Every finding on record at South Peninsula Hospital LTC

.Based on record review and interview, the facility failed to ensure that interest earned on residents' trust accounts was correctly credited to the residents' accounts. This failure affected 23 of 26 residents reviewed (Residents #1, 2, 3, 4, 5, 6, 7, 9, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 24, 25, and 26). The facility did not apply the interest earned to either the residents' actual account balances or to their account statements. As a result, residents and/or their representatives were not given timely or accurate information about the interest accrued in their personal funds.Findings:.Past non-compliance: The last standard recertification survey was conducted on 8/23/24. During the Recertification survey conducted on 9/12/25 past noncompliance was identified at F567. The state agency verified that the facility took appropriate corrective actions for noncompliance found at F567 with a correction date of 8/6/25. During the 9/8-12/25 recertification survey, it was found that the facility failed to include the trust account interest in the residents' trust account statements from 10/31/24 until 8/6/25 as evidenced by:During a joint interview on 9/10/25 at 1:05 PM, with the [NAME] Specialist (BS), the Director of Nursing (DON) and the Social Services Coordinator (SSC), the BS stated the residents' personal funds were held in an interest- bearing trust account. The DON stated that interest was appropriately distributed to each residents' account. Review of the following residents' trust statements revealed:Trust statements for period from 10/31/24 -7/31/25Resident #s 1, 4, 5, 6, 7, 9, 14, 15, 16, 18,19, 21, 22, 24, 25, 26 trust account interests for the period of 10/1/24-12/31/24, 1/1/25-3/31/25 and 4/1/25-6/30/25 were not recorded in the applicable trust statement from 10/31/24 -7/31/25.Trust statements for period from 12/31/24 -7/31/25Resident #s 3 and 20 trust account interests for the period of 10/1/24-12/31/24, 1/1/25-3/31/25 and 4/1/25-6/30/25 were not recorded in the applicable trust statement from 12/31/24 -7/31/25.Trust statements for period from 2/28/25 -7/31/25Resident #12's trust account interests for the period of 1/1/25-3/31/25 and 4/1/25-6/30/25 were not recorded in the applicable trust statement from 2/28/25 -7/31/25.Trust statements for period from 3/31/25 -7/31/25Resident # 11's trust account interests for the period of 1/1/25-3/31/25 and 4/1/25-6/30/25 were not recorded in the applicable trust statement from 3/31/25 -7/31/25.Trust statements for period from 6/30/25-7/31/25Resident #s 2, 13, and 17's trust account interests for the period of 4/1/25-6/30/25 were not recorded in the applicable trust statement from 6/30/25-7/31/25. During an interview and concurrent review of the trust account statements on 9/12/25 at 9:26 AM, the BS stated the facility issued monthly trust statement instead of quarterly per federal regulation. She stated the trust account interest should have been reflected in the monthly statement. She explained that she was out on leave for a certain amount of time and the trust account interest was not reflected in Resident's monthly trust account, instead she entered all interests on 8/6/25 as a way of correction for not having it done timely.Review of the facility's policy Management of Resident Personal Funds by LTC & PFS [Patient Financial Services] Department, effective 5/6/25, revealed: . The PFS staff will setup an individual interest-bearing account for funds in excess of $50.00 (fifty). All interest earned must be credited to that account.Review of the Code of Federal Regulations (CFR) S483.10(f)(10)(i)-(ii) Definitions, revealed: . 'Interest bearing' means a rate of return equal to or above the rate at local banking institutions in the area. If pooled accounts are used, interest must be prorated per individual on the basis of actual earnings or end-of quarter balance.Corrective Action(s)During an interview on 9/12/25 at 1:50 PM, the Business Office Supervisor (BOS) confirmed all accrued interest for the period of 10/1/24-12/31/24, 1/1/25-3/31/25, and 4/1/25-6/30/25 were posted on 8/6/25 in each of the residents' trust statements.

.Based on record review and interview, the facility failed to ensure residents and/or resident representatives' participation in the development of the residents' care plan and document in the medical record an explanation of the residents and resident representatives' inability to participate for 2 residents (#3 and #20) out of 12 sampled residents. This failed practice denied the residents and/or resident's representatives the opportunity to make decisions regarding residents' care and treatment .Findings:.Resident #3Record review on 9/8-12/25, revealed Resident #3 was admitted to the facility with diagnoses that included nonrheumatic aortic valve stenosis (a type of heart valve disease wherein the valve is narrowed and doesn't open fully), unspecified dementia (loss of cognitive functioning) and major depression.Review of the Minimum Data Set (MDS - a federally required assessment) quarterly assessment, dated 8/26/25, revealed Resident #3 had a BIMS (Brief Interview of Mental Status) score of 15 (meaning the resident was cognitively intact).During an interview on 9/9/25 at 11:20 AM, Resident #3 stated he/she would like to attend a care planning meeting but had not attended any meetings. When asked if somebody represented him/her in the meeting, Resident #3 stated no. During an interview on 9/10/25 at 11:12 AM, the Social Services Coordinator (SSC) stated she sent an email invitation to Resident #3's representative with the zoom link (a software that facilitates online meeting) regarding the upcoming care conference. The SSC stated a follow-up call would be made but sometimes the resident representative did not answer the phone or did not provide the reason why they could not attend. The care conference invitation to Resident #3's representative dated 12/19/24, 2/17/25, 5/22/25, and 8/21/25 was provided after the interview.During the same interview, when asked if Resident #3 was invited to the care conference, the SSC stated Resident #3 refused to attend when invited.Care Conference DocumentationReview of Resident #3's care conference notes, dated 12/16/24, in the resident and resident representative section, revealed OPA (Office of Public Advocacy) Guardian was unable to attend. Resident #3's inability to attend was not documented nor an explanation for his/her lack of attendance.Review of Resident #3's care conference notes, dated 2/18/25, in the resident and resident representative section, revealed: unable to attend. Further review of the document revealed it did not specify whether it was Resident #3 or resident representative that was unable to attend nor a rationale for their lack of attendance.Review of Resident #3's care conference notes, dated 5/19/25, in the resident and resident representative section, revealed OPA Guardian was unable to attend. Resident #3's inability to attend was not documented nor an explanation for his/her lack of attendance.Review of Resident #3's care conference notes, dated 8/27/25, in the resident and resident representative section, revealed: n/a [not applicable]. Further review of the document revealed it did not specify whether it was Resident #3 or resident representative that was unable to attend nor an explanation for lack of attendance.During a joint interview on 9/10/25 at 11:13 AM, the SSC and the Director of Nursing (DON) stated the facility should have documented the reason for Resident #3 and his/her representative's lack of attendance in the medical record.During an interview and concurrent review of Resident #3's care conference notes from 12/16/24 - 8/27/25, on 9/12/25 at 10:44 AM, the DON confirmed that Resident #3 did not attend all the care conferences, instead the facility documented the attendance of the resident representative in the care conference notes.Resident #20Record review on 9/8-12/25, revealed Resident #20 was admitted to the facility with diagnoses that included hemiplegia (one-sided paralysis of the body) and hemiparesis (one- sided muscle weakness of the body), and type 2 diabetes mellitus.Review of the MDS quarterly assessment, dated 7/9/25, revealed Resident #20 had a BIMS score of 14 (meaning the resident was cognitively intact).During an interview on 9/10/25 at 11:12 AM, the SSC stated she sent an email invitation to Resident #20's representative with the zoom link regarding the upcoming care conference. The SSC stated a follow-up call would be made but sometimes the resident representative did not answer the phone or did not provide the reason why they could not attend. The evidence of the care conference invitation to Resident #20's representative dated 4/7/25 and 7/8/25 was provided after the interview.During an interview on 9/10/25 at 11:12 AM, the SSC, when asked if Resident #20 was invited to the care conference, did not answer the question instead the SSC stated Resident #20 did not want to be disturbed at a certain hour and it was included in the care plan.Review of Resident #20's Care Plan Report, printed on 9/10/25, revealed: . [Resident #20] prefers to sleep in and not be awakened for breakfast.Care Conference DocumentationReview of Resident #20's care conference notes, dated 1/22/25, in the resident and resident representative section, revealed: unable to attend. Further review of the document revealed it did not specify whether if it was Resident #20 or resident representative that was unable to attend nor an explanation for his/her lack of attendance.Review of Resident #20's care conference notes, dated 4/9/25, in the resident and resident representative section, revealed: family unable to attend. Resident #20's inability to attend was not documented nor an explanation for his/her lack of attendanceReview of Resident #20's care conference notes, dated 7/16/25, in the resident and resident representative section, revealed: n/a. Further review of the document revealed it did not specify whether if it was Resident #20 or resident representative that was unable to attend nor an explanation for his/her lack of attendance.During an interview and concurrent review of Resident #20's care conference notes from 1/22/25 - 7/18/25, on 9/12/25 at 10:44 AM, the DON confirmed that Resident #20 did not attend all the care conferences, instead the facility documented the attendance of the resident representative in the care conference notes.Care Planning ProcedureDuring a joint interview on 9/10/25 at 11:12 AM, the DON, the SSC and Clinical Care Coordinator (CCC), the DON stated a baseline care plan would be created upon admission, then the Interdisciplinary (IDT) team with the resident and/or resident representative would meet together to create the resident's comprehensive care plan and then, review and revise the care plan during a quarterly care conference. The DON added that the care plan would be reviewed and revised should there be a significant change in resident's condition or resident preferences had changed. The DON stated the care conference was the same as care planning.During the same interview, the SSC stated she would ask the residents if they wanted to attend their care conference. However, sometimes the residents did not want to participate. The SSC further stated that if the resident or resident representative was unable to attend the care conference, it would be documented in the care conference notes in Point Click Care (facility's electronic heath record). However, the SSC stated she did not document the reason for a resident and/or resident representative's inability to attend the meeting, instead she would document as n/a or unable to attend.During an interview on 9/12/25 at 10:44 AM, the DON stated there was no documentation in the medical record when they invited the residents to attend and the reason for not attending the care conference. She stated the facility updated the form after the interview on 9/10/25 to show that the resident was offered to attend or the resident declined to attend the care conference. She further stated the facility would use the updated form in their future care conference.Review of the facility's policy Care Plan Documentation, effective date 1/3/25, revealed: . South Peninsula Hospital (SPH) Long Term Care facility (LTC) provides an individualized, interdisciplinary plan of care for all Residents that shall be appropriate to the Resident's needs, strengths, limitations, and goals.Results of assessment are used to develop, review, and revise the Resident's comprehensive plan of care . Care, treatment, and services are planned to ensure that they are individualized to the Resident's needs. Reviewed and revised by the interdisciplinary team and Resident and/or legal representative through the Care Conference process. A. Care Conference meetings are held after each assessment (admission, quarterly, and comprehensive), and as needed. B. The following participants will review and revise the care plan, as needed, after each assessment 1) The attending provider; 2) A registered nurse; 3) A certified nurse aide; 4) Dietitian or member of Nutrition Services staff; 5) Resident and/or Resident legal representative; 6) Other appropriate staff or professionals as disciplines as determined by the Resident needs or as requested by the Resident (i.e., [for example] interdisciplinary team members).

