown. On 2/28/12 at 7:15 a.m. surveyor # interviewed DON-B (Director Of Nursing). DON-B indicated on 2/27/12 the facility had revised the plan of care for resident #11 to include actions to protect resident #11 from additional skin breakdown. "We were missing that."