Based on observations, interview, and record review the facility failed to ensure storage and preparation of food in accordance with professional standards for food service safety for 24 residents (#1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18, #19, #20, #21, #23, #24, #25) out of 25 residents who received meals from the kitchen. This failed practice placed all residents at risk to receive contaminated food and placed these 24 residents at risk of foodborne illnesses. Findings: Food Storage: During an initial tour of the kitchen, on [DATE] at 11:03 AM, revealed in the stand-alone refrigerator near the preparation station in the main kitchen, unlabeled food items were stored such as: one unlabeled bag of frozen breaded items resembling chicken, one unlabeled bag of frozen breaded items resembling Chicken Cordon Blue, one unlabeled brown bag resembling frozen potato fries, one unlabeled rectangular container of what appeared to be pre-made chicken salad wrapped in saran wrap. During an interview on [DATE] at 11:10 AM, [NAME] #1 stated he/she thought the salad is a mystery salad referring to the chicken salad and that the other items were unlabeled prior to his/her arrival: I just started my shift, it's my Monday . have no idea of what's going on in these fridges. An observation on [DATE] at 11:15 AM, revealed in the walk-in refrigerator #1, expired and dented food items were stored such as: one package of Almond Original Milk Barista had an open date [DATE], which should have been discarded one month after this date, and one dented package (roughly 1 inch wide of the lower portion of this package) of 100% Prune Juice. An observation on [DATE] at 11:19 AM, revealed in the walk-in refrigerator #2 unlabeled, moldy, and uncovered vegetables were stored such as: one unlabeled bag of multicolor shredded carrots, one package of several strawberries with mold (roughly 0.5 inches of mold spread through each strawberry in the package), two yellow bell peppers with mold (roughly 0.5 inches of mold at the bottom of both peppers), eight green cabbage heads with mold (roughly 1.5 inches of mold unevenly spread), one tray containing seven uncovered peeled [NAME]. An observation on [DATE] at 11:25 AM, revealed in the dry storage, one package of Pretzel salt with a compromised, cracked lid and punctured package's seal, and seven containers of Grey Poupon Dijon Mustard each with an expiration date of [DATE]. An observation on [DATE] at 11:30 AM, in the walk-in freezer #1, revealed boxes of food were stacked up to the ceiling such as: seven boxes of Jumbo Beef Ravioli, five boxes of Tricolor Cheese Tortellini, three boxes of Ground [NAME], two boxes of Beyond Burger, and seventeen card boxes of different frozen foods. The boxes were stacked about in some cases 0.5 to 6 inches from the ceiling and in other cases touching the ceiling with the top lid being open that could compromise air circulation inside the refrigerator. During an interview on [DATE] at 2:05 PM, the Kitchen Manager acknowledged the surveyors' concerns regarding all the above-mentioned items, agreeing to remove all perished and expired items as well as addressing these findings with the lack of labeling in the upcoming Thursday huddle meeting, to which surveyors were provided a copy of the minutes after it happened. At the same interview, on [DATE] at 2:05 PM, the KM acknowledged that frozen food items were stack up to the ceiling and stated [he/she] was aware of the policy, but they just have to organize it better. Under no circumstance should there be stacking, and we will fix it immediately. During an interview on [DATE] at 9:30 AM, the Dietary Manager (DM) stated, the hospital has an 18 inches clearance policy for items to be off the ceiling; it's standard practice that if there is a sprinkler in the room, everything in the room has to be 18 inches cleared off the ceiling; the walk-ins are considered individual small rooms. She/he also added that magnetic blue tape has been purchased for it to stick to the freezer walls and then it's visible it marks the limits. Review of the checklist titled Environmental Safety Rounds, dated [DATE], revealed: Items are stored at least 18 inches clearance around sprinkler heads. Review of the policy and procedure titled: Job Safety Observations and Environmental Safety Rounds, last revised on [DATE], revealed, . Job safety observations will be conducted by department staff, with peer-to-peer observation and documentation of correct or incorrect performance of the targeted procedure. Review of the document Huddle Notes, dated [DATE], revealed: Fire code states there must be a clearance of 18 inches from finished ceiling height in a space to the top of shelving/products. This is including coolers and freezers; Hairnets or a clean hat, and beard nets, are required when in the kitchen. If there are any stray hair/ponytails it must be restrained; Watch out for, and dispose of, moldy or rancid produce/leftovers, and out of date food items. Use of Hairnet: During an observation on [DATE] at 11:00 AM, [NAME] #1 was observed to be in the kitchen preparing food at a prep table. [NAME] #1 was observed to have a cap on that covered the top half of his/her head. [NAME] #1's hair was observed to be tied back into a short ponytail about 1 ,d+[DATE] inches long and 1 inch wide. The bottom section of the hair, both on the sides of the head and rear of the head, were not covered with a hairnet. During an interview on [DATE] at 2:00 PM, the KM stated that hair should be completely covered with a hair net or a cap. During an interview on [DATE] at 9:45 AM, the DM stated that hair not completely covered with a hair net, or a cap was a concern and would be addressed. This was verified on the following days surveyors were on site. The DM stated, We follow the Serv-Safe course for food handlers and these hair nets are a part of the attire, we go through it in every orientation checklist to the kitchen with every employee. Review of the document Nutrition Services Department Orientation Check Off sheet, dated [DATE] and [DATE] , for both cooks (#1 and #2) revealed signed documents acknowledging New hire will dress in appropriate department uniform when ordered and has arrived for use, respectively signed by the employees on [DATE] for [NAME] #1 and [DATE] for [NAME] #2. Review of the document provided by the DM titled The Safe Food Handler - table 3.2: Work Attire Guidelines, undated, regarding Hair Restraints: wear a clean hat or other restraint when in a food-prep area. This can keep hair from falling into food and onto food-contact surfaces; Do NOT wear hair accessories that could become physical contaminants. Hair accessories should be limited to items that keep hands out of hair and hair out of food. 50078

Based on interview and record review, the facility failed to ensure full and complete accounting of personal funds were reported quarterly to all 25 residents (#s 1, 2, 3, 4, 5, 6, 7, 8, 9, 10,11,12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 26) out of 25 residents residing at the facility, or their representatives with personal funds being managed by the facility. This failed practice denied the residents and/or representatives the right to be informed of a detailed accounting of their personal funds. Findings: During a joint interview on 8/21/24 at 4:09 PM with Account Specialist (AS) #1, Business Office Supervisor (BOS), Activities Coordinator (AC), Director of Nursing (DON), and Social Worker (SW), AS #1 stated the facility managed the residents' personal funds. The BOS stated each resident had an individual personal fund account recorded in Point Click Care (PCC). She stated all residents' personal funds were deposited in one trust account at the bank. The trust account was an interest-bearing account. The interest would be divided based on the individual accounts of the residents. The monthly statements were sent to the resident or representatives. When asked if the residents could withdraw money from their personal fund accounts, AS #1 stated yes, the resident could request for withdrawal through a petty cash account at any time. The resident would submit a receipt of their expenditures to AS #1, and then the AS #1 would record the expenses in the resident's individual trust account. During an interview on 8/22/24 at 1:46 PM, when asked to explain the account statements, AS #1 stated the facility would send monthly statements to the residents and/or representatives. AS #1 confirmed the trust balance was listed, but the following withdrawal transactions: for example: massages, outings, haircuts and shopping money, were not included. He/She stated residents could get the details of the withdrawal transactions/expenditures if they requested it. When asked if the interest was included in the statement, AS #1 stated no, only the trust balance was in the statement. During an interview on 8/23/24 at 10:10 AM, when asked to define the difference between trust accounts and personal fund accounts, the BOS stated trust accounts meant personal funds. The BOS also confirmed that the trust balance listed in the monthly statements of account would mean personal funds account. In the same interview, the BOS confirmed that personal funds were deposited into one bank account. The bank account had an interest-accruing component, and the interest was distributed to each resident's trust account and recorded in Point Click Care. When asked what accounting principles the business office used, the BOS stated accounting principles meant complete itemized statements. When asked to specify what complete itemized meant, she stated credits (an entry recording a sum received), debits (an entry recording an amount owed), expenditures, current balance and interest would be included in the statements of account. Review of the monthly statements of resident accounts, from May to August 2024, for Resident #s 1, 2, 3, 4, 5, 6, 7, 8, 9, 10,11,12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 26, revealed the statements only reflected the payments and balances due for costs of care. Further review revealed, the trust balance was listed on the statements, but the full and complete accounting of the trust funds (personal funds), including credits, debits, and interest accrued, were not listed. During an interview on 8/23/24 on 10:56 AM with AS #1 through phone interview in the presence of BOS in the room, when asked if he/she sent quarterly statements to the resident or its representatives, AS #1 stated he/she provided monthly statements with complete accounting of the personal funds to one resident representative, because Resident #6's Power of Attorney (POA) wanted to know of every penny spent. AS #1 stated, nobody else requested it; therefore, he/she just sent all other residents and/or representatives a monthly statement that showed the trust account balance. Further review of the statements of account revealed only Resident #6 had expenses listed. Review of the facility's policy Management of Resident Personal Funds by LTC [Long Term Care] and PFS [Patient Financial Services] Department, dated 5/16/24, revealed: .POLICY: A. In accordance with .483.10 (f)(10)(iii) Accounting and Records (F568): 1.PFS on behalf of the facility and its Residents will: a) Establish and maintain a system that assures a full and complete accounting , according to generally acceptable accounting principles. c) The individual financial record will be available to the resident through quarterly statements and upon request. PROCEDURE: A. Residents Accounts . 3. The PFS staff will set up an individual interest-bearing account for funds in excess of $50.00 (fifty). All interest earned must be credited to that account. 6. PFS will assure that the Resident and/or her/his financial POA will receive minimally, a quarterly accounting of the money held in trust in the Resident's personal account.

Based on observation, interview, and record review, the facility failed to ensure food was served at a palatable temperature. This failed practice had the potential to place all residents, based on a census of 25, at risk for poor nutrition due to foods served outside of palatable temperatures. Findings: During an observation beginning in the main kitchen on 5/8/23 at 12:20 PM, Cook #1 placed all the food from the steam table onto a cart and delivered the food to the Long-Term Care (LTC) kitchen. Upon reaching the LTC kitchen he/she washed his/her hands, put on gloves, prepared a pail of bleach water, wiped the steam table and placed the pans from the cart onto the steam table. He/she removed gloves, sanitized his/her hands and put on new gloves. Then, the cook began plating food according to each resident's diet card. The Cook did not check the temperature of the food which included mechanically altered food such as pork, potato, gravy, and soup. During an interview on 5/8/23 at 1:10 PM, Resident #17 stated the chicken was cold on his/her lunch tray. During an interview on 5/8/23 at 3:16 PM, Resident #17 stated a lot of time the food was served cold, especially the meat. The Resident further stated the potato was hot, but the meat was cold during lunch on 5/8/23. During an interview on 5/9/23 at 10:50 AM, Resident #14 stated sometimes the food was cold when it was served. During an interview on 5/9/23 at 12:00 PM, when asked the procedure to check the temperature of the food, Cook #1 stated he/she would have checked the temperature of the food before placing the food in the steam table and would have recorded the temperature in the log. When asked if he/she checked the temperature of the food at the LTC kitchen steam table on 5/8/23, the Cook stated he/she did not check the temperature of the food during lunch on 5/8/23. During an interview on 5/10/23 at 12:40 PM, the Nutrition Services Manager (NSM) stated food temperatures should have been checked 3 times during the food preparation process. The food temperature should have been checked: 1) before taking the food from the oven; 2) in the steam table in the main kitchen; 3) after the food was delivered to LTC kitchen. The NSM stated after each temperature check, the temperature should have been recorded in the hot line log. She also stated the current log had two temperature readings for acute care and LTC recorded and she planned to revise the log to add a temperature check before taking the food from the oven. Pureed food: An observation on 5/9/23 at 11:25 AM revealed Cook #1 prepared the following pureed food: -pureed open faced roast beef sandwich The Cook pureed together a slice of bread, mashed potato, slices of roast beef, gravy, and a cup of hot tap water in the blender. Then, the cook poured the pureed food in the bowl, then placed the bowl in the steam table. The Cook did not check the temperature of the pureed food. -pureed baked vegetables The Cook pureed the baked vegetables with one-half cup of hot tap water in the blender. Then, the cook poured the pureed food in a bowl, then placed the bowl in the steam table. The Cook did not check the temperature of the pureed food. -pureed rockfish The Cook pureed the rockfish with one-half cup of hot tap water in the blender. Then, the cook poured the pureed food in a bowl, then placed the bowl in the steam table. The Cook did not check the temperature of the pureed food. -pureed mashed potatoes The Cook pureed mashed potatoes with one-half cup of hot tap water in the blender. Then, the cook poured the pureed food in a bowl, then placed the bowl in the steam table. The Cook did not check the temperature of the pureed food. During an interview on 5/9/23 at 12:00 PM, Cook #1 stated he/she was not taught to check the temperature of the pureed food. This surveyor asked Cook #1 to check the temperature of the pureed food in the steam table. The Cook stated the food must have been cooled down after pureeing it. The temperature checks revealed: Pureed mashed potato- 132 degrees F, Pureed baked vegetables- 136 degrees F Pureed open faced roast beef sandwich - 132 degrees F Pureed rock fish- 123 degrees F Record review on 5/9/23 at 12:30 PM of TRACKING FORM: ACUTE & LTC HOT LINE DAILY REPORT, revealed the recommended temperatures for the following: Vegetables - 160 degrees F; Roast Beef- 130-145 degrees F; Beef, Pork, Fish- 145 degrees F During an interview on 5/10/23 at 12:40 PM, when asked if the pureed food temperature should have been recorded, the NSM stated the procedure for checking the food temperature was the same in all food types including mechanically altered/pureed food and liquids. The NSM further stated that if the food temperature was not within the set parameters, the food should have been reheated. Food heated in the microwave During an observation and interview on 5/9/23 at 11:25 AM, Cook #1 opened a can of cream of chicken soup, poured the soup in a bowl, and heated the soup in the microwave. Then, the cook left to get the fish from the oven and transferred the fish to the steam table. The Cook returned to the microwave and reheated the soup again without checking the temperature. The Cook removed the bowl from the microwave, covered it, labeled the lid, and then placed the bowl in the steam table. The Cook did not check the temperature of the reheated soup. When asked the amount of time he/she reheated the cream of chicken soup in the microwave, the Cook stated he/she reheated the soup for 1 and a half minutes. When asked the temperature of the reheated cream of chicken soup, the Cook stated he/she did not check the temperature. This surveyor asked the Cook to check the temperature. The temperature read 158 degrees F. Further review of TRACKING FORM: ACUTE & LTC HOT LINE DAILY REPORT, revealed the recommended temperatures for the soup was 165 degrees F. During an interview on 5/10/23 at 12:40 PM, when asked what the temperature parameters for heating canned soup in the microwave, the NSM stated the soup should have been heated to 165 degrees F. She further stated the food should have been reheated once, and the Cook should have started over, using a new can of soup instead of reheating a second time. Review of the facility's policy Reheating liquids, dated 4/4/19, revealed: .any liquid that is re-heated must be temperature checked . Review of the Centers for Disease Control and Prevention (CDC), Four Steps to Food Safety: Clean, Separate, Cook, Chill, Cook to the right temperature, dated 3/24/23. Accessed at https://www.cdc.gov/foodsafety/keep-food-safe.html, revealed: .Microwave food thoroughly .when reheating, use a food thermometer to make sure that microwaved food reaches 165 F. Review of the Food and Drug Administration Food Code 2022, dated 1/18/23. Accessed at https://www.fda.gov, revealed: . 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 74oC (165oF) and the FOOD is rotated or stirred, covered, and allowed to stand covered for 2 minutes after reheating . Test Tray On 5/9/23 at 11:25 AM, the surveyor requested a test tray from the LTC kitchen. During an observation on 5/9/23 at 1:35 PM, two test trays were delivered from the LTC kitchen to room [ROOM NUMBER] [this room was used by the surveyors]. The first test tray had a regular meal consisting of fish covered with gravy, mashed potatoes and gravy, roasted vegetables, and a bowl of orange-colored soup. The second test tray had a chopped meal plate consisting of hamburger in gravy on soft bread, mashed potatoes, and vegetables. At 1:37 PM, the surveyor tasted the food on the tray. The soup, fish and hamburger with gravy were cool to the taste and not at a palatable temperature. Review of the facility's policy, Meal Service for Long Term Care Residents, dated 9/9/21, revealed, Each Resident receives, and the facility provides food prepared by methods that conserve nutritive value, flavor & appearance; and . at proper temperature .

Based on record review, observation and interview, the facility failed to ensure their medication error rate was below 5%. Specifically, errors for 3 out of 27 medication opportunities during medication administration review resulted in a 11% error rate. This failed practice placed 2 residents (#'s 77 and 18) at risk for adverse effects. Findings: Resident #77: Record review from 5/8-12/23 revealed Resident #77 was admitted to the facility with diagnoses that included dementia and hypothyroidism. Review of Resident #77's current Physician's Orders revealed an order for Levothyroxine Sodium Oral Tablet [Synthroid-a thyroid medication] 75 mcg [micrograms] .one time a day related to HYPOTHYROIDISM, UNSPECIFIED. During an observation on 5/10/23 at 8:50 AM, Licensed Nurse (LN) #3 began preparing Resident #77's morning medications, which included the Levothyroxine Sodium Oral Tablet. The Resident was observed to be seated in the dining room eating his/her breakfast when LN #3 administered the medications to the resident. During an interview on 5/11/23 at 10:42 AM, when asked the recommended administration time for the levothyroxine medication, Pharmacist #1 stated the medication should have been given on an empty stomach. When asked the risk of taking the medication during a meal, the Pharmacist stated the medication would have been absorbed differently, and the electronic medication record (eMAR) should have included the recommendation for the medication to be given on an empty stomach. Further review of Resident #77's current Physician's Orders revealed no recommendations for the Levothyroxine medication. During an interview on 5/11/23 at 1:37 PM, Pharmacist #2 clarified if a Resident was to take the levothyroxine medication at the same time every day and that time was during a meal, then it would have been okay to give that medication with food, if it was consistently given that way. During a second observation on 5/11/23 at 9:40 AM, Resident #77 was observed to be seated at the dining room table. LN #2 delivered the Resident's medications, which included the levothyroxine medication. During an interview on 5/11/23 at 2:19 PM, LN #1 stated Resident #77 had a snack at 4:30 AM that morning, and then ate his/her breakfast at 8:00 AM. Review of HIGHLIGHTS OF PRESCRIBING INFORMATION, revised 10/2022, accessed at https://www.rxabbvie.com/pdf/synthroid.pdf revealed Administer SYNTHROID as a single daily dose, on an empty stomach, one-half to one hour before breakfast. Resident #18: Record review from 5/8-12/23 revealed Resident #18 was admitted to the facility with diagnoses that included heart failure and hypertension. Review of Resident #18's current Physician's Orders revealed an order for Losartan Potassium Tablet [blood pressure medication] 50 mg [milligrams] .one time a day related to HYPERTENSIVE HEART AND CHRONIC KIDNEY DISEASE WITH HEART FAILURE . During an observation and interview on 5/11/23 at 9:28 AM, LN #2 was preparing Resident #18's morning medications. The LN prepared 25 mg of Losartan Potassium Tablet and administered the incorrect dose to Resident #18. After the medication pass for Resident #18 was completed, the LN was made aware of the error and verified the incorrect dosage was given to the resident. Further Review of Resident #18's current Physician's Orders revealed an order for Ferrous Sulfate Syrup [iron supplement] and Levothyroxine Sodium Tablet. During an observation on 5/11/23 at 9:28 AM, LN #2 was preparing Resident #18's morning medications which included the Ferrous Sulfate Syrup and Levothyroxine Sodium Tablet. The resident was observed to take his/her morning medications at the same time, including the Ferrous Sulfate syrup and Levothyroxine tablet. Review of HIGHLIGHTS OF PRESCRIBING INFORMATION, revised 10/2022, accessed at https://www.rxabbvie.com/pdf/synthroid.pdf revealed: Concurrent use may reduce the efficacy of SYNTHROID by binding and delaying or preventing absorption, potentially resulting in hypothyroidism .Phosphate Binders (e.g., .ferrous sulfate .) .may bind to levothyroxine. Administer SYNTHROID at least 4 hours apart from these agents.

Based on facility policy review, record review, and interview the facility failed to ensure allegations of abuse and/ or neglect were thoroughly investigated, and a 5-Day investigation report was submitted to the State Agency for three of four sampled residents reviewed for abuse and/or neglect (resident #s 1, 2 and 3). The failure to complete a thorough investigation of potential abuse and/or neglect and report the resulting investigation to the State Agency, places residents at risk of harm from abuse and/or neglect. Findings: Review of the facility's policy titled Abuse, Neglect, Exploitation, and Misappropriation of Property- Identifying, Reporting, and Investigating revised 12/21/2020, revealed, . Procedure: II. Management of Suspected Abuse. C. An alleged violation of abuse . will be reported immediately, but no later than: i) Two (2) hours if the alleged violation involves abuse . 2. Role of the Licensed Nursing Home Administrator (LNHA): . D. The LTC Director, with the approval from the LNHA, will work collaboratively with Human Resources and suspend immediately any employee who has been accused of the resident abuse, neglect, pending the outcome of the investigation. The employee will be placed in administrative leave and will remain in leave until the investigation is complete . 3. Role of the LTC Director (the Investigator): A. The LTC Director will conduct the investigation which includes, as a minimum: Review the resident's medical record to determine events leading up to the incident; . iii) Interview any witnesses to the incident; iv) Interview the resident's non-cognitively impaired residents who may be involved as appropriately); vi) Interview staff members (on all shifts) who have had contact with the resident during the period of the alleged incident (including the residents attending nurse, all licensed professionals and certified nurse aides); vii) Interview other residents to whom the accused employee provides care or services; . B. The following guidelines will be used when conducting interviews: .v) Witness reports will be obtained in writing. Either the witness will write his/her statement and sign and date it, or the investigator may obtain a statement, read it to the member and have him/her sign and date it . Additional Consideration(s): 7. Staff Education: All staff education at orientation, and as needed, addressing how to recognize signs of possible abuse and neglect, reporting of abuse/neglect, and follow-up . Resident #1 1. Review of the facility's internal investigation report for an allegation of abuse dated 7/19/21, involving Resident #1 revealed Current Status of the Resident(s) involved: Baseline: Resident was observed smiling/talking through the incident with charge RN [Registered Nurse] immediately following .Incident Summary: Resident [by name] was involved with an incident with CNA [by name] during lunch Saturday 7/17 [7/17/21]. One staff member believes resident dropped his fork and asked CNA to pick it up, who said it could wait while he/she finished another task. Another staff member believes resident was attempting to pick it up himself/herself and continue to use it, and CNA intervened. What staff does agree on, however, is that the incident escalated and [name of resident] began to yell and curse at [CNA by name]. He/she raised her voice back and got her face close to his (he is in a wheelchair). Another CNA intervened by taking the resident to his room . Further review of the investigation revealed no written statements with dates times of when the interviews were conducted. There were no interviews with residents included. Under actions taken, training was marked. Under conclusions: While this situation did not end in immediate or obvious harm to [name of resident], it shed light on an educational opportunity for LTC staff, as well as room for improvement in [name of CNA] professional behavior . The date of the investigation was 7/19/21. Review of Resident #1's quarterly Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) 10/15/21 indicated Resident #1 had a Brief Interview Mental Status (BIMS) score of 10 out of 15, which indicated the resident was moderately cognitively impaired. During an interview on 11/16/21 at 1:58 PM, the DON was asked about the incident. The DON stated it occurred on a Saturday [7/17/21]. The DON stated he/she was not aware of the alleged abuse until Monday [7/19/21]. The DON was asked how he/she found out about the alleged abuse. The DON stated he/she received an e-mail from one of the CNA's that worked that day. The DON was asked about a complete investigation with statements, dated and timed. The DON stated, I conducted the interviews, but did not date or time them nor did I get written statements. Review of the e-mail sent to the DON on 7/18/21 at 6:47 am revealed that a CNA had reported a interaction between Resident #1 and another CNA. During an interview on 11/16/21 at 3:21 PM, the consulting Administrator stated the Abuse Coordinator was the DON. Resident #1 & Resident #2 Review of the facility's internal investigation report for an allegation of abuse between Resident #1 and Resident #2 revealed Incident Summary: .verbal altercation between two wheelchair- bound residents as it escalated to physical altercation in the hallway. Both residents were in route to their rooms (able to self- propel) following dinner. These two residents have been seen arguing in the day room in recent past and social worker has been involved . Continued review of the facility's internal investigation revealed no documented evidence the facility completed an investigation and reported the results of the investigation to the State Agency (SA) within five working days. Review of Resident #1's quarterly MDS with an ARD of 10/15/21, located in the resident's EMR, under the MDS tab indicated Resident #1 had a BIMS score of 10 out of 15 which indicated the resident was moderately cognitively impaired. Review of Resident #1's Progress Notes dated 8/8/21, revealed, Verbal altercation with another resident after dinner that escalated to physical (swinging/clawing at each other) in hallway. Resident #2's quarterly MDS assessment dated , 10/8/21, indicated Resident #2 had a BIMS score of nine out of 15, which indicated the resident was moderately cognitively impaired. During an interview on 11/16/21 at 3:15 PM, Resident #1 was asked if he/she recalled the incident. Resident #1 stated, Yes. I was going to my room and as I went by, He/she called me a Son of a [OBSCENITY] . I told him I was not and hit him. During an interview on 11/17/21 at 10:43 am, the DON was asked about the incident. The DON stated he/she had worked the night that the resident-to-resident altercation occurred. The DON stated he/she did not actually see it at the time but heard a staff member yelling, Stop and ran over to the residents. When asked what he/she thought the cause was, the DON stated they thought it was because the two residents were from different tribes. The DON added, There had been issues in the past involving the two residents. Resident #3 Review of Resident #3's admission MDS with an ARD of 8/30/21, showed Resident #3 had a BIMS score of 14 out of 15 which indicated he/she was cognitively intact. Review of the facility's Final Report of Harm, dated 10/9/21, provided to the survey team by the DON, showed that on 10/3/21 at 4:15 PM, that .Resident's [Resident #3] daughter asked to speak with the Nurse. Both Licensed Nurse (LN) #2 and LN #4 called daughter on speaker phone, with resident present. The daughter was concerned with night shift CNA #2 taking care of him/her [Resident #3]. Last evening, he/she got a phone call from him/her [Resident #3] talking about CNA #2. Resident said CNA #2 would not take him/her to the bathroom when he/she needed to urinate. He/she stated that she [CNA #2] told him/her that he/she had already gone an hour ago. Resident said he/she was not able to wait and urinated in his/her pants and sat in wet pants for a while. He/she also stated he/she tried to get up to [sic] bathroom and [CNA #2] jerked him/her back into his/her chair. Daughter stated that this may be a personality conflict. He/she would prefer that [CNA #2] not take care of her [Resident #3] . In an interview on 11/16/21 at 1:58 PM, the DON was asked if there was an allegation of abuse, what should he/she do. The DON stated the staff person would be immediately placed on suspension pending investigation. The DON was asked if, during his/her investigation, if he/she had asked other residents on the hall if they had received rough care by CNA #2. The DON stated, I did not. According to the fax transmission report of the facility's 5-day completed investigation, dated 10/11/21 at 12:39 PM, showed only the Long-Term Ombudsman (LTC Ombudsman) was notified and not the State Agency (SA) as required.

Based on interview, and record review the facility failed to report allegations of abuse to the Administrator and State Survey Agency (SSA) immediately, but not later than two hours; and failed to report findings of their investigations within five working days of the allegations for four of four sampled residents reviewed for abuse/neglect (Resident #1, Resident #2, Resident #3, and Resident #117). This failed practice placed the residents at risk for potential abuse and/or neglect. Findings: Review of the facility's policy titled, Abuse, Neglect, Exploitation, and Misappropriation of Property-Identifying, Reporting, and Investigating, Revised 11/17/21, revealed, .An alleged violation of abuse, neglect, exploitation or mistreatment (including injuries of unknown source and misappropriation of resident property) will be reported immediately, but not later than: two (2) hours if the alleged violation involves abuse OR has resulted in serious bodily injury; or twenty-four (24) hours if the alleged violation does not involve abuse AND has not resulted in serious bodily injury .The Administrator, or his/her designee, will provide the appropriate agencies or individuals listed above with a final written report of the findings of the investigation within five (5) working days of the occurrence of the incident . Resident #1: Review of the facility's internal investigation report for an allegation of abuse involving Resident #1, dated 7/19/21, revealed Incident Summary: Resident [Resident #1 by name] was involved with an incident with CNA [by name] during lunch, Saturday 7/17 [7/17/21]. One staff member believes resident dropped his fork and asked CNA to pick it up, who said it could wait while he/she finished another task. Another staff member believes resident was attempting to pick it up himself and continue to use it, and CNA intervened. What staff does agree on, however, is that the incident escalated and [name of resident] began to yell and curse at [CNA by name]. he/she raised her voice back and got her face close to his/her (he/she is in a wheelchair). Another CNA intervened by taking the resident to his/her room. During an interview on 11/16/21 at 1:58 PM, the Director of Nursing (DON) was asked about the incident. The DON stated it occurred on a Saturday 7/17/21. The DON stated he/she was not aware of the alleged abuse until Monday 7/19/21. The DON was asked how he/she found out about the alleged abuse. The DON stated he/she received an e-mail from one of the CNA's that worked that day. The DON was asked if he/she was aware that the alleged abuse should have been reported with a two-hour time frame after the alleged abuse occurred. The DON stated, I have never done that. I did not know that. During an interview on 11/16/21 at 3:21 PM, the consulting Administrator stated the Abuse Coordinator was the DON, was clinically responsible, and usually ran the first report within 24 hours. Resident #s 1 and 2 Review of the facility's internal investigation report for an allegation of abuse between Resident #1 and Resident #2 dated 8/9/21 revealed Incident Summary .verbal altercation between two wheelchair- bound residents as it escalated to physical altercation in the hallway. Both residents were in route to their rooms (able to self- propel) following dinner. These two residents have been seen arguing in the day room in recent past and social worker has been involved . During an interview on 11/17/21 at 10:16 am, the ADON (Assistant Director of Nursing) stated the facility did not send in the initial report to State Agency (SA) of the resident-to-resident altercation until today when the facility realized the report did not go through back in August. Resident # 3: Review of Resident #3's undated Face Sheet revealed Resident #3 was admitted to the facility with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the facility's Final Report of Harm, dated 10/9/21, provided to the survey team by the Director of Nursing (DON), showed the date and time of the incident was 10/2/21 at 10:00 PM. The incident summary showed that, Resident (and daughter, subsequently) alleged that a CNA [Certified Nursing Assistant] #2 refused to toilet resident while he/she was in recliner in the day room one night. Resident #3 reportedly had two episodes of incontinence and accused CNA of roughly repositioning him/her, telling him/her to be quiet, and threatening to have him/her kicked out of the facility. According to the fax transmission report of the facility's 5-day completed investigation, dated 10/11/21 at 12:39 PM, showed only the Long-Term Ombudsman (LTC Ombudsman) was notified and not the State Agency (SA) as required. During an interview on 11/16/21 at 12:56 PM, the DON stated that when the initial report was faxed, it went to both the State Agency and the LTC Ombudsman however, when the final report was faxed, it was only faxed to the Ombudsman and not the SA, as required. Resident #117: Review of Resident #117's undated Face Sheet revealed Resident #117 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the facility's Final Report of Harm, which showed an allegation of Other, provided to the survey team by the DON, showed a Date of Initial Report of 8/13/21 at 2:00 PM. The Incident Summary documented, Resident was found to have a blanchable reddened area to her/his toe approximately two months ago. Despite multiple interventions and frequent observation, including weekly rounds by a wound care nurse, the resident underwent [MEDICAL RECORD OR PHYSICIAN ORDER] . A fax cover sheet, dated 08/16/21, showed that both the SA and the LTC Ombudsman were to be notified of the final report however, the fax transmission sheet showed only the LTC Ombudsman was notified. In an interview on 11/16/21 at 4:30 PM, the DON stated that only the LTC Ombudsman was notified of the 5- day findings, and the report was never sent to the SA.

Based on interview, record review, and facility policy review, the facility failed to ensure one resident (Resident #12) of five residents reviewed for unnecessary medication, had an order for an as-needed (PRN) [CONDITION(S)] medication (a medication that affects a person's mental state) that did not extend beyond 14 days, without a Stop Date as to the need for the PRN medication, as required. This failure placed the resident at risk of adverse side effects from unnecessary medications. Findings: Review of the facility's policy titled, [CONDITION(S)] Medication Use, revised 11/20/18, showed, .A [CONDITION(S)] drug that affects the brain activities associated with mental processes and behavior .These drugs include, but are not limited to anti-psychotic, anti-depressant, antianxiety and hypnotics .PRN orders for [CONDITION(S)] drugs are limited to 14 days. If the attending physician believes that it is appropriate for the PRN order to be extended beyond 14 days, he or she should document their rationale in the resident's medical record and indicate the duration for the PRN orders . Review of Resident #12's undated Face Sheet located in the Profile tab of the electronic medical record (EMR), revealed Resident #12 was admitted to the facility on [DATE] with diagnoses which include anxiety disorder. Review of Resident #12's annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 9/3/21, located in the MDS tab of the EMR, revealed Resident #12 was administered an antianxiety medication daily during the assessment period. Review of Resident #12's Physician Orders located in the Orders tab of the EMR, revealed the physician had prescribed lorazepam (an antianxiety medication) 0.5 milligrams (mg) every eight hours as needed (PRN) for anxiousness on 8/18/21. The order did not contain a Stop Date, as required. During an interview on 11/16/21 at 5:11 PM, the Assistant Director of Nursing (ADON) was asked if he/she was aware that PRN [CONDITION(S)] medications required a Stop Date. He/she stated he/she was not aware the PRN [CONDITION(S)] medications required a Stop Date. During an interview on 11/17/21 at 12:48 PM, the Pharmacist stated that he/she reviewed the monthly medication records and checked to ensure that PRN's have an expected duration, however, he/she was not aware that [CONDITION(S)] medications required a Stop Date.

Based on interview and record review, the facility failed to ensure the accuracy of Minimum Data Set (MDS) assessments for one of 14 residents (Resident #3) whose assessments were reviewed. The facility failed to accurately assess the use of anticoagulant (blood-thinning) medication. Findings: Review of the Centers for Medicare and Medicaid Services Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 Manual, dated October 2019 revealed .The intent of the items in this section is to record the number of days, during the last 7 days (or since admission/entry or reentry if less than 7 days) that any type of injection, insulin, and/or select medications were received by the resident .Review the resident's medication administration records for the 7-day look-back period (or since admission/entry or reentry if less than 7 days). 2. Review documentation from other health care locations where the resident may have received injections while a resident of the nursing home (e.g., flu vaccine in a physician's office, in the emergency room - as long as the resident was not admitted ). 3. Determine if any medications were received by the resident via injection. If received, determine the number of days during the look-back period they were received .Medications are an integral part of the care provided to residents of nursing homes. They are administered to try to achieve various outcomes, such as curing an illness, diagnosing a disease or condition, arresting or slowing a disease's progress, reducing or eliminating symptoms, or preventing a disease or symptom. Residents taking medications in these medication categories and pharmacologic classes are at risk of side effects that can adversely affect health, safety, and quality of life. While assuring that only those medications required to treat the resident's assessed condition are being used, it is important to assess the need to reduce these medications wherever possible and ensure that the medication is the most effective for the resident's assessed condition . Review of Resident #3's admission MDS with an Assessment Reference Date (ARD) of 8/30/21, revealed that it documented the resident received an anticoagulant medication and had physical restraints for seven out of seven days during the assessment period. Review of the Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . In an interview on 11/16/21 at 1:25 PM, the MDS Coordinator was asked if he/she was aware that [MEDICATION(S)] was an antiplatelet medication and not an anticoagulant. He/she stated he/she did not think to question the [MEDICATION(S)] as an anticoagulant but agreed that it should not have been coded as such.

Based on interview, record review, and review of the facility policy, the facility failed to ensure residents were free from abuse for two of 13 residents (Resident #1 and Resident #2). Resident #1 and Resident #2 were involved in a resident-to-resident altercation. Findings: Review of the facility's policy titled Abuse, Neglect, Exploitation, and Misappropriation of Property- Identifying, Reporting, and Investigating revised 12/21/2020, revealed Definition(s) Abuse: The willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. Physical Abuse: includes hitting, slapping, pinching, and kicking. It also includes controlling behavior through corporate punishment . All residents .have the right to be free from abuse .This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual, or physical abuse . Review of Resident #1's undated Admission Record under the Profile tab in the electric medical record (EMR) revealed Resident #1 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #1's quarterly Minimum Data Set (MDS) with an assessment reference date (ARD) of 10/15/21, located in the resident's EMR under the MDS tab revealed Resident #1 had a Brief Interview Mental Status (BIMS) score of 10 out of 15, which indicated the resident was moderately cognitively impaired. Review of Resident #1's Progress Notes dated 8/8/21, located in the resident's EMR under the Progress Notes tab revealed, Verbal altercation with another resident after dinner that escalated to physical (swinging/clawing at each other) in hallway. Review of Resident #2's undated Admission Record under the Profile tab in the EMR revealed Resident #2 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Review of Resident #2's quarterly MDS with an ARD of 10/8/21, located in the resident's EMR under the MDS tab revealed Resident #2 had a BIMS score of nine out of 15, which indicated the resident was moderately cognitively impaired. Review of the facility's internal investigation report for an allegation of abuse between Resident #1 and Resident #2 revealed Incident Summary: .verbal altercation between two wheelchair- bound residents as it escalated to physical altercation in the hallway. Both residents were in route to their rooms (able to self- propel) following dinner. These two residents have been seen arguing in the day room in recent past and social worker has been involved . During an interview on 11/16/21 at 3:15 PM, Resident #1 was asked if he/she recalled the incident. Resident #1 stated, Yes. I was going to my room and as I went by, He/she called me a Son of a [OBSCENITY] . I told him I was not and hit him. During an interview on 11/17/21 at 10:43 am, the DON was asked about the incident. The DON stated he/she had worked the night that the resident-to-resident altercation occurred. The DON stated he/she did not actually see it at the time but heard a staff member yelling, Stop and ran over to the residents. When asked what he/she thought the cause was, the DON stated they thought it was because the two residents were from different tribes. The DON added, There had been issues in the past involving the two residents.

Based on record review and interview, the facility failed to ensure comfortable and safe temperature levels. Specifically, the facility failed to respond to the rising heat in the facility in a timely manner, and a temperature reading on 8/16/20 was measured at 89.5 degrees. This failed practice caused resident #1 to suffer medical problems requiring hospitalization . Record review from 10/20-27/20 revealed Resident #1 was admitted to the facility with [DIAGNOSES REDACTED]. other heart-related complications). Record review on 10/21/20 at 9:30 am of an LTC (long term care) PROGRESS NOTE, dated 8/17/20 at 7:28 pm, signed by the Medical Director (MD), revealed (Resident) was transferred yesterday from the long-term care to the emergency room because of rapid heart rate and elevated temp (temperature) .(He/She) was felt to be in (A-fib) with dehydration, especially resulting from long-term care being terribly hot yesterday. There was a malfunction in the circulation system for the air currents here. We do not have air conditioning in long-term care, but the vents were spewing out hot air and (Resident) became distressed as well as very warm. During a phone interview on 10/21/20 at 10:50 am, when asked about the events that took place on 8/16/20, Licensed Nurse (LN) #3 stated that he/she was on duty that day. The LN explained that the LTC was hot that day, so he/she called Facility Engineer (FE) #2, who was on call that day, to report the problem. LN #3 further stated he/she was told by FE #2 to call and report the problem to FE #1. The LN further explained that he/she spoke with FE #1, who informed him/her that the heat problem happened in the summer and directed him/her to close the curtains in the dayroom. When asked what time he/she informed the FEs, the LN stated he/she believed it was prior to 10:00 am. The LN further stated that they (a facility engineer) didn't come into the facility until around 5:30 pm, and the problem was fixed after a few hours. In the interim, the LN stated that staff had brought the Residents into the dayroom where it was cooler and got fans going, as well as giving the Residents cold fluids and ice pops. During an interview on 10/21/20 at 4:39 pm, The Director of Nursing (DON) stated that she received a phone call at home that day at 4:30 pm from the Administrative Assistant stating that the unit was hot. The DON stated the vents on the unit were blowing hot air into the rooms because there was an equipment malfunction. The DON further stated at 4:30 pm, she called FE #1 and told him/her that the staff reported it was hotter than it had ever been, and he/she would meet FE #1 at the facility. The DON stated the FE arrived at the facility and started checking temperatures. The DON stated the staff had pulled the blinds and obtained industrial fans to cool the Residents. The DON further stated she gave direction to move some of the Residents into the cooler dayroom. At this point, the DON stated she had noticed a Certified Nursing Assistant (CNA) attending to Resident #1, who had displayed signs of heat exhaustion. The DON stated, we went into action, staff provided cold towels to the Resident and called a rapid response, which lead to the Resident being transferred to the emergency department for evaluation. The Resident subsequently stayed at the hospital for treatment for 3 days. During an interview on 10/22/20 at 9:55 am, the FE #1 stated that he/she was first notified of the issue after he/she received a phone call from the DON around 5:00 pm explaining the scenario. The FE #1 stated Resident rooms 6 through 16 were on an older system, while rooms 1-6 and the dayroom were on automatic system in which he/she could have controlled from home. The FE #1 stated that when he/she arrived at the long-term care, the heat gun (temperature) measurement gathered in Resident room [ROOM NUMBER], 10 or 14 measured 89.5 degrees. During an interview on 10/23/20 at 9:45 am, when asked if Resident #1's medical emergency was directly related to the temperature in the building, The MD stated that the air that day was hot, there was no circulation and the unit was greater than 85 degrees. The MD further stated that Resident #1 was fair skinned, and he/she became hot from the lack of air flow. The Resident also had a history of [REDACTED]. During an interview on 10/22/20 at 9:55 am, the FE #1 stated it was customary for staff to call engineering if there was a problem. The FE #1 further stated that FE #2 had been on call that day, but he/she had an emergency and notified FE #1 at 12:00 pm that he/she needed a replacement, at which time FE #1 assumed call. The FE #1 further stated that FE #2 did not notify him/her of the temperature problem in the LTC during the phone call exchange to transfer the on-call duties. The FE #1 further stated that FE #2 should have responded in some way, and the heating problem did not get passed off to him/her at that time. During an interview on 10/22/20 at 10:22 am, when asked about the policy for the FE's on call schedule, the Facilities Director (FD) stated that the response time was 15 minutes after a call request was received. The FD further stated that a phone call was the typical way the FE was notified of a problem. The FD stated that he/she would have asked the staff member reporting the problem to also write out a work request to document the time of the problem. The FD further stated that the FE would not wait for the completed work request before responding to an issue. During an email exchange with the Facility Administrator (FA) on 10/6/20 at 12:09 pm, when asked if there were any work order requests for 8/16/20, the FA responded that there was not a work order request because it was an emergency and not a work order item. During an email exchange with the FA on 10/6/20 at 2:05 pm, when asked if there was a policy on work orders, the FA wrote that there was not. Review on 10/22/20 at 7:00 pm of SOUTH PENINSULA HOSPTIAL POSITION DESCRIPTION, for the Facilities Engineer 4, dated 11/4/15, revealed This position is routinely scheduled for Engineer on-call duty. This duty has a fifteen-minute response time and may be called to work at any hour of the day or night to deal with maintaining a safe and secure environment for patients, visitors and staff. During an interview on 10/22/20 at 5:05 pm, the Facility Administrator (FA) stated there was no policy or procedure regarding FE's on-call duties, nor a policy or procedure regarding facility emergency or triage response for FEs. During an interview on 10/22/20 at 2:00 pm, the FA stated that facility performed a root cause analysis (RCA - a structured method used to analyze serious adverse events). The FA stated the RCA discussed the heating issue but did not fully address the failed maintenance response. Review on 10/22/20 at 6:30 pm of the Root Cause Analysis Long Term Care Heating Issue, dated 8/25/20, revealed on 9/2020 an action was to Update/develop standards for responding to environmental temperature fluctuations to include resident assessment. The goal listed was to Standardize response to environmental temperature fluctuation to increase timeliness and effectiveness of care. Status listed on the RCA stated, In process. Review on 10/22/20 at 7:15 pm, of the facility's policy SUBJECT: Protocol: Ambient Temperature Out of Range, dated 8/26/20, revealed Upon discovery that the ambient temperature is outside the acceptable range of 71-81 degrees Fahrenheit the charge nurse institutes the following actions: 1. Notified Facilities/Maintenance personnel 2. Notified Director of Nursing (DON) a. DON to contact Facilities Director directly as indicated . The policy did not mention steps to be taken within the Facilities/Maintenance department.

Based on record review and interview, the facility failed to ensure possible neglect of 1 resident (#1) was thoroughly investigated and appropriate corrective actions based on the findings were taken. Specifically, other residents and primary certified nursing assistants (CNAs) for resident #1 had not been interviewed, and corrective actions taken by the facility had not been completed. This failed practice had the potential to affect all residents, based on a census of 18. Report of Harm: Record review from 10/20-27/20 revealed Resident #1 was admitted to the facility with [DIAGNOSES REDACTED]. heart-related complications). Record review on 10/21/20 at 9:30 am of an LTC (long term care) PROGRESS NOTE, dated 8/17/20 at 7:28 pm, signed by the Medical Director (MD), revealed (Resident) was transferred yesterday from the long-term care to the emergency room because of rapid heart rate and elevated temp (temperature) .(He/She) was felt to be in (A-Fib) with dehydration, especially resulting from long-term care being terribly hot yesterday. There was a malfunction in the circulation system for the air currents here. We do not have air conditioning in long-term care, but the vents were spewing out hot air and (Resident) became distressed as well as very warm. During an interview on 10/21/20 at 4:39 pm, The Director of Nursing (DON) stated that she received a phone call at home that day at 4:30 pm from the Administrative Assistant stating that the unit was hot. The DON stated the vents on the unit were blowing hot air into the rooms because there was an equipment malfunction. The DON stated the staff had pulled the blinds and obtained industrial fans to cool the Residents. The DON further stated she gave direction to move some of the Residents into the cooler dayroom. At this point, the DON stated she had noticed a CNA attending to Resident #1, who had displayed signs of heat exhaustion. The DON stated, we went into action, staff provided cold towels to the Resident and called a rapid response, which lead to the Resident being transferred to the emergency department for evaluation. The Resident subsequently stayed at the hospital for treatment for 3 days. During the same interview, the DON stated she was alerted by CNA #5 that he/she had requested Licensed Nurse (LN) #4 to check on Resident #1 prior to the emergency response, because the Resident did not appear well. When asked what actions were taken after CNA #5 made the report, the DON stated she interviewed LN #4, who stated he/she looked at an area of concern during a dressing change and stated the Resident had looked fine. The DON further stated LN #4 had not performed an assessment. The DON stated that LN #4 submitted his/her resignation before the investigation was completed. During an interview on 10/23/20 a 9:30 am, when asked about staff's response to Residents requesting assistance, CNA #5 stated that he/she was working with the activities department that day. He/she had made rounds and noticed that Resident #1 was groggy and that something seemed off. CNA #5 stated he/she reported his/her concern to LN #4, and the LN responded by asking if the Resident was having a stroke. The CNA further stated that he/she replied that he/she did not know if the Resident was having a stroke. The CNA then stated that the primary CNAs had returned from break and he/she went back to working with activities. CNA #5 further stated that he/she assumed that LN #4 would have checked on Resident #1 right away. During a phone interview on 10/27/20 at 10:34 am, CNA #6 , the primary CNA for Resident #1, recalled the temperature on the unit was hot that day, and stated it started to get really hot around 3:00 pm when hot air started blowing out of the vents. CNA #6 stated that he/she went on break and did not notice any issues with Resident #1. When he/she returned from break, he/she was going to do cares with Resident #1. CNA #6 stated that he/she asked LN #4 if he/she wanted to assess the Resident's skin since he/she was going to perform cares. CNA #6 stated LN #4 replied No. CNA #6 further stated that when he/she entered the room, the Resident was hot. The CNA had prepared cold towels, when LN #4 came into the room and told him/her to take the Resident into the dayroom. CNA #6 stated he/she put the Resident into a chair and assisted the Resident to the dayroom. CNA #6 recalled once in the dayroom, he/she took to Resident to be near the fan. During a phone interview on 10/30/20 at 8:12 am, LN #4 stated he/she remembered that day because it was so hot. LN #4 stated CNA #5 approached him/her and stated Resident #1 looked warm and red. LN #4 stated that he/she knew and was trying to get the Residents up and out of their rooms into the cooler dayroom. LN #4 stated he/she was working with another Resident and was putting ice packs on him/her, while Resident #1 had two CNAs tending to him/her. The CNAs got the Resident into a chair and brought him/her into the dayroom. Then, the DON arrived in the unit and stated that Resident #1 didn't look well. LN #4 responded by saying that he/she had been in Resident #1's room to change his dressing, and the CNAs were getting the Resident out of bed, so LN #4 left to work with a different Resident. During an interview on 10/23/20 at 9:45 am, when asked if Resident #1's medical emergency was directly related to the temperature in the building, The MD stated that the air that day was hot, there was no circulation and the unit was greater than 85 degrees Fahrenheit. The MD further stated that Resident #1 was fair skinned, and he/she became hot from the lack of air flow. The Resident also had a history of [REDACTED]. Review of the Resident's South Peninsula Hospital- LTC Progress Notes for the day of 8/16/20 revealed no assessment or care notes documented after CNA #5 reported Resident #1's condition to the LN. Further review revealed a Change in Condition Note written by the DON at 8/16/20 at 5:17 pm, stating Temperature of department above normal, Resident flushed, diaphoretic with delayed responses. Temp(erature) 100.2 Resident (complained of) nausea. Call placed to (MD), (voice order) for resident to be evaluated in the (emergency room ). Charge nurse notified; floor nurse notified Rapid response called. Review of the facility's policy Abuse Neglect, Exploitation and Misappropriation of Property, effective 10/4/19, revealed In instances of investigations concerning a staff members' behavior .All allegations shall be immediately and thoroughly investigated until conclusion. During an interview on 10/23/20 at 10:47 am, when asked if she interviewed the CNAs responsible for Resident #1's care that day, the DON stated she did not interview them, that she only interviewed CNA # 5, who had relieved the primary CNAs while they were on break. When asked if she had interviewed other Residents that LN #4 took care of that day, the DON responded she had not. Review of the facility's policy Abuse Neglect, Exploitation and Misappropriation of Property, effective 10/4/19, revealed Neglect- The failure by the nursing home, it's staff, or outside service providers to provide service and goods to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. Further review revealed Management of Suspected Abuse/Neglect .Careful assessment and documentation of physical findings can help provide the data that are believed to confirm diagnosis. History taking and examination of all resident shall be done promptly and in privacy. Root cause Analysis (RCA - a structured method used to analyze serious adverse events).: During an interview on 10/21/20 at 11:00 am, the Facility Administrator (FA) stated that the DON's investigation showed that she spoke to LN #4 that day. The FA further stated that the DON checked the Hill-rom badge (locator) device, which revealed the LN was in Resident #1's room for a short period of time. The Administrator remarked that the LN could not have done an assessment of the Resident in that short period of time. The FA further stated an RCA was performed by the facility and there were two issues of concern- the failed maintenance response and the failed response by the LN. The FA further stated that a second RCA should have been performed because the first RCA addressed the heating issue, but did not fully address the failed response by the LN. Review of REPORT OF HARM, final report dated 8/21/20 at 11:00 am revealed a root cause analysis (RCA) was performed by the facility and revealed on 8/16/2020 1600 (4:00 pm) CNA alerted (LN) that resident didn't seem right and requested (LN) to check on him. Through investigation process (LN) reports that at no time did (he/she) complete a physical or neurological assessment of the resident. (LN) indicated I went in right after (CNA) told me and changed (the Resident's) dressing and (he/she) was fine. Further investigation demonstrated that Hill-ROM badge locator reports indicated that attending nurse .was not in the resident's room until (4:56 pm) for a total of 4 min(utes) 8 sec(onds). During an interview on 10/23/20 at 10:47 am, when asked about the results of the RCA, the DON replied that plans were put in place to correct the heat issue, a protocol for staff was put in place if the temperature was out of range, and the situation with the LN resolved itself with the LN quitting. Review on 10/22/20 at 6:30 pm of the Root Cause Analysis Long Term Care Heating Issue, dated 8/25/20 revealed 4. Residential negative impact a. Delay in noticing struggling resident b. Safety rounds i. How often? ii. Resident assessments when concerns arise iii. Reporting in the EMR (Electronic Medical Record). Further review revealed Action Plan: .5. Develop a process for vital signs check. Further review revealed ACTION . Update/develop standards for responding to environmental temperature fluctuations to include resident assessment .GOAL .Standardize response to environmental temperature fluctuation to increase timeliness and effectiveness of care .STATUS .In process. Review on 10/22/20 at 7:15 pm, of the facility's policy SUBJECT: Protocol: Ambient Temperature Out of Range, dated 8/26/20, revealed Upon discovery that the ambient temperature is outside the acceptable range of 71-81 degrees Fahrenheit the charge nurse institutes the following actions: 1. Notified Facilities/Maintenance personnel 2. Notified Director of Nursing (DON) a. DON to contact Facilities Director directly as indicated . The policy did not mention steps to be taken regarding Resident assessments, safety rounds or reporting.

Based on record review, observation, and policy review, the facility failed to ensure staff performed handwashing between gloves changes when performing personal care for 2 residents (#s 2 and 5) out of 6 sampled residents. This failed practice had the potential to spread infectious diseases such as COVID-19 (an infection caused by [DIAGNOSES REDACTED]-CoV-2 virus that may result to acute respiratory syndrome, multi-organ system failure and septic shock) Findings: Resident #2: Record review on 8/11/20 revealed Resident #2 had [DIAGNOSES REDACTED]. Review of the most recent Minimum Data Set (MDS) quarterly assessment, dated 7/30/20, revealed the Resident required extensive assistance with personal hygiene and total assistance with transfers. The Resident was always continent of bowel and frequently incontinent of urine. Observation during personal care on 8/11/20 at 9:10 am, Certified Nursing Assistant (CNA) #2 sanitized both hands with hand sanitizer, donned gloves and entered Resident #2's room. The Resident stated he/she was ready to get out of bed and needed to use the commode. CNA #1 entered the room, sanitized both hands and donned gloves. After assisting the Resident with turning to his/her side, CNA #2 removed the Resident's wet disposable incontinence brief from under the buttocks and used disposable wipes to clean Resident #2's peri area. CNA #2 then removed both soiled gloves, and without performing hand hygiene, donned a new pair of gloves. Both CNAs then positioned a transfer sling under the Resident and used the ceiling lift to transfer him/her to the commode. After the Resident had a bowel movement in the commode, CNA #2 cleaned Resident #2's buttocks with a disposable wipe. CNA #2 then removed both soiled gloves, and without performing hand hygiene, donned a new pair of gloves and both CNAs transferred the Resident to his/her lounge chair. During the transfer, CNA #2 touched multiple items in the room with the same gloved hands. Resident #5: Record review on 8/11/20 revealed Resident #5 had a history of [REDACTED]. Review of a MDS quarterly assessment, dated 7/24/20, revealed Resident #5 needed total assistance with toileting and extensive assistance with hygiene. The Resident was always incontinent of urine and frequently incontinent of stool. Observation during personal care on 8/11/20 at 11:30 am, CNA # 1 and Licensed Nurse (LN) #1 assisted Resident #5 with personal cares. After entering the room, sanitizing hands, and donning gloves CAN #1 removed the urine soaked incontinence pad wrapped around the penis, and used disposable wipes to clean the Resident's groin. After he/she placed the soiled items in the trash, CNA #1 removed both gloves, and without performing hand hygiene, retrieved a pair from a box by the door, and changed into the new pair of gloves, while stating No Gloves in my pocket of course. CNA #1 then placed a clean incontinence pad around Resident #5's penis, and pulled a pad up between the Resident's legs. While wearing the same gloves, the CNA and LN #1 pulled the Resident up in bed and CNA #1 placed a wedge pillow under the Resident's right side, used a disinfecting wipe to clean the Resident's call light and side rails, and adjust both feet. Both staff then exited the room. Review of the Meeting Minutes, on 8/10/20, for the all staff meeting, conducted 6/17/20, revealed Change gloves and perform hand hygiene when performing care moving from a Dirty Area (peri care) to Clean Area (face/oral care) if moving from a contaminated body site to a clean body site during patient care .No gloves inside pockets! Considered dirty. According to CDC guidelines on hand hygiene in health care settings, accessed on 8/21/20 at https://www.cdc.gov/handhygiene/providers/guideline.html, stated Healthcare personnel should use an alcohol-based hand rub or wash with soap and water for the following clinical indications: Immediately before touching a patient; Before performing an aseptic task .; Before moving from work on a soiled body site to a clean body site on the same patient; After touching a patient or the patient's immediate environment; After contact with blood, body fluids, or contaminated surfaces; (and) Immediately after glove removal

Based on observation, interview, and policy review, the facility failed to ensure employees practiced effective hand hygiene, effectively cleaned a glucometer after use, and transported clean linen in a manner to reduce cross contamination. These failures had the potential to affect any of the 23 people residing in the facility. Findings: 1. In an observation on 3/10/20 at 11:08 am in the medication room, Licensed Nurse (LN) #1 removed a glucometer from the plastic case and laid it on the counter, scanned in a strip and inserted it into the glucometer; gathered lancet, alcohol wipe and 2x2 gauze, and performed hand hygiene with hand sanitizer. LN#1 then walked to/into the resident's room, set the glucometer directly on the resident's overbed table, donned gloves, and performed the blood glucose test. At 11:11 am, LN#1 went to the sink, laid the glucometer on the sink counter, wet hands, applied soap, and performed a seven second hand scrub, rinsed and used paper towel to dry hands. LN#1 then picked up the glucometer, spoke to resident and used hand sanitizer as he/she left the room. At 11:13 am, LN#1 placed the glucometer on the counter in the medication room and used a Sani-Cloth Germicidal Disposable Wipe (which stated on the front container label Disinfects in 3 minutes,) LN1 wiped the glucometer and placed it in the container plastic case, then wiped the counter. When asked what the contact time would be for the disinfect wipe, LN#1 stated, dry for 3 - 5 minutes. At 11:14 am, LN#1 confirmed the glucometer was showing streaking (signs of drying), and LN#1 stated, Normally I don't time it, I'd be doing other stuff. At 11:15 am, LN1 confirmed the counter was streaking as it dried No, it hasn't been three to five minutes. LN#1 then looked at the glucometer in the plastic case, stated It appears to be dry, so I don't want to touch it. and closed the case lid. In an interview on 3/11/20 at 10:00 am, the Director of Nurses (DON) stated, It's a three minute dry time. When asked if the chemical was effective if dry, the DON corrected herself and stated, It has to be wet for three minutes. Review of LN#1's 2/1/19 Long Term Care Annual Skill Fair showed a slash through glucometer row (and two more lines), below that there was a row with a date and a line straight down thru a few additional training categories. The row Hand Hygiene on the first page had a line straight down through it from a category 3 rows above with the date 2-1-19. In an interview on 3/11/20 at DON stated at 10:20 AM that she thought the slashes meant the person on the top line did all those items, but confirmed the slash was different than a line straight down. Review of the facility policy Equipment & Area Cleaning, revised 10/29/19, showed Policy: All equipment on Long Term Care will be cleaned or replaced according to a schedule specific to the equipment, recognized standards of care, infection control practices, and manufactures recommendation. On page 3/5, the policy stated glucometers were to be cleaned by the Nurse after every use, and the cleaner was Sani-cloth HB, Sani-Cloth Plus, and Super Sani-Cloth. Review of the Sani-Cloth Germicidal Disposable Wipe back label showed: . TO DISINFECT AND DEODORIZE: Unfold a clean wipe and thoroughly wet surface. Allow treated surface to remain wet for three (3) minutes. Let air dry, if present, remove gross filth prior to disinfecting 2. Observation of meal service on 3/10/20 at 12:48 showed Certified Nurse Aide (CNA) #2, commenting about not using the alcohol-based hand sanitizer, entered kitchen to use the hand wash sink. CNA #2 turned on the water, applied soap to his/her hands, performed a six second hand scrub (the vigorous rubbing of hands together covering all surfaces), rinsed, used a paper towel to dry hands then turned the water off with a paper towel. At 12:50 pm, CNA #1 was observed to turn the water on, apply soap, perform a five second hand scrub, left water on for the next person, retrieved a paper towel and dried hands. In an interview on 3/10/20 at 1:50 pm regarding how to wash hands, CNA #2 stated, Turn on water, wet your hands, soap and hand scrub for two Happy Birthday or one time if it sung properly (clarified to mean slowly). In an interview on 3/10/20 at 2:00 pm regarding how to wash hands, CNA #1 stated, Turn on the water, make sure it's warm, wet your hands, add soap, scrub your hands for 25 seconds, rinse, get a towel to dry your hands then turn off the water. Review of the facility policy HW-136 Hand Hygiene, last revised 5/13/16, showed: . 3. Use the following procedure for hand washing: -Turn faucets on to obtain a tepid flow (knee manipulated faucet handles are best, otherwise use hands.) -Do not allow your body or clothes to touch sink -Keeping hands pointing downward, to prevent water from running up the arms, wet hands with running water. Apply soap and thoroughly distribute over hands. Vigorously rub hands together for at least l5-20 seconds, generating friction on all surfaces of the hand and fingers. -Rinse hands thoroughly under running water, keeping the hands pointing down. -If hands are grossly soiled, i.e. contact with fecal discharges, oral secretions, or wound drainage, the entire wash process should be repeated using 30 second sudsing process. -Dry hands thoroughly using a disposable towel, then discard towel -If manually operating faucets are used, turn handle off using a separate dry paper towel so as not to recontaminate the hands. 4. Hand antisepsis with an alcohol-based hand rub may be used as an alternative to hand washing in general, except when hands are obviously soiled OR in cases as noted in item 2. 3. An observation on 3/9/20 at 4:40 pm revealed CNA #2 pushing a linen cart down the hallway with clean washcloths and towels. CNA #2 stopped outside of room [ROOM NUMBER], gathered some of the clean linens, and took them into the room. The remainder of the clean linen was left in the hallway without a protective cover and unattended by staff. An interview with CNA #2 on 3/9/20 at 4:42 pm revealed, I count out exactly the amount of clean linens I need for the residents before I load them onto my cart. I thought I didn't have to cover the linens in the hallway so long as I didn't return any of them to the clean utility room or take the cart inside a resident room. An interview with the Administrator on 3/10/20 at 9:15 am revealed, Yes, those linens should have been covered. We will make sure all the CNA's get that information right away. Review of the facility's Handling, Transporting, Processing and Storage of Linen policy, dated 6/30/14, revealed, . All clean linens will be transported in a clean, covered cart that has been designated for clean linens use only .

Based on observation, interview, and record review, the facility failed to identify [MEDICAL CONDITION] on the lower legs for one resident (Resident #4) of 12 sampled residents. This failure resulted lack of monitoring and treatment for [REDACTED]. Findings: Review of Resident #4's Face Sheet revealed he/she was admitted to the facility on [DATE]. Review of the resident's Medical [DIAGNOSES REDACTED]. Review of Resident #4's Admission Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 1/21/20 revealed the resident had no wounds, [MEDICAL CONDITION], or other skin concerns; and was receiving no skin treatment including ointments or other medications. Review of Resident #4's Weekly Skin assessment dated [DATE] revealed a negative response to the question, Does the resident have any skin issues? A corresponding diagram of the human body was blank, indicating no wounds, scratches, [MEDICAL CONDITION], or other concerns with the resident's skin. An observation of Resident #4 on 3/8/20 at 12:15 pm revealed multiple small [MEDICAL CONDITION], some of which had small open areas which had scabbed over. Three of the [MEDICAL CONDITION] had open areas in the center from which trickles of blood were running down the resident's leg. When asked about the areas, Resident #4 stated, I have liver failure, and when I was in the hospital, I had swelling really bad in my legs. They gave me medicine for that, and it helped with the swelling, but now I've got those little sores and they itch. So, I scratch them. Resident #4 stated the nursing staff knew about his [MEDICAL CONDITION] and had provided a container of lotion he/she could use. Resident #4 stated, I use it sometimes, but sometimes it doesn't work, and I just like to scratch. An observation of Resident #4 on 3/10/20 at 10:07 am revealed multiple [MEDICAL CONDITION] to the lower legs, many with scabbed areas in the center. Resident #4 pointed to a container of over-the-counter lotion on his nightstand and stated, I can use that, but sometimes it doesn't help, and I just end up scratching. Review of Resident #4's record revealed no further documentation had been completed on his skin since 3/3/20. Review of Resident #4's record revealed a Weekly Skin assessment dated [DATE] and signed as complete at 2:37 pm. Review of the skin assessment revealed a negative answer to the question, Does the resident have any skin issues? A corresponding diagram of the human body was blank. An interview with Licensed Nurse (LN) #2 on 3/10/20 at 3:05 pm revealed he/she was the nurse who had examined Resident #4's skin and completed the Weekly Skin Assessment at 2:37 pm that day. The LN stated offhand, she was not aware of any skin concerns for Resident #4 and confirmed that based on the Weekly Skin Assessment in Resident #4's record there should be no [MEDICAL CONDITION], scabs, or other areas on his/her body. Along with the surveyor LN #2 went to Resident #4's room to look at the resident's legs, which had several [MEDICAL CONDITION] present, many with dried scabs in the center. At the time of this observation, five of the [MEDICAL CONDITION] had open areas in the center with trickles of blood running down the resident's legs. LN #2 stated, Those weren't like that before, and asked Resident #4 how the areas occurred. Resident #4 stated, They itch . so I scratched them. LN #2 handed Resident #4 the container of lotion and encouraged him/her to use the lotion. An interview with LN#2 on 3/10/10 at 3:10 pm revealed she had not documented the areas on Resident #4's legs because I only have to document new things. If I already know about them, I don't put them on the form. Review of Resident #4's Weekly Skin Assessment on 3/10/10 at 4:15 pm revealed the skin assessment had been updated at 3:19 pm. The question, Does the resident have any skin issues? was now answered in the affirmative, and the corresponding body diagram noted scratches to all aspects of both lower legs. An interview with the Director of Nursing (DON) on 3/10/10 at 4:16 revealed Resident #4 was known to have extremely dry skin related to liver failure. The DON stated her expectation for a Weekly Skin Assessment was that the nurse should note any skin issues, even those previously known, and document accordingly for accurate monitoring of healing. Review of the facility's Skin Care policy dated 2/4/19 revealed, . All residents will have their skin integrity assessed and documented upon admission, weekly, and as needed .

Based on staff interview, resident interview, family interview, and record review, the facility failed to ensure an anticoagulant medication was coded on the Minimum Data Set assessment for one of six residents (Resident #18) reviewed for unnecessary medications. Findings: In an interview on 3/9/20 at 4:01 pm, Family Member (FM) #1 stated Resident #18 was on a blood thinner because of a pacemaker. Review of Resident #18's Orders tab in the electronic medical record (EMR) showed an order for [REDACTED]. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] medication section showed Resident #18 did not receive an anticoagulant medication on any of the seven days of the assessment. Review of the 10/18/19, 7/26/19, and 5/27/19 MDS assessments showed Resident #18 received an anticoagulant medication seven of seven days for each assessment period. In an interview on 3/11/20 at 1:30 pm, MDS Coordinator stated, I was training someone, and it was missed. I was responsible, and it was coded wrong. I'll fix it now. Review of the Resident Assessment Instrument (RAI) Manual, October 2019, page N-7 showed: Record the number of days an anticoagulant medication was received by the resident at any time during the 7-day look-back period (or since admission/entry or reentry if less than 7 days). Do not code antiplatelet medications such as aspirin/extended release, [MEDICATION NAME], or [MEDICATION NAME] here.

Based on interview, and record review the facility failed to ensure residents had the opportunity to select their code status for two residents (Resident #s 22 and 23) of 12 sampled residents. This failure could have resulted in their wishes for treatment to not be followed. Findings: a. Review of Resident #22's Face Sheet revealed he/she was admitted to the facility on [DATE]. Further review of the resident's face sheet revealed the resident had a Do Not Resuscitate (DNR). Further review of Resident #22's record revealed no documentation that had been discussed with the resident, or that the resident had opted to be a DNR. b. Review of Resident #23's Face Sheet revealed he/she was admitted to the facility on [DATE]. Further review of the resident's face sheet revealed the resident had a DNR status. Further review of Resident #23's record revealed no documentation that had been discussed with the resident, or that the resident had opted to be a DNR. An interview with the Social Worker (SW) on 3/10/20 at 2:06 pm revealed the facility's practice was to ensure all residents and/or their representatives had the opportunity to select a code status. The SW stated that there should be a signed document in the record as to what the resident's choice After reviewing Resident #22 and Resident #23's records, the SW was unable to locate signed documents from either resident. Review of the facility's Advanced Directives in Long Term Care policy, dated 10/16/19, revealed, . The resident has the right to make decisions about their care and treatment. Thus, each Resident has the right to formulate . decisions about their wishes for end of life care .

Based on interviews and record reviews the facility failed to ensure nurse aide competency in the area of communication with cognitively impaired and/or mentally ill residents for 3 certified nursing assistant (CNA #s 1, 2, and 3) . The failed practice had placed 3 residents (#s 1, 2, and 3), out of 4 residents reviewed, that had experienced negative interactions with facility staff, at risk for abuse and/or neglect. Findings: Review of allegation #1 that occurred on 6/26/19: CNA #1 During an interview on 1/21/20 at 1:25 pm, Licensed Nurse (LN) #1 stated CNA #1 had been verbally aggressive with Resident #1 on the evening of 9/26/19. Record review on 1/21/20 revealed Resident #1 had [DIAGNOSES REDACTED]. During an interview on 1/21/20 at 7:26 pm, LN #3 stated s/he was working the night of 9/26/19 and saw the incident between Resident #1 and CNA #1. The LN stated as CNA #1 kept repeating directions (telling the Resident it was time to go to bed) to the Resident, the CNA's tone became more agitated. LN #3 stated when s/he saw LN #2 approach the Resident and the CNA; s/he felt LN #2 had mitigated any concerns. LN #3 stated s/he eventually assisted the Resident to bed that evening. During an interview on 1/22/20 at 10:30 am, CNA #1 stated Resident #1 was not standing up to go to bed, thinking the Resident had not heard the request, s/he reproached several times and asked the Resident if s/he wanted to go to bed. LN #2, who was at the medication cart on the other side of the room, came over, stepped in front and attempted to assist the Resident. The CNA stated s/he had taken care of Resident #1 for several years, and had good rapport with the Resident. The CNA stated the Resident had experienced a change in cognitive function and had become more confused prior to this event. When asked about dementia training provided by the facility, the CNA stated s/he could not recall any education. Review of CNA #1's employee record revealed, prior to this event, the employee was a CNA at the long-term care for 5 years. There was no evidence or review that demonstrated competency in CNA #1's record. During an interview on [DATE] at 1:30 pm, when asked about the incident between CNA #1 and Resident #1, LN #2 stated the CNA had raised his/her voice, telling the Resident (Resident #1) get up! loudly enough that s/he heard it across the room. The LN stated s/he did not say anything to the CNA, but tried to get the Resident to stand up. When unsuccessful s/he requested LN #3's help. LN #2 stated Resident #1 had a recent decline in condition and had become harder to care for. Review of allegation #2 that occurred on 8/26/19: CNA #2 During an interview on 1/21/20 at 1:46 pm, when asked about an allegation of verbal CNA #2 had exhibited towards Resident #2 when serving the Resident breakfast, the LN #1 stated the facility had initially removed the CNA from the Resident's care. The Resident had [MEDICAL CONDITION] disorder (mental health disorder than can cause hallucinations, delusions, and/or mood disorders) and was difficult to care for. After the incident, the LN stated the CNA had reviewed the Resident's plan of care and conduct policies. During an interview on 1/21/20 at 3:30 pm, when asked about Resident #2 often being unhappy with the food, CNA #5 stated the staff never knows how Resident #3 was going to act on a day-to-day basis. The CNA stated it was always a gamble, referring to giving the Resident her meals. During an interview on 1/21/20 at 3:40 pm, when asked about the incident regarding Resident #2's breakfast, CNA #2 stated it didn't matter what food was served, the Resident was never happy. The CNA denied there was any type of verbal abuse as s/he had merely told the Resident it was going to be marked refused in his/her record. During an interview on 1/21/20 at 3:50 pm, Social Worker (SW) #1 was asked about what happened between CNA #2 and Resident #2. The SW stated s/he had overheard the CNA serving the Resident breakfast, when Resident #2 stated s/he did not like eggs cooked that way the CNA had not attempted to reproach or provide other options. The SW further stated the CNA had responded to the Resident in short tone; it would just have to be marked refused, without offering other options. The SW stated the Resident's criticisms and obsession with not eating certain types of food, was a new development. Review of CNA #2's employee record revealed the CNA had worked at the long-term care for almost 2 years. The employee file had no information that documented competency in communications with residents that had dementia and/or mental illness. Review of CNA #2's transcript from HealthStream (online education training) revealed the CNA had completed SPH (South Peninsula Hospital) Resident Rights estimated time 30 minutes, within the past 2 years. The CNA had attended the dementia booth at the health fair last spring. Review of a LTC (Long Term Care) Facility Orientation Checklist and the LTC CNA Orientation Check List, dated 3/5/18, revealed no documentation of demonstrated/ or verbalized competency for communication and care of residents with dementia and/or mental illness. Review of the 1 hour workshop Positive Approach to Care implemented by the facility on 1[DATE] revealed CNA #2 had not attended. There was no documentation the CNA had recently reviewed the Resident's care pan or the facility's conduct policy. During an interview on 1/22/20 at 1:15 pm, the DON stated CNA #2 had attended Feeding and Nutrition in Dementia Care in November 2019. Review of allegation #3 that occurred on 12/6/19: CNA #3 During an interview on 1/22/20 at 1:55 pm, when asked about the incident (12/6/19) with Resident #3, CNA #4 stated Resident #3 had a recent decline in status and had become more combative. The CNA stated the Resident was soiled and they were trying to help. When the Resident began to call out, s/he witnessed CNA #3 had put his/her hand by the Residents mouth and tried to shush him/her. The CNA stated s/he had reported it to the nurse. When asked what training facility had provided the CNA stated s/he attended the Teepa Snow (Positive Approach to Care) last month. During an interview with CNA #3 on 1/22/20 at 2:15 pm, when asked about the incident with Resident #3, the CNA stated s/he had not actually covered the Resident's mouth but had put his/her had up near the Resident's mouth and shushed the Resident, in attempt to calm the him/her. The CNA stated the Resident had soiled him/herself with feces 3 times that evening and they were just attempting to clean him/her. The CNA stated that Resident #3 had had a significant decline in behavior and mobility and had become increasing confused and combative over the past couple weeks. Review of CNA #3's employee record revealed the CNA had worked in the long-term care for over 2 years. The employee file had no information that documented competency in communications with residents that had dementia and/or mental illness. Review of CNA #2's transcript from Healthstream revealed the employee had completed SPH Resident Rights, estimated time 30 minutes, and attended the dementia booth at the health fair. During the interview on 1/22/20 at 1:55 pm, CNA #3 stated the facility had recently had him/her start watching the Positive Approach to Care videos. The CNA stated the videos had been very helpful. During an interview on 1/22/20 at 1:15 pm, when asked about dementia training for CNA #s 1, 2, and 3, the DON and Administrator stated facility staff completed courses in Healthstream and had attended the dementia booth at the skill fair last year and the facility started to implement more in-depth training that started in December 2019. Record review, on 1/22/20 of the Healthstream curriculum revealed no specific dementia education. .

Based on record review, observation, and interview the facility failed to: Implement interventions to prevent a pressure ulcer and identify deep tissue injury for 1 resident (#22), out of 13 sampled residents. This failed practice contributed to the development of an unstageable pressure ulcer which could increase the resident's risk for infection, pain, and impeded the ability for the Resident to attain or maintain the highest practicable physical, mental, and psychosocial well-being. Findings: Resident #22 Record review on 10/22-26/18 revealed Resident #22 was admitted to the facility with [DIAGNOSES REDACTED]. Review of the most recent MDS (minimum data set, a federally mandated assessment), an admission assessment, dated 9/23/18, revealed the Resident coded as requiring limited assistance, one person physical assist, with bed mobility; transfer; walk in room; walk in corridor; dressing; toilet use; and personal hygiene. Further review of the MDS revealed the Resident was at high risk for pressure ulcers but had no pressure ulcers on admission. In addition, the MDS indicated skin/ulcer treatment included pressure reducing device for chair and bed. Review of the Resident's Nursing Admission Physical Assessment, dated 9/17/18, revealed the resident had a history of [REDACTED]. Review of the Resident's care plan revealed: Focus statement, last revised 10/2/18: SKIN INTEGRITY: (Resident) is at risk for pressure ulcer (related to) nutritional intake, limited mobility. (History) of stage 1 pressure injury over (his/her) coccyx .10/1 Blanchable redness and chafing to buttocks. Goal for skin integrity, last revised on 10/1/18: (Resident) will show no signs of reoccurrence of pressure injury over (his/her) coccyx area. Goal for skin integrity, last revised on 10/17/18: Buttocks chaffing will resolve by review date. Intervention for skin integrity, last revised on 9/29/18: Roho cushion (a pressure relief cushion for wheelchairs that are made of soft, flexible air cells) in (wheelchair). Intervention for skin integrity, last revised on 9/25/18: Treatments per MAR/TAR (medical administration record/treatment administration record). Review of Resident #22's MAR/TAR orders revealed: An order on 10/1/18 at 3:16 pm: Bath/Shower Day: Document, in a progress note, any unusual skin observations and initiate interventions as appropriate. Check coccyx for redness. History of stage 1. Every day shift every (Monday) for skin observation. An order added on 10/2/18 at 5:39 am: House stocked Zinc Oxide cream Apply to buttocks topically every shift for reddened areas; moisture associated skin damage . An order added on 10/21/18 at 8:26 pm: Monitor Blister on coccyx (every) shift, until resolved. Document assessment/treatment in progress note . Nurse Progress Notes: Review of the Resident's nursing progress notes, from admission through 10/25/18, revealed the following skin assessments and or interventions: 9/25/18 at 1:47 pm: .has small area on coccyx nickel size, blanchable. Over Bony prominence. Barrier cream applied and resident encouraged to not sit in one position to long. Charge nurse informed . 10/1/18 at 3:15 pm: .coccyx red, (Wound Care Nurse (WCN) #1) in at bedside, new treatment ordered, will continue to monitor. 10/2/18 at 11:05 am: .(Zinc Oxide) applied to buttocks, resident reminded to turn in sleep. Staff encouraged to remind resident to turn in bed to relieve pressure from bony prominences. 10/8/18 at 9:18 am: .Skin is intact and free of redness, except for coccyx area where it is blanching . There were no skin or wound assessments documented from 10/9-20/18. 10/21/18 8:26 pm: .dressing starting to curl on lower aspect between 5 and 7 if the anus were a clock, [MEDICATION NAME] down, blister remains intact at this time. 10/22/18 at 9:24 am: .Blister remains intact. Left (dressing) in place. 10/23/18 at 3:34 pm: .Blister is open. Cleansed, applied [MEDICATION NAME], covered with padded duoderm. 10/24/18 at 8:13 am: .at this time dressing is dry and intact. 10/25/18 at 5:28 am: .New thin duoderm (a dressing used to treat pressure sore made of a substance that forms a gel in the presence of a liquid) applied. 10/25/18 at 8:47 am: .dressing dry and intact, not removed. 10/25/18 at 9:03 pm: .dressing clean, dry, and intact. Wound Care Nurse (WCN) Assessment Notes: Review of Resident #22's skin/wound notes from WCN staff revealed the following 3 notes: 10/1/18 at 3:11 pm: BUTT[NAME]KS RED BUT BLANCHABLE. SOME CHAFING NOTED ON BUTT[NAME]KS. NO DRAINAGE. INITIATED STANDING ORDER FOR REDNESS/MASD. SEE BELOW House stocked Zinc Oxide cream. Apply to buttocks topically every shift for reddened areas; moisture associated skin damage APPLY WITH CARES PRN UNTIL RESOLVED. CNA MAY APPLY. MAY KEEP AT BEDSIDE. STANDING ORDER. 10/4/18 at 9:15 am: Buttocks assessed again today during toileting. Skin is pink, no longer red. Chafing is resolving. House stock zinc oxide cream applied with cares. 10/26/18: Skin & Wound - Wound Assessment, Progress: Effected area noted initially was red & slow to blanch barrier cream was applied. A intact fluid filled dark blister over coccyx area which is quite prominent developed 1-2 week ago. Initial (treatment) was skin prep, polymen covered with [MEDICATION NAME] boarder (dressing). This (morning) a wound assessment was done, a duoderm was found above the wound area rolled up. Duoderm removed, wound area cleansed with wound cleanser, skin prep applied followed by a [MEDICATION NAME] boarder (dressing}. Education: Care plan and TAR to be updated next (dressing) change if wound unchanged will applied Medi honey, followed by a [MEDICATION NAME] boarder (dressing}. Will change 3-5 days & (as needed). During an interview on 10/24/18 at 9:40 am, Licensed Nurse (LN) #2 stated WCNs do rounds once a week and documented the assessment in the progress notes. Observations: During an observation on 10/22/18 at 2:15 pm, Resident #22 was in his/her wheelchair with no Roho cushion on the chair. He/she was sitting on a chair alarm pad. During an observation on 10/23/18 at 1:00 pm, Resident #22 was in his/her wheelchair with no Roho cushion on the chair. He/she was sitting on a chair alarm pad. During an observation on 10/24/18 5:00 pm, WCN #3 completed a dressing change on the Resident's coccyx. Observation revealed a dry, black eschar wound the size of a dime on Resident's coccyx bony prominence. WCN #3 stated this wound was originally a blister, then changed to a stage 1 pressure ulcer, and is now a stage 2 ulcer. WCN #3 stated that the physician assessed the wound earlier in the day. During this observation, it was also noted the Resident had not been sitting on the Roho cushion in his/her wheelchair and had sat directly on the chair alarm pad. Review on 10/25-26/18 of the Resident's physician's note, from admission through 10/24/18 revealed no documentation of an assessment or recommendations for the Resident's coccyx wound. Wound Care Observation on 10/26/18 at 9:30 am, during a dressing change by WCN #2 revealed, the duoderm dressing was observed to be rolled up and off the coccyx area and wound site, leaving the wound exposed and unprotected. During an interview at the time of the dressing change, WCN #2 stated he/she was the Resident's WCN and stated the coccyx wound was an unstageable pressure ulcer. The black eschar wound measured - area: 1.5 cm squared, length: 1.4 cm, width: 1.3 cm. Review of the MAR/TAR orders written on 10/26/18 revealed: (treatment) for unstable pressure injury over coccyx area, includes weekly photos until resolved. Cleanse wound/peri wound with wound cleanser, apply skin protectant to peri wound, followed by medi honey and [MEDICATION NAME] (dressing). Change (every) 3-5 days and (as needed) until resolved or (treatment) changes. Review of the single Weekly Wound Assessment note, dated 10/26/18, revealed: Type of wound: Pressure Location: Sacrum. Stage: Unstageable: Obscured full-thickness skin and tissue loss . During an interview on 10/26/18 at 9:40 am, LN #2 stated she was unaware of Resident #22's wound progression. She stated the order was just to monitor the blister and the dressing was always intact. Physical Therapy Note Review of (Physical Therapy/Occupational Therapy) Note, dated 10/26/18, revealed: (Registered Nurse) and (Physical Therapist) consult regarding (Resident's) pressure ulcer on coccyx. Roho in (wheelchair) is appropriately inflated. (chair alarm pad) to be placed under legs, not bottom. (Physical Therapist) plan on placing a roho in resident recliner also, as resident often sleeps much of the night there. Consults with (Physical Therapist) and (Restorative Aide) will continue and care plan will be updated when changes are made. Review of the facility's (Long Term Care) Standing Medical Orders, revised 7/17/18, revealed: OPEN AREAS: WOUND MEASUREMENTS (EVERY) WEEK WITH PHOTOS OF WOUND IF CONSENT OBTAINED. DRESSING & TREATMENT MANAGEMENT PER WOUND CARE PROT[NAME]OL OR AS DEFINED BY PROVIDER. NURSE OR PROVIDER TO STAGE WOUND IF OVER BONY PROMINENCE .STAGE 2 PRESSURE INJURY: If an intact blister: protect with non-sting barrier film and cover with an acrylic dressing .If an open wound: protect with peri-wound with non-sting barrier film and cover with an acrylic dressing .change dressing every 5-7 days and (as needed). Check (every) shift. During an interview on 10/25/18 at 8:18 am, WCN #1 stated the facility used Lippincott guidelines to classify and care for wounds and there were also (Long Term Care) Standing Medical Orders the nurses used to define and treat wounds. WCN #1 further stated the protocol within the facility was for the nurse to contact the WCN staff and use the standing medical orders until WCN staff provided more guidance. During an interview on 10/25/18 at 3:53 pm, the Long Term Care Administrator stated pressure ulcers of stage 2 or more were addressed by the Interdisciplinary (IDT) Team to determine if they were avoidable or unavoidable. She stated stage 1 pressure injuries were not assessed by the IDT team. She further stated Resident #22's coccyx wound had not been ascertained to be a pressure wound. Review of the facility's guidelines from Lippincott's Nursing Procedures Pressure Injury Management, Long-Term Care, revised 8/17/18, revealed: A stage 2 pressure injury .may also present as an intact or open serum-filled blister .slough, and eschar aren't present. A stage 3 pressure injury is characterized by full-thickness loss of skin .Slough, eschar, or both .may be present. A stage 4 pressure injury involves full-thickness and tissue loss .Slough or eschar may be present . An unstageable pressure injury is characterized by full-thickness skin and tissue loss in which the base of the injury in the wound bed is covered by slough, eschar, or both, obscuring the extent of the damage.

Based on record review, observation, and interview, the facility failed to ensure 1 resident (#6) out of 6 sampled residents received the necessary care and services to prevent the development of avoidable pressure ulcers after a surgical procedure. Specifically, staff did not wrap the wound area appropriately. This failure caused pressure ulcers and a delay in recovery and healing. Findings: Record Review on 8/9-11/16 revealed Resident #6 was admitted to the facility with [DIAGNOSES REDACTED]. Additionally, the Resident had a right below knee amputation (BKA) on 4/27/16. Record review of the MDS (Minimum data Set-a federally required assessment) PPS (Prospective Payment System) assessment dated [DATE] revealed the Resident had developed one unstageable pressure ulcer (full thickness and skin loss in which the extent of tissue damage cannot be confirmed) and one, Stage 2 pressure ulcer (partial-thickness skin loss with exposed dermis). Review of the Physician's post-operative orders, dated 4/30/16, Dressing changes q (every) 48 (hours) done today .,Leave Brace in place until PT (Physical Therapy) evaluation .PT eval (evaluate) and treat. Observation on 8/8/16 at 12:25 pm revealed Resident #6 had 2 wounds on his/her RLE (right lower extremity). Dressing instructions from Patient Progress Notes (PPN): 5/2/16 - .no longer using the brace portion. Cover staples with 4x4 (4 x 4 size of gauze type dressing) so they don't snag. Then do a figure-8 wrap of stump going up above knee. Start at the end of the stump. Do not stretch Ace wrap more than 50 % .When the staples are out we' ll get a bit more aggressive with firmness on the wrap. Wrap is described in care plan . Review of the PPN, PT inpatient daily notes and physician notes revealed the following findings: PPN (Nursing): · 4/30/16 - Dressing changed as ordered by the physician. · 5/2/16 - Dressing was changed by the nurse in the morning and by the physical therapist in the evening. · 5/3/16 - Dressing was changed twice by nurses and stump was wrapped in Ace bandage. · 5/4-7/16 - Dressing was changed daily by various nurses and stump was wrapped in Ace bandage. · 5/8/16 - there was no documentation of dressing change. · 5/9/16 - Clinical Care Coordinator (CCC) did the dressing change and noted, Increased redness noted above suture line .(dark) purplish discolored area noted .Area noted at (right) lateral (pertaining to the side) area over fib (fibula-long, thin and lateral bone of the lower leg) head .followed by figure 8 ace wrap. Photos taken, will update MD. · 5/10/16 - RLE (Right lower extremity): Amputated stump .Distal to knee are 2 wounds: Anterior (in front) wound is red, 6 cm X 3.5 cm, skin is intact .Lateral wound is red, appears to be a blister .4.3 cm x 4 cm. Stump wrapped with Ace bandage. · 5/11/16 - stump dressing was changed by CCC with Ace wrap as per instruction from PT. · 5/12/16 - .Dressing removed .(Right) lateral aspect of stump had previous blister, when dressing was removed top layer of skin removed from blister. Blister wound is superficial, measures 3.2 cm x 3.5 cm. Wound bed is beefy red .then followed by Ace wrap . · 5/13-16/16 - Dressing was changed daily by various nurses and stump was wrapped in Ace bandage. · 5/17/16 - Dressing was changed, 2 wounds .Anterior wound .irregular shape, 3.8 cm x 2.7 cm. Lateral wound .The inner dry portion is 3.1cm x 3 cm irregular shape and the entire wound .is 4.7 cm x 7 cm .Then wrapped with Ace, using . · 5/18-23/16 - Dressing was changed daily by various nurses and stump was wrapped in Ace bandage. PT (physical therapy) inpatient daily notes: · 5/4/16 - residual limb wrapped and looked good, did not unwrap today . Short Term Goals .Using wraps, shape stump so patient can eventually be fit with prosthesis. · 5/9/16 - .right incision wrapped, but not the right compression, removed, noted skin over fib head looks like a blister was present at one time, also tib tub (tibial tuberosity-oval elevation of the anterior surface of the tibia (shin bone) redness noted .Call placed to (CCC) about limb, rewrapped with new gauze in place. · 5/11/16 - removed stump wrap and inspected limb . · 5/16/16 - .despite attempts to educate staff on wrapping, RN reports it is not always wrapped correctly and apparently the shrinker (elastic bandage) was too painful at this time . · 5/17/16 - .Dressing in place .I (physical therapist) did rewrap . · 5/18/16 - .stump wrapped and dressed, rewrapped after inspection and measurements today . · 5/19/16 - .rewrapped (Resident #6) limb . Physician's Notes: · 5/17/16 - .He does have 2 sores well away from the incision line probably secondary to wrapping of the leg which has been modified. · 5/20/16 - .Above the incision about 3-4 inches away, just below the knee, he has anteriorly and laterally 2 open areas which I am pretty sure are secondary to pressure from the initial wrapping after the surgical bandages were removed. · 5/23/16 - DC (Discontinue) Ace wrap to (right) stump for now. Continue [MEDICATION NAME] as ordered to stump wounds follow with ABD (highly absorbent dressing) and Kerlix (gauze bandage rolls) wrap. During an interview on 8/10/16 at 2:45 pm, the CCC confirmed that the wounds on the anterior & lateral aspect on the amputation site were pressure ulcers from the Ace wrapping ordered for stump shaping. She stated the Resident's circulation did not tolerate the ace wrap and confirmed the pressure sores were classified as unstageable. During an interview on 8/10/16 at 12:00 pm with LN #1, one of several nurses who changed the ace wrap, LN #1 stated she had not received any education about the Ace wrapping for Resident #6